Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience

From Disruption to Reconstruction: Implementing Peer Support in Homelessness During Times of Crisis for Health and Social Care Services

Introduction

Peer support workers-people with a significant lived and living experience of a social or health condition-use their experiential knowledge and obtain training to help and care for others. They are integrated in different clinical settings, including those for people experiencing homelessness. Most research on peer support implementation in homelessness has not considered the timing of the implementation, particularly in periods of crisis.

Description

During the COVID-19 pandemic crisis, a participatory research project examined the integration of a peer support worker in a primary and community care clinic that serves people experiencing homelessness in Montreal (Canada). This article presents a narrative case study analysis of the specific data on implementation derived from this project.

Results

Three main learning points are of interest regarding implementation: 1) crises can precipitate challenges but also particular opportunities for the implementation of peer support initiatives in homelessness; 2) even during a crisis, certain key steps cannot be skipped when the goal is a successful implementation; and 3) research can be an external asset for clinical teams as they struggle to deliver care during periods of crisis.

Conclusion

Peer support initiatives in homelessness can be implemented in the Canadian context during periods of crisis-for example, the COVID-19 pandemic-for health and social care services. Moreover, the concept of crisis itself can be reexamined by clinical and research teams worldwide as potentially enabling the implementation of novel initiatives.

Effectiveness of psychosocial intervention and functionality among homeless persons with mental illness

BACKGROUND

Homelessness is a deeply ingrained aspect of our culture. It has a detrimental influence on people of all ages' physical and mental well-being, child development, academic success and the establishment and upkeep of families. Homelessness and mental illness have a reciprocal relationship that makes them two interrelated social issues that affect people's ability to function and communities all over the world.

METHODS

The study followed a Quasi-experimental research design - Pre and Post without control group, conducted in an urban rehabilitation center. A basic random sampling technique was used to select a sample of the respondents. All eligible participants who gave their consent were given the WHO Disability Assessment Schedule (WHODAS 2.0) and a semi-structured interview schedule. Statistics procedures used frequency distribution and inferential statistics such as t-tests, chi-square and correlation.

RESULTS

The results of the study show that the majority of the respondents (60.00%) were in the age group 20 to 40 years, 73.3% were male, 50% were married, 62.7% had no children and their educational status shows that the majority of them (63.3%) were literate 56.7% were unemployed prior to institutionalisation. The mean percentage of disability of the respondents followed by the intervention (30.9 ± 16.4) was found to be significantly lesser than (t = 11.6, df = 29, p < .001) their level of disability (52.7 ± 17.8) before the psychosocial intervention. A significant negative correlation exists between disability and income (r = -.48, p < .01).

DISCUSSION

Psychosocial intervention plays an essential role in enhancing functionality among homeless persons with mental illness in terms of self-help skills, social skills development, casework, group work, working with family and community and networking with community-based organisations to develop a support system. The present study revealed a significant negative correlation between disability and income.

Healthcare workers' perspectives on a prescription phone program to meet the health equity needs of patients in the emergency department: a qualitative study

OBJECTIVES

People experiencing homelessness and marginalization face considerable barriers to accessing healthcare services. Increased reliance on technology within healthcare has exacerbated these inequities. We evaluated a hospital-based prescription phone program aimed to reduce digital health inequities and improve access to services among marginalized patients in Emergency Departments. We examined the perceived outcomes of the program and the contextual barriers and facilitators affecting outcomes.

METHODS

We conducted a constructivist qualitative program evaluation at two urban, academic hospitals in Toronto, Ontario. We interviewed 12 healthcare workers about their perspectives on program implementation and outcomes and analyzed the interview data using reflexive thematic analysis.

RESULTS

Our analyses generated five interrelated program outcomes: building trust with patients, facilitating independence in healthcare, bridging sectors of care, enabling equitable care for marginalized populations, and mitigating moral distress among healthcare workers. Participants expressed that phone provision is critical for adequately serving patients who face barriers to accessing health and social services, and for supporting healthcare workers who often lack resources to adequately serve these patients. We identified key contextual enablers and challenges that may influence program outcomes and future implementation efforts.

CONCLUSIONS

Our findings suggest that providing phones to marginalized patient populations may address digital and social health inequities; however, building trusting relationships with patients, understanding the unique needs of these populations, and operating within a biopsychosocial model of health are key to program success.

Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review

BACKGROUND

Homelessness creates a significant social and economic burden in the society. Homelessness and mental illness are two interconnected social issues that poses challenges to individuals and communities across the globe. This systematic review aims to synthesize the existing literature on interventions for the homeless persons with mental illness.

OBJECTIVES

To systematically review the existing literature on psychosocial interventions for homeless persons with mental illness.

SEARCH METHODS

Five databases including PubMed, ProQuest, Cochrane Library, OVID, and Google Scholar were searched using homelessness, psychosocial interventions, mental ill, residential mental health facility, and case management for experimental studies published from January 2000 to December 2022.

STUDY SELECTION

Abstract review was conducted for the screened studies, and full-text review was done for studies which met inclusion exclusion criteria.

DATA EXTRACTION AND ANALYSIS

Among the 6,387 studies screened 20 studies were selected which fulfilled inclusion criteria. The full text review yielded data of 12,174 homeless persons with mental illness who undergone intervention.

RESULTS

The major psychosocial interventions found including critical time intervention, case management, housing support intervention, assertive community treatment, and life skills training. These interventions were helpful in sustaining housing stability, preventing relapse, reducing hospitalizations, and improving quality of life of the homeless persons with mental illness.

CONCLUSION

Targeted and integrated interventions addressing homelessness and mental illness are required to tackle the social problems of homelessness and mental illness. Further research is required to explore the most effective strategies that address homelessness and mental illness.

Housing status and accidental substance-related acute toxicity deaths in Canada, 2016-2017

INTRODUCTION

There is a complex relationship between housing status and substance use, where substance use reduces housing opportunities and being unhoused increases reasons to use substances, and the associated risks and stigma.

