Scoping review of the characteristics assessed by vulnerability indices applied to people experiencing homelessness

Prehospital Care for Persons Experiencing Homelessness: A Cross-Sectional Survey of the Challenges, Experiences, and Perspectives of Operational EMS Agency Medical Directors

OBJECTIVE

Persons experiencing homelessness (PEH) are among the most vulnerable populations and experience significant health disparities. Nationally, PEH utilize Emergency Medical Services (EMS) at disproportionately higher rates than their housed peers. Developing optimal strategies to care for PEH has become critically important. However, limited data exists on best practices, challenges, and experiences of providing care to PEH. The objective of this study was to describe the experiences, challenges and perspectives of operational EMS agency medical directors in Los Angeles (LA) County as they confront the homelessness crisis.

METHODS

We performed a cross-sectional survey of 9-1-1 operational EMS agency medical directors in LA County, which has one of the largest populations of PEH nationally. Twenty-nine 9-1-1 operational EMS agencies operate in LA County. The link to an anonymous, web-based survey examining documentation, training, resources, operational impact, and care challenges was emailed to medical directors with three reminders during the study period (4/19/2023-9/15/2023).

RESULTS

Three quarters (75.9%; 22/29) of operational EMS agencies responded to the survey, with all questions answered in 69% (20/29) of surveys. Of these, 68.2% (15/22) of agencies document housing status and 75% (15/20) agreed or strongly agreed that homelessness presents operational challenges. No operational EMS agency reported adequate EMS clinician training on homelessness. Operational EMS agencies most commonly utilized domestic violence resources (43%, 9/21), social services (38%, 8/21), and law enforcement (38%, 8/21) services to assist PEH. Referrals were limited by accessibility (86%, 18/21), time (52%, 11/21), lack of awareness (52% 11/21) and lack of mandates (52%, 11/21). All operational EMS agencies agreed or strongly agreed that mental health and substance use disorders are major issues for PEH. The most common daily challenges reported were mental health (55%, 11/20), substance use (55%, 11/20), and patient resistance (35%, 7/20).

CONCLUSION

In LA County, EMS agencies experience important operational and clinical challenges in caring for PEH, with limited resources, minimal training, and high rates of substance use disorders and mental health comorbidities. Further prehospital research is essential to standardize documentation of housing status, to identify areas for intervention, increase linkage to services, and define best practices.

Examining the Role of Self-Harm in the Relationship between Emergency Department Service Utilization and Trauma-Induced Homelessness among Homeless Individuals in Texas

Homelessness is a complex public health problem in the United States. Current or ongoing history of trauma among individuals adds to the complexity and challenges of homelessness. Our study assessed the moderating role of self-harm in the association between emergency department (ED) service utilization and trauma-induced homelessness (TIH) among adults in Texas. Homeless adults (N = 282) who completed their baseline Vulnerability Index Service Prioritization Decision Assistance Prescreen Tool survey between February 2021 and February 2022 at a Local Mental Health Authority in Texas were selected. The outcome variable, TIH, was assessed by current period of homelessness due to experiencing trauma or abuse. The main independent variable was ED utilization, while self-harm in the past year was assessed as the moderating variable. A multivariate logistic regression with a moderation analysis was conducted while adjusting for the covariates. Individuals who utilized ED services and engaged in self-harm and risky behaviors had greater odds of experiencing current period of TIH. Male respondents were less likely to experience TIH. Finally, engaging in self-harm significantly moderated the association between ED service use and TIH. This study may help inform efforts to develop tailored interventions and promote resilience-based approaches to improve health outcomes among individuals experiencing homelessness due to TIH.

Specialised residential care for older people subject to homelessness: experiences of residents and staff of a new aged care home in Australia

BACKGROUND

The number of older people experiencing homelessness in Australia is rising, yet there is a lack of specialised residential care for older people subject to homelessness with high care and palliative needs. To address this significant gap, a purpose-built care home was recently opened in Sydney, Australia.