METHODS

In this descriptive analysis of people without housing who died of accidental substance-related acute toxicity in Canada, we used death investigation data from a national chart review study of substance-related acute toxicity deaths in 2016 and 2017 to compare sociodemographic factors, health histories, circumstances of death and substances contributing to death of people who were unhoused and people not identified as unhoused, using Pearson chi-square test. The demographic distribution of people who died of acute toxicity was compared with the 2016 Nationally Coordinated Point-In-Time Count of Homelessness in Canadian Communities and the 2016 Census.

RESULTS

People without housing were substantially overrepresented among those who died of acute toxicity in 2016 and 2017 (8.9% versus <1% of the overall population). The acute toxicity event leading to death of people without housing occurred more often in an outdoor setting (24%); an opioid and/or stimulant was identified as contributing to their death more frequently (68%-82%; both contributed in 59% of their deaths); and they were more frequently discharged from an institution in the month before their death (7%).

CONCLUSION

We identified several potential opportunities to reduce acute toxicity deaths among people who are unhoused, including during contacts with health care and other institutions, through harm reduction supports for opioid and stimulant use, and by creating safer environments for people without housing.

Examining the experiences of vulnerably housed patients visiting Kingston, Ontario's emergency departments: a qualitative analysis

INTRODUCTION

Vulnerably housed individuals access emergency departments (EDs) more frequently than the general population. Despite Canada's universal public health care system, vulnerably housed persons face structural barriers to care and experience discrimination from healthcare providers. This study examines how vulnerably housed persons perceive their experience of care in the ED and Urgent Care Center (UCC) in Kingston, Ontario and aims to develop strategies for improving care for this group.

METHODS

As part of a larger mixed-methods study, narratives were collected from participants attending the ED/UCC as well as community-based partner organizations, asking them to describe an experience of a recent ED visit (< 24 months). Participants could identify as members of up to three equity-deserving groups (EDGs) (for example homeless, part of an ethnic minority, having a disability, experiencing mental health issues). Coding and thematic analysis were completed for the experiences of participants who identified as being vulnerably housed (n = 171). Results were presented back to individuals with lived experience and service providers working with clients with unstable housing.

RESULTS

Participants reported judgement related to a past or presumed history of mental health or substance use and based on physical appearance. They also often felt unheard and that they were treated as less than human by healthcare providers. Lack of effective communication about the ED process, wait times, diagnosis, and treatment led to negative care experiences. Participants reported positive experiences when their autonomy in care-decision making was respected. Furthermore, having a patient-centered approach to care and addressing specific patient needs, identities and priorities led to positive care experiences.

CONCLUSIONS

The ED care experiences of vulnerably housed persons may be improved through healthcare provider training related to trauma-informed and patient-centered care and communication strategies in the ED. Another potential strategy to improve care is to have advocates accompany vulnerably housed persons to the ED. Finally, improving access to primary care may lead to reduced ED visits and better longitudinal care for vulnerably housed persons.

BETTER LIFE- guidelines for chronic disease preventive care for people aged 18-39 years: a literature review

BACKGROUND

The original 'BETTER' (Building on Existing Tools To Improve Chronic Disease Prevention and Screening in Primary Care) approach consisted of a prevention-focused visit between participants aged 40-65 years and a "Prevention Practitioner" (PP), who empowered the participant to set achievable prevention and screening goals for cancers and chronic diseases. BETTER was successfully adapted for economically deprived communities (BETTER HEALTH) in Canada. Our objective was to conduct a review of guidelines in preparation for adapting the 'BETTER HEALTH' approach for younger adults aged 18-39 years living with lower income, a group known to have earlier mortality due to a higher prevalence of preventable chronic diseases than their peers with higher income.

METHODS

We searched multiple electronic databases and grey literature for clinical practice guidelines on prevention/screening and included those that met the following criteria: published in English from 2008-2020 in Canada or any of the following countries (Australia, Ireland, New Zealand, Scotland, United States and England); and addressed prevention or screening. We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and extracted data (publication details, recommendations, and Quality/Level of evidence as reported by authors) from sources with overall scores of 5 or higher. Final recommendations were compiled after harmonization with input from diverse stakeholders (co-investigators, PPs, and the Community Advisory Committee).

RESULTS

We included a total of 85 guidelines, and developed a final list of 42 recommendations for 18-39 year-olds across 21 topics. Specific recommendations fell under the following topics: cancers, cardiovascular disease, diabetes, obesity, lifestyle (alcohol; healthy nutrition/physical activity); healthy relationships and healthy sexuality, immunization, oral health, social determinants of health, and substance use.

CONCLUSION

We identified evidence-based guidelines on individual-level prevention/screening actions for adults 18-39 years old and relevant for those living with lower income which will directly inform development and implementation of the BETTER LIFE intervention.

Cancer risk factors and access to cancer prevention services for people experiencing homelessness

Cancer is one of the most pressing global health issues, and populations with complex needs, such as people experiencing homelessness, have higher cancer incidence and mortality rates compared with the housed population. We mapped the evidence on cancer risk factors as well as barriers and facilitators to cancer prevention services among people experiencing homelessness, which is key to localising research gaps and identifying strategies for tailored interventions adapted to people experiencing homelessness. The results of 40 studies contribute to an understanding of the dynamic, interactive factors at different levels that determine access to cancer prevention services: socioeconomic, psychological, and physical factors (individual level); practical support and relational loops between health-care providers and people experiencing homelessness (interpersonal level); housing and regular medical care (system level); and interventions to facilitate access to cancer prevention (policy level). Furthermore, studies reported higher prevalence of various cancer-associated risk factors among people experiencing homelessness with the most common being tobacco use, ranging from 26% to 73%. The results show the importance of interventions to facilitate cancer prevention services through social support and low-threshold interventions (eg, navigation programmes), and training health-care staff in creating supportive and trusting environments that increase the likelihood of the continuity of care among people experiencing homelessness.

Operationalizing the GRADE-equity criterion to inform guideline recommendations: application to a medical cannabis guideline

OBJECTIVES

Incorporating health equity considerations into guideline development often requires information beyond that gathered through traditional evidence synthesis methodology. This article outlines an operationalization plan for the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-equity criterion to gather and assess evidence from primary studies within systematic reviews, enhancing guideline recommendations to promote equity. We demonstrate its use in a clinical guideline on medical cannabis for chronic pain.

STUDY DESIGN AND SETTING

We reviewed GRADE guidance and resources recommended by team members regarding the use of evidence for equity considerations, drafted an operationalization plan, and iteratively refined it through team discussion and feedback and piloted it on a medicinal cannabis guideline.

RESULTS

We propose a seven-step approach: 1) identify disadvantaged populations, 2) examine available data for specific populations, 3) evaluate population baseline risk for primary outcomes, 4) assess representation of these populations in primary studies, 5) appraise analyses, 6) note barriers to implementation of effective interventions for these populations, and 7) suggest supportive strategies to facilitate implementation of effective interventions.

CONCLUSION

Our approach assists guideline developers in recognizing equity considerations, particularly in resource-constrained settings. Its application across various guideline topics can verify its feasibility and necessary adjustments.

An Understated Comorbidity: The Impact of Homelessness on Traumatic Brain Injury

Traumatic brain injury (TBI), a neurovascular injury caused by external force, is a common diagnosis among veterans and those experiencing homelessness (HL). There is a significant overlap in the veteran and homeless population, possibly accounting for the two to seven times greater incidence of TBI among those experiencing HL than the general population. Despite these statistics, individuals experiencing HL are often underdiagnosed and ineffectively treated for TBI. We introduced a novel model of HL. Over 5 weeks, adult Sprague-Dawley rats were randomly assigned to one of the following conditions: TBI only, HL only, TBI + HL, or control (n = 9 per group). To emulate HL, animals (2 animals per cage) were exposed to soiled beddings for 5 weeks. Subsequently, animals were introduced to TBI by using the moderate controlled cortical impact model, then underwent 4 consecutive days of behavioral testing (beam walk (BW), elevated body swing test (EBST), forelimb akinesia (FA), paw grasp (PG), Rotorod, and elevated T-maze). Nissl staining was performed to determine the peri-impact cell survival and the integrity of corpus callosum area. Motor function was significantly impaired by TBI, regardless of housing (beam walk or BW 85.0%, forelimb akinesia or FA 104.7%, and paw grasp or PG 100% greater deficit compared to control). Deficits were worsened by HL in TBI rats (BW 93.3%, FA 40.5%, and PG 50% greater deficit). Two-way ANOVA revealed BW (F(4, 160) = 31.69, p < 0.0001), FA (F(4, 160) = 13.71, p < 0.0001), PG (F(4, 160) = 3.873, p = 0.005), Rotorod (F(4, 160), p = 1.116), and EBST (F(4, 160) = 6.929, p < 0.0001) showed significant differences between groups. The Rotorod and EBST tests showed TBI-induced functional deficits when analyzed by day, but these deficits were not exacerbated by HL. TBI only and TBI + HL rats exhibited typical cortical impact damage (F(3,95) = 51.75, p < 0.0001) and peri-impact cell loss compared to control group (F(3,238) = 47.34, p < 0.0001). Most notably, TBI + HL rats showed significant alterations in WM area measured via the corpus callosum (F(3, 95) = 3.764, p = 0.0133). Worsened behavioral outcomes displayed by TBI + HL rats compared to TBI alone suggest HL contributes to TBI functional deficits. While an intact white matter, such as the corpus callosum, may lessen the consequent functional deficits associated with TBI by enhancing hemispheric communications, there are likely alternative cellular and molecular pathways mitigating TBI-associated inflammatory or oxidative stress responses. Here, we showed that the environmental condition of the patient, i.e., HL, participates in white matter integrity and behavioral outcomes, suggesting its key role in the disease diagnosis to aptly treat TBI patients.

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review

Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized. This rapid review aimed to identify the housing-related outcomes of high-risk behaviours and challenges in permanent supportive housing settings, as well as the approaches used by agencies and residents to address them. A range of high-risk behaviours and challenges were examined, including risks to self (overdose, suicide/suicide attempts, non-suicidal self-injury, falls/fall-related injuries), and risks to multiple parties and/or building (fire-setting/arson, hoarding, apartment takeovers, physical/sexual violence, property damage, drug selling, sex trafficking). The search strategy included four components to identify relevant academic and grey literature: (1) searches of MEDLINE, APA PsycINFO, and CINAHL Plus; (2) hand searches of three journals with aims specific to housing and homelessness; (3) website browsing/searching of seven homelessness, supportive housing, and mental health agencies and networks; and (4) Advanced Google searches. A total of 32 articles were eligible and included in the review. Six studies examined the impacts of high-risk behaviours and challenges on housing tenancies, with overdose being identified as a notable cause of death. Twenty-six studies examined approaches and barriers to managing high-risk behaviours and challenges in PSH programs. These were categorized into eight types of approaches: (1) clinical, (2) relational/educational, (3) surveillant, (4) restrictive, (5) strategic, (6) design-based, (7) legal, and (8) self-defence. Consistent across all approaches was a lack of rigorous examination of their effectiveness. Further, some approaches that are legal, restrictive, surveillant, or strategic in nature may be used to promote safety, but may conflict with other program objectives, including housing stability, or resident empowerment and choice. Research priorities were identified to address the key evidence gaps and move toward best practices for preventing and managing high-risk behaviours and challenges in permanent supportive housing.

Equity considerations in clinical practice guidelines for traumatic brain injury and homelessness: a systematic review

Background

Clinical practice guidelines (CPGs) predominantly prioritise treatment and cost-effectiveness, which encourages a universal approach that may not address the circumstances of disadvantaged groups. We aimed to advance equity and quality of care for individuals experiencing homelessness and traumatic brain injury (TBI) by assessing the extent to which homelessness and TBI are integrated in CPGs for TBI and CPGs for homelessness, respectively, and the extent to which equity, including consideration of disadvantaged populations and the PROGRESS-Plus framework, is considered in these CPGs.

Methods

For this systematic review, CPGs for TBI or homelessness were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of eligible CPGs on November 16, 2021 and March 16, 2023. The proportion of CPGs that integrated evidence regarding TBI and homelessness was identified and qualitative content analysis was conducted to understand how homelessness is integrated in CPGs for TBI and vice versa. Equity assessment tools were utilised to understand the extent to which equity was considered in these CPGs. This review is registered with PROSPERO (CRD42021287696).