METHODS

This qualitative study explores the experiences of both residents and staff who were living and working in the home over the first twelve months since its opening. Residents were interviewed at baseline (n = 32) and after six months (n = 22), while staff (n = 13) were interviewed after twelve months. Interviews were analysed using a reflexive thematic analysis approach informed by grounded theory.

RESULTS

Three main themes emerged: (1) Challenges in providing care for older people subject to homelessness with high care needs; (2) Defining a residential care service that supports older people subject to homelessness with high care needs, and (3) Perception of the impact of living and working in a purpose-built care home after six months (residents) and twelve months (staff) since its opening. A key finding was that of the complex interplay between resident dependency and behaviours, referral pathways and stakeholder engagement, government funding models and requirements, staff training and wellbeing, and the need to meet operational viability.

CONCLUSION

This study provides novel insights into how the lives of older people subject to homelessness with high care needs are affected by living in a specifically designed care home, and on some of the challenges faced and solved by staff working in the care home. A significant gap in the healthcare system remains when it comes to the effective provision of high care for older people subject to homelessness.

Multistage Psychometric Testing of the Homeless Health Access to Care Tool

People experiencing homelessness find it challenging to access the healthcare they so desperately need. To address this, we have developed the Homeless Health Access to Care Tool, which assesses health related vulnerability (burden of injury and/or illness and ability to access healthcare) and can be used to prioritize people for access to healthcare. Here, we report the initial psychometrics of the Homeless Health Access to Care Tool. To assess interrater reliability, clinician participants were invited to instinctually rate the health-related vulnerability of 18-fictional case studies and then apply the Homeless Health Access to Care Tool to these same case studies. To assess convergent validity, the Homeless Health Access to Care Tool and the tool it was adapted from, the Australian Vulnerability Index Service Prioritization Decision Assistance Tool were administered to people experiencing homelessness. Feedback was sought from the participants receiving these two tools and from those administering them. The Homeless Health Access to Care Tool demonstrated a high interrater reliability and internal consistency. Participants using and receiving the Homeless Health Access to Care Tool reported it as straightforward, unintrusive and clear. Median time of administration was 7 min 29 s (SD 118.03 s). Convergent validity was established for the Homeless Health Access to Care Tool with a moderate correlation (r = 0.567) with the total score of the Australian Vulnerability Index Service Prioritization Decision Assistance Tool. Findings suggest that the Homeless Health Access to Care Tool is feasible and reliable. Larger samples are required to report construct validity.

Development of the Homeless Health Access to Care Tool to identify health-related vulnerability among people experiencing homelessness: Delphi study, Australia

OBJECTIVES

In this paper, we report the development of the Homeless Health Access to Care Tool. This tool aims to improve the gap in assessing health need and capacity to access healthcare of people experiencing homelessness. Tools exist that prioritise people experiencing homelessness for housing, but none specifically designed to prioritise for healthcare, or that are succinct enough to be easily implemented to emergency department or primary healthcare settings.

DESIGN AND SETTING

The Homeless Health Access to Care Tool has been adapted from an existing tool, the Vulnerability Index Service Prioritisation Decision Assistance Tool through a five-step process: (1) domain identification, (2) literature review, (3) analysis of hospital admission data, (4) expert judges, and (5) Delphi study.

PARTICIPANTS

The tool was adapted and developed by homeless health clinicians, academics and people with lived experience of homelessness. The Delphi study (n=9) comprised emergency department and homeless health clinicians.

RESULTS

Consensus was gained on all but one item, five new items were added, and wording changes were made to six items based on expert feedback. Participants perceived the tool would take between 5 to 11 min to complete, the number of items were appropriate, and the majority agreed it would facilitate the assessment of health needs and capacity to access healthcare.

CONCLUSION

Robust development of the Homeless Health Access to Care Tool through the Delphi is the first phase of its development. The Homeless Health Access to Care Tool offers an opportunity to assess both health need and capacity to access healthcare with the aim to improve access to healthcare for people experiencing homelessness. This tool will facilitate standardised data collection to inform service design and data linkage regarding access to healthcare of people experiencing homelessness. The next stages of testing include construct validity, feasibility, usability and inter-rater reliability, and pilot implementation.