Findings

Fifty-eight CPGs for TBI and two CPGs for homelessness met inclusion criteria. Only three CPGs for TBI integrated evidence regarding homelessness by recognizing the prevalence of TBI in individuals experiencing homelessness and identifying housing as a consideration in the assessment and management of TBI. The two CPGs for homelessness acknowledged TBI as prevalent and recognised individuals experiencing TBI and homelessness as a disadvantaged population that should be prioritised in guideline development. Equity was rarely considered in the content and development of CPGs for TBI.

Interpretation

Considerations for equity in CPGs for homelessness and TBI are lacking. To ensure that CPGs reflect and address the needs of individuals experiencing homelessness and TBI, we have identified several guideline development priorities. Namely, there is a need to integrate evidence regarding homelessness and TBI in CPGs for TBI and CPGs for homelessness, respectively and engage disadvantaged populations in all stages of guideline development. Further, this review highlights an urgent need to conduct research focused on and with disadvantaged populations.

Funding

Canada Research Chairs Program (2019-00019) and the Ontario Ministry of Health and Long-Term Care (Grant #725A).

A Pragmatic Randomized Controlled Trial of Financial Incentives in Case Management for Homeless Adults With Mental Illness

OBJECTIVE

Financial incentives can facilitate behavior change and service engagement in health care settings, but research on their use with adults experiencing homelessness is limited. This study examined the effectiveness of financial incentives in improving service engagement and health outcomes among homeless adults with mental illness in Toronto.

METHODS

The authors of this randomized controlled trial recruited 176 participants receiving brief multidisciplinary case management services for homeless adults with mental illness after hospital discharge. In a 1:1 randomization design, 87 participants received a financial incentive of CAN$20 for every week they remained engaged with the service for up to 6 months. The remaining 89 participants received treatment as usual. The primary outcome was service contact rates for up to 6 months of follow-up. Secondary outcomes included self-reported health status, mental health symptoms, substance use, quality of life, housing stability, acute health service use, and working alliance. Negative binomial regression models, analyses of covariance, generalized estimating equations models, and Wilcoxon rank sum tests were used to examine differences between the financial incentive and treatment-as-usual groups across outcomes of interest.

RESULTS

No significant differences were found between the financial incentive and treatment-as-usual groups in service contact rates or any of the secondary outcomes examined over the 6-month period.

CONCLUSIONS

In low-barrier, brief case management programs tailored to the needs of adults experiencing homelessness, financial incentives may not affect service engagement or health outcomes. Further research is needed to identify the effect of financial incentives on engagement in other services, including housing-based interventions.

Partnering with charity-care services to manage cirrhosis with ascites in an adult experiencing homelessness: A case report

Charity care services can be an important tool for reducing healthcare disparities among populations with housing instability.

Homeowner perspectives on the implementation of the Community Homes for Opportunity (CHO) program: an ethnographic group homes study in Southwestern Ontario Canada

BACKGROUND

The global extant literature acknowledge that housing serves as a key social determinant of health. Housing interventions that involve group homes have been found to support the recovery of persons with mental illness and those with addiction issues. The current study explored the views of homeowners in relation to a supportive housing program called Community Homes for Opportunity (CHO) that modernised a provincial group home program (Homes for Special Care [HSC]) and provided recommendations for improving the program implementation in other geographical areas of Ontario.

METHODS

We applied ethnographic qualitative techniques to purposefully recruit 36 homeowner participants from 28 group homes in Southwest Ontario, Ontario Canada. Focus group discussions were conducted at two time points, during CHO program implementation (Fall 2018, and post implementation phases (Winter 2019) respectively.

RESULTS

Data analysis yielded 5 major themes. These include: (1) general impressions about the modernization process, (2) perceived social, economic and health outcomes, (3) enablers of the modernization program, (4) challenges to implementation of the modernization program, and (5) suggestions for implementation of the CHO in future.

CONCLUSIONS

A more effective and expanded CHO program will need the effective collaboration of all stakeholders including homeowners for successful implementation.

Substance use and posttraumatic stress disorder: 12-month outcomes among adults experiencing chronic homelessness in Australia

INTRODUCTION

Substance use disorder and posttraumatic stress disorder (PTSD) are highly prevalent among individuals who experience homelessness. However, evaluations of interventions that combine housing and mental health services have reported inconsistent mental health and substance use outcomes when compared to usual services. We investigated 12-month change in substance use severity and PTSD symptom severity among adults experiencing chronic homelessness and tested whether observed differences were associated with housing, support from mental health services or the Journey to Social Inclusion (J2SI) program.

METHODS

A randomised controlled trial compared the J2SI program with standard service provision (N = 135). Secondary analyses compared those who obtained housing or received mental health services with those who did not. Primary outcomes were alcohol and illicit substance use severity (alcohol, smoking and substance involvement screening test) and PTSD symptom severity (six-item PTSD checklist).

RESULTS

There was significant improvement at 12 months in alcohol use severity, illicit substance use severity and PTSD symptoms in the overall sample. Having seen a mental health professional in the previous 12 months was associated with a significant reduction in alcohol and illicit substance use severity but was not associated with changes in PTSD symptom severity. Being housed at 12 months was associated with significantly higher alcohol use severity.

DISCUSSION AND CONCLUSIONS

Findings highlight the importance of access to mental health care for people with a history of chronic homelessness. Research is needed to develop and test therapeutic and housing approaches to reduce PTSD symptom severity among people with experience of homelessness.

Navigator programme for hospitalised adults experiencing homelessness: protocol for a pragmatic randomised controlled trial

INTRODUCTION

People experiencing homelessness suffer from poor outcomes after hospitalisation due to systemic barriers to care, suboptimal transitions of care, and intersecting health and social burdens. Case management programmes have been shown to improve housing stability, but their effects on broad posthospital outcomes in this population have not been rigorously evaluated. The Navigator Programme is a Critical Time Intervention case management programme that was developed to help homeless patients with their postdischarge needs and to link them with community-based health and social services. This randomised controlled trial examines the impact of the Navigator Programme on posthospital outcomes among adults experiencing homelessness.

METHODS AND ANALYSIS

This is a pragmatic randomised controlled trial testing the effectiveness of the Navigator Programme at an urban academic teaching hospital and an urban community teaching hospital in Toronto, Canada. Six hundred and forty adults experiencing homelessness who are admitted to the hospital will be randomised to receive support from a Homeless Outreach Counsellor for 90 days after hospital discharge or to usual care. The primary outcome is follow-up with a primary care provider (physician or nurse practitioner) within 14 days of hospital discharge. Secondary outcomes include postdischarge mortality or readmission, number of days in hospital, number of emergency department visits, self-reported care transition quality, and difficulties meeting subsistence needs. Quantitative outcomes are being collected over a 180-day period through linked patient-reported and administrative health data. A parallel mixed-methods process evaluation will be conducted to explore intervention context, implementation and mechanisms of impact.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Unity Health Toronto Research Ethics Board. Participants will be required to provide written informed consent. Results of the main trial and process evaluation will be reported in peer-reviewed journals and shared with hospital leadership, community partners and policy makers.

TRIAL REGISTRATION NUMBER

NCT04961762.

Engaging stakeholders to inform national implementation of critical time intervention in a program serving homeless-experienced Veterans

The Veterans Affairs (VA) Grant and Per Diem Case Management "Aftercare" program provides 6 months of case management for homeless-experienced Veterans (HEVs) transitioning to permanent housing, with the aim of decreasing returns to homelessness. Implementing Critical Time Intervention (CTI)-an evidence-based case management practice-would standardize care across the 128 community-based agencies that provide Aftercare services. To prepare for national CTI implementation in Aftercare, guided by Replicating Effective Programs (REP), we conducted a four-site pilot in which we adapted a CTI implementation package (training, technical assistance, and external facilitation); characterized stakeholder perspectives regarding the acceptability and appropriateness of this package; and identified contextual factors that affected CTI implementation. We engaged a stakeholder workgroup to tailor existing CTI training and technical assistance materials for Aftercare. To provide tailored support for providers and leaders to adopt and incorporate evidence-based practices (EBPs) into routine care, we also developed external facilitation materials and processes. Over 9 months, we implemented this package at four sites. We conducted semi-structured interviews at pre-implementation, mid-implementation, and 6 months post-implementation, with HEVs (n = 37), case managers (n = 16), supervisors (n = 10), and VA leaders (n = 4); these data were integrated with templated reflection notes from the project facilitator. We used rapid qualitative analysis and targeted coding to assess the acceptability and appropriateness of CTI and our implementation package and identify factors influencing CTI implementation. Stakeholders generally found CTI acceptable and appropriate; there was consensus that components of CTI were useful and compatible for this setting. To adapt our implementation package for scale-up, this pilot highlighted the value of robust and tangible CTI training and technical assistance-grounded in real-world cases-that highlights the congruence of CTI with relevant performance metrics. Variations in agency-level contextual factors may necessitate more intense and tailored supports to implement and sustain complex EBPs like CTI. Processes used in this pilot are relevant for implementing other EBPs in organizations that serve vulnerable populations. EBP scale-up and sustainment can be enhanced by engaging stakeholders to tailor EBPs for specific contexts; pilot testing and refining implementation packages for scale-up; and using qualitative methods to characterize contextual factors that affect EBP implementation.

A comparison of the COVID-19 response for urban underserved patients experiencing healthcare transitions in three Canadian cities

OBJECTIVES

The COVID-19 pandemic and response has highlighted existing strengths within the system of care for urban underserved populations, but also many fault lines, in particular during care transitions. The objectives of this study were to describe COVID-19 response policies for urban underserved populations in three Canadian cities; examine how these policies impact continuity of care for urban underserved populations; determine whether and how urban underserved community members were engaged in policy processes; and develop policy and operational recommendations for optimizing continuity of care for urban underserved populations during public health crises.

METHODS

Using Walt & Gilson's Policy Triangle framework as a conceptual guide, 237 policy and media documents were retrieved. Five complementary virtual group interview sessions were held with 22 front-line and lived-experience key informants to capture less well-documented policy responses and experiences. Documents and interview transcripts were analyzed inductively for policy content, context, actors, and processes involved in the pandemic response.

RESULTS

Available documents suggest little focus on care continuity for urban underserved populations during the pandemic, despite public health measures having disproportionately negative impacts on their care. Policy responses were largely reactive and temporary, and community members were rarely involved. However, a number of community-based initiatives were developed in response to policy gaps. Promising practices emerged, including examples of new multi-level and multi-sector collaboration.

CONCLUSION

The pandemic response has exposed inequities for urban underserved populations experiencing care transitions; however, it has also exposed system strengths and opportunities for improvement to inform future policy direction.

Rehabilitation among individuals experiencing homelessness and traumatic brain injury: A scoping review

Traumatic brain injury (TBI) is disproportionately prevalent among individuals experiencing homelessness. While rehabilitation is critical to facilitating recovery after TBI, there is currently limited information on the extent to which rehabilitation is provided to individuals experiencing homelessness and TBI. If unaddressed, this knowledge gap can perpetuate TBI-related challenges and contribute to a repetitive cycle of TBI and homelessness. This scoping review explored the extent to which rehabilitation, including the types of rehabilitation interventions, are available to, or used by, individuals experiencing homelessness and TBI. A systematic search of electronic databases (MEDLINE, Embase, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Applied Social Sciences Index and Abstracts, and Proquest Nursing and Allied Health) was conducted to identify peer-reviewed articles that met predetermined eligibility criteria. Gray literature and reference lists of eligible articles were also searched for relevant content. A descriptive numerical summary of extracted data was conducted, and qualitative analytic techniques were applied to analyze the data. Fifteen peer-reviewed articles and three gray literature reports were included, describing interventions for individuals experiencing homelessness and TBI (N = 4), rehabilitation for individuals experiencing homelessness without specific inclusion criteria for TBI (N = 11), and rehabilitation interventions that included individuals experiencing homelessness and TBI, without specific inclusion criteria for experiences of homelessness or TBI (N = 3). This review demonstrates that rehabilitation programs or interventions for this population already exist, and those that are focused on individuals experiencing homelessness are already serving individuals with TBI. Findings highlight opportunities to adapt existing rehabilitation for individuals who experience homelessness and TBI through screening for TBI, conducting cognitive and functional assessments, and tailoring interventions with multidisciplinary teams. Education and training for healthcare professionals working with individuals experiencing homelessness and TBI should be explored, including structured education and training, collaboration with a multidisciplinary team, and co-development of educational materials with service users. Research that considers the rehabilitation needs of diverse individuals experiencing homelessness and TBI is urgently needed.

Primary care embedded within permanent supportive housing for people who use substances: A qualitative study examining healthcare access in Vancouver, Canada

Marginally housed people who use drugs and alcohol (PWUD/A) face barriers in accessing healthcare services, which may be improved by providing healthcare in housing settings. This case study examines the experiences of healthcare access amongst PWUD/A who live in a permanent supportive housing model in Vancouver, Canada. This model has an embedded multidisciplinary clinic providing in-reach services. Thirty participants were recruited via posters placed throughout the building and semi-structured qualitative interviews were conducted remotely. Interviews were conducted with participants who accessed onsite care regularly (n = 15) and those who do not (n = 15). Data were analysed to identify both a priori and emerging themes. Participants who accessed the onsite clinic reported benefiting from stigma-free care. Close proximity and convenience of drop-in appointments enabled participants to engage with healthcare services more consistently, though hours of operation and privacy concerns were barriers for others. Participants who did not use the onsite clinic highlighted the importance of continuity of care with their pre-existing primary care team, particularly if their clinic was in close geographic proximity. However, they also described utilising these services for urgent health needs or as an occasional alternative source of care. Shared perspectives across all participants emphasised the importance of low-barrier services, including medication delivery, convenience and positive therapeutic relationships. Our findings suggest that embedding access to primary care within supportive housing benefits PWUD/A who have previously encountered barriers to healthcare access. This model could be implemented to prevent utilisation of acute healthcare resources and improve health outcomes amongst PWUD/A.

Determinants of Hospital Use and Physician Services Among Adults With a History of Homelessness

Background:

People experiencing homelessness have diverse patterns of healthcare use. This study examined the distribution and determinants of healthcare encounters among adults with a history of homelessness.

Methods:

Administrative healthcare records were linked with survey data for a general cohort of adults with a history of homelessness and a cohort of homeless adults with mental illness. Binary and count models were used to identify factors associated with hospital admissions, emergency department visits and physician visits for comparison across the 2 cohorts.

Results:

During the 1-year follow-up period, a higher proportion of people in the cohort with a mental illness used any inpatient (27% vs 14%), emergency (63% vs 53%), or physician services (90% vs 76%) compared to the general homeless cohort. People from racialized groups were less likely use nearly all health services, most notably physician services. Other factors, such as reporting of a regular source of care, poor perceived general health, and diagnosed chronic conditions were associated with higher use of all health services except psychiatric inpatient care

Conclusion:

When implementing interventions for patients with the greatest health needs, we must consider the unique factors that contribute to higher healthcare use, as well as the barriers to healthcare access.

Social service providers' perspectives on caring for structurally vulnerable hospital patients who use drugs: a qualitative study

Background

People who use drugs and are structurally vulnerable (e.g., experiencing unstable and/or lack of housing) frequently access acute care. However, acute care systems and providers may not be able to effectively address social needs during hospitalization. Our objectives were to: 1) explore social service providers’ perspectives on addressing social needs for this patient population; and 2) identify what possible strategies social service providers suggest for improving patient care.

Methods

We completed 18 semi-structured interviews with social service providers (e.g., social workers, transition coordinators, peer support workers) at a large, urban acute care hospital in Western Canada between August 8, 2018 and January 24, 2019. Interviews explored staff experiences providing social services to structurally vulnerable patients who use drugs, as well as continuity between hospital and community social services. We conducted latent content analysis and organized our findings in relation to the socioecological model.

Results

Tensions emerged on how participants viewed patient-level barriers to addressing social needs. Some providers blamed poor outcomes on perceived patient deficits, while others emphasized structural factors that impede patients’ ability to secure social services. Within the hospital, some participants felt that acute care was not an appropriate location to address social needs, but most felt that hospitalization affords a unique opportunity to build relationships with structurally vulnerable patients. Participants described how a lack of housing and financial supports for people who use drugs in the community limited successful social service provision in acute care. They identified potential policy solutions, such as establishing housing supports that concurrently address medical, income, and substance use needs.

Conclusions

Broad policy changes are required to improve care for structurally vulnerable patients who use drugs, including: 1) ending acute care’s ambivalence towards social services; 2) addressing multi-level gaps in housing and financial support; 3) implementing hospital-based Housing First teams; and, 4) offering sub-acute care with integrated substance use management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08498-x.

Photo elicitation to explore health and social exclusion with rooming house residents in Ottawa, Canada

Little is known about how rooming house residents perceive how housing influences their health, despite higher morbidity and premature death compared to other Canadians. The social exclusion framework of the Social Knowledge Exchange Network (SEKN) conceptualized by Popay et al. (2008) was used to investigate how rooming houses are linked to health among ten rooming house residents from six rooming houses in Ottawa, Ontario, Canada. Study activities included taking photos to show how living in a rooming house affects health, a community walk-about with the principal investigator, a focus group, and individual interviews. Thematic analysis revealed two broad themes: Housing is Health Care, and Just Managing Today. Findings suggest that structural inequalities and siloed care contribute to the health of rooming house residents, including the balance between poverty and desire to maintain housing, and how residents cope with this stress. If health care providers want to help alleviate the disparities in rooming house residents' health, they need to broaden the lens through which health is conceptualized.

A systematic review protocol for assessing equity in clinical practice guidelines for traumatic brain injury and homelessness

Background

When used optimally, clinical practice guidelines (CPGs) can reduce inappropriate variations in practice, improve application of research to practice, and enhance the quality of healthcare. However, a common criticism, despite its potential, is the lack of consideration for equity and disadvantaged populations.

Objectives

This protocol is for a systematic review of CPGs for traumatic brain injury (TBI) and homelessness that aims to assess (1) the extent to which evidence regarding TBI and homelessness is integrated in CPGs for homelessness and TBI, respectively, and (2) equity considerations in CPGs for TBI and homelessness.

Methods and analysis

The methodology for this review is guided by the PRISMA-P, validated search filters for CPGs, and methodological guides to searching systematic reviews and gray literature. CPGs will be identified from (a) databases for peer-reviewed literature (MEDLINE, Embase, CINAHL, and PsycInfo), (b) targeted websites and Google Search for gray literature, and (c) reference lists of peer-reviewed and gray literature that meet the eligibility criteria. Searching for gray literature, including from guideline-specific resources, is a critical component of this review and is considered an efficient approach to identifying CPGs, given the low precision of searching peer-reviewed databases. Two independent reviewers will screen all articles based on pre-determined eligibility criteria. A narrative synthesis will be conducted to identify the proportion of CPGs that integrate evidence about TBI and homelessness and how TBI and homelessness is or is not integrated in CPGs. Quality appraisal will take the form of an equity assessment of CPGs and will be completed independently by two reviewers.

Conclusion

This protocol outlines the methodology for a systematic review of CPGs for TBI and homelessness. The resulting systematic review from this protocol will form an evidence-based foundation to advance CPGs for individuals with lived experience of TBI and homelessness.

Systematic review registration

identifier: CRD42021287696.

Drug Overdoses During the COVID-19 Pandemic Among Recently Homeless Individuals

AIMS

To examine how weekly rates of emergency department (ED) visits for drug overdoses changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the pre-pandemic, peak, and re-opening periods of the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control.

DESIGN

Population-based retrospective cohort study conducted between September 30, 2018 and September 26, 2020.

SETTING

Ontario, Canada.

PARTICIPANTS

A total of 38 617 IRHH, 15 022 369 housed individuals, and 186 858 low-income housed individuals matched on age, sex, rurality, and comorbidity burden.

MEASUREMENTS

ED visits for drug overdoses of accidental and undetermined intent.

FINDINGS

Average rates of ED visits for drug overdoses between January and September 2020 were higher among IRHH compared with housed individuals (rate ratio [RR], 148.0; 95% CI, 142.7-153.5) and matched housed individuals (RR, 22.3; 95% CI, 20.7-24.0). ED visits for drug overdoses decreased across all groups by ~20% during the peak period (March 17 to June 16, 2020) compared with corresponding weeks in 2019. During the re-opening period (June 17 to September 26, 2020), rates of ED visits for drug overdoses were significantly higher among IRHH (RR, 1.56; 95% CI, 1.44-1.69), matched housed individuals (RR, 1.25; 95% CI, 1.08-1.46), and housed individuals relative to equivalent weeks in 2019 (RR, 1.07; 95% CI, 1.02-1.11). The relative increase in drug overdose ED visits among IRHH was larger compared with both matched housed individuals (P = 0.01 for interaction between group and year) and housed individuals (P < 0.001) during this period.

CONCLUSIONS

Recently homeless individuals in Ontario, Canada experienced disproportionate increases in ED visits for drug overdoses during the re-opening period of the COVID-19 pandemic compared with housed people.

Hospitalizations During the COVID-19 Pandemic Among Recently Homeless Individuals: a Retrospective Population-Based Matched Cohort Study

BACKGROUND

Hospitalizations fell precipitously among the general population during the COVID-19 pandemic. It remains unclear whether individuals experiencing homelessness experienced similar reductions.

OBJECTIVE

To examine how overall and cause-specific hospitalizations changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control.

DESIGN

Population-based cohort study conducted in Ontario, Canada, between September 30, 2018, and September 26, 2020.

PARTICIPANTS

In total, 38,617 IRHH, 15,022,368 housed individuals, and 186,858 low-income housed individuals matched on age, sex, rurality, and comorbidity burden.

MAIN MEASURES

Primary outcomes included medical-surgical, non-elective (overall and cause-specific), elective surgical, and psychiatric hospital admissions.

KEY RESULTS

Average rates of medical-surgical (rate ratio: 3.8, 95% CI: 3.7-3.8), non-elective (10.3, 95% CI: 10.1-10.4), and psychiatric admissions (128.1, 95% CI: 126.1-130.1) between January and September 2020 were substantially higher among IRHH compared to housed individuals. During the peak period (March 17 to June 16, 2020), rates of medical-surgical (0.47, 95% CI: 0.47-0.47), non-elective (0.80, 95% CI: 0.79-0.80), and psychiatric admissions (0.86, 95% CI: 0.84-0.88) were significantly lower among housed individuals relative to equivalent weeks in 2019. No significant changes were observed among IRHH. During the re-opening period (June 17-September 26, 2020), rates of non-elective hospitalizations for liver disease (1.41, 95% CI: 1.23-1.69), kidney disease (1.29, 95% CI: 1.14-1.47), and trauma (1.19, 95% CI: 1.07-1.32) increased substantially among IRHH but not housed individuals. Distinct hospitalization patterns were observed among IRHH even in comparison with more medically and socially vulnerable matched housed individuals.

CONCLUSIONS

Persistence in overall hospital admissions and increases in non-elective hospitalizations for liver disease, kidney disease, and trauma indicate that the COVID-19 pandemic presented unique challenges for recently homeless individuals. Health systems must better address the needs of this population during public health crises.

Family matters in Canada: understanding and addressing family homelessness in Ontario

Background

Homelessness is becoming an international public health issue in most developed countries, including Canada. Homelessness is regarded as both political and socioeconomic problems warranting broad and consistent result-oriented approaches.

Methods

This paper represents the qualitative findings of a project that explored risk factors associated with family homelessness and strategies that could mitigate and prevent homelessness among families using a focused ethnographic study guided by the principles of participatory action research (PAR). The sample includes 36 family members residing at a family shelter who participated in focus groups over two years (between April 2016 and December 2017). Most of the participants were single-parent women.

Results

The analysis yielded five major themes including, life challenges, lack of understanding of the system, existing power differentials, escaping from hardship, and a theme of proposed solutions for reducing family homelessness in the community.

Conclusion

The findings illustrated the complex nature of family homelessness in Ontario; that the interaction of multiple systems can put families at risk of homelessness. Findings from this study underscore the need for urgent housing protocols aimed at educating homeless families on how to navigate and understand the system, enhance their conflict resolution skills, and develop strategies beyond relocation to help them to cope with difficulties with housing.

Interventions to treat post-traumatic stress disorder (PTSD) in vulnerably housed populations and trauma-informed care: a scoping review

OBJECTIVES

The goals of this study are to identify and analyse interventions that aim to treat post-traumatic stress disorder (PTSD) and complex PTSD in people who are vulnerably housed and to describe how these treatments have been delivered using trauma-informed care.

DESIGN

Scoping review.

SEARCH STRATEGY

We searched electronic databases including MEDLINE, Embase, PsycINFO, CINAHL, the Cochrane Library, Web of Science and PTSDpubs for published literature up to November 2021 for any studies that examined the treatment of PTSD in adults who were vulnerably housed. Websites of relevant organisations and other grey literature sources were searched to supplement the electronic database search. The characteristics and effect of the interventions were analysed. We also explored how the interventions were delivered and the elements of trauma-informed care that were described.

RESULTS

28 studies were included. We identified four types of interventions: (1) trauma focused psychotherapies; (2) non-trauma psychotherapies; (3) housing interventions and (4) pharmacotherapies. The trauma-informed interventions were small case series and the non-trauma focused therapies included four randomised controlled trials, were generally ineffective. Of the 10 studies which described trauma-informed care the most commonly named elements were physical and emotional safety, the experience of feeling heard and understood, and flexibility of choice. The literature also commented on the difficulty of providing care to this population including lack of private space to deliver therapy; the co-occurrence of substance use; and barriers to follow-up including limited length of stay in different shelters and high staff turnover.

CONCLUSIONS

This scoping review identified a lack of high-quality trials to address PTSD in people who are vulnerably housed. There is a need to conduct well designed trials that take into account the unique setting of this population and which describe those elements of trauma-informed care that are most important and necessary.

Standardized wording to improve efficiency and clarity of GRADE EtD frameworks in health guidelines

BACKGROUND

Grading of Recommendations Assessment, Development and Evaluation (GRADE)Evidence-to-Decision (EtDs) frameworks are increasingly applied by health guideline developers to improve the use of evidence and transparency of health recommendations. Typically, EtDs include 12 criteria but these are flexible and EtDs have been adapted to different types of health decisions. However, developers of health recommendations struggle with the content that they should include in the EtD. The goal of this work was to provide a standardized template that facilitate the development of GRADE EtDs in health guidelines and examples for practical training.

METHODS

We began by establishing the need for standardized wording templates in 10 American Society of Hematology guidelines with over 250 recommendations. We drafted template wording, and examples, and sought iterative feedback from methodologists and guideline panels in this guideline and two additional guidelines.

RESULTS

We generated templates for all EtD criteria describing the type of research evidence considered, ideally based on systematic reviews, using standardized reporting of effect size, integrating the certainty of evidence and addition additional considerations. We also produced templates to inform the completion of the EtD conclusions section that includes recommendations, justification, implementation considerations, monitoring and evaluation and research priorities.

CONCLUSION

We have taken an applied approach to develop a pragmatic and useful tool to support clarity, transparency, and efficiency of the guideline GRADE EtD process.

Workplace trauma and chronic stressor exposure among direct service providers working with people experiencing homelessness

BACKGROUND

Service providers working with people experiencing homelessness can be directly and indirectly exposed to trauma and other chronic stressors in their work. The types of individuals that are most at-risk of problematic outcomes from traumatic event exposure are unknown.

AIM

This study examined exposure to and effects of workplace traumas and stressors among service providers working with people experiencing homelessness in Canada.

METHODS

A cross-sectional survey was completed by 701 direct service providers working in the homeless service, supportive housing, and harm reduction sectors. Descriptive statistics, hierarchical multiple regression, and double moderation models were used in the analysis.

RESULTS

Employment in homeless service settings, service provision to single adults, and more time in direct contact with service users were each positively associated with the frequency of exposure to critical events and chronic stressors. Younger age, lived experience of behavioural health problems, more frequent exposure to chronic stressors, and less social support from coworkers were significantly correlated with post-traumatic stress and general psychological distress. Emotional support from supervision moderated the relationship between direct exposure to workplace critical events and post-traumatic stress.

CONCLUSIONS

More trauma-informed psychosocial supports tailored to the needs of direct service providers working with people experiencing homelessness are needed.

Perceptions of Homeless Adults and Their Providers on Coping With the Impact of COVID-19 Pandemic on Mental Health, Substance Use, and Harm Reduction Services

Adults experiencing homelessness experience a disproportionate burden of health disparities which has further exacerbated mental health, substance use, and coping during the COVID-19 pandemic. As limited data is available to understand the experience of adults experiencing homelessness and their health during this time, the purpose of this study was to explore how COVID-19 may have impacted their mental health, substance use, and ways of coping in this population. Using community-based participatory research, a community advisory board was established and remote individual interviews with 21 adults experiencing homelessness and 10 providers were conducted in Skid Row, Los Angeles. Using a qualitative, data analytic approach, the following major themes emerged: (1) Negative Impact of COVID-19 on Mental Health; (2) Negative Impact of COVID-19 on Limitation of Harm Reduction Services; and (3) Coping Strategies Utilized During the COVID-19 Pandemic. More research is needed to understand the impact of this pandemic on underserved communities.

Health services and the Project RoomKey COVID-19 initiative for the unhoused: A university and community partnership

A hotel-based clinic to serve Project RoomKey residents is a model for meeting the health care needs of an unhoused population. The purpose of this paper is to describe the health services provided by students and licensed clinicians at a hotel that was designed to allow unhoused community residents to shelter in place during the early stages of the Covid pandemic (May 1–June 30, 2020). Documents developed for the project may be useful to others who are setting up similar services for unhoused residents in their own communities.

Protocol for a scoping review on rehabilitation among individuals who experience homelessness and traumatic brain injury

INTRODUCTION

Rehabilitation is key to improving outcomes and quality of life after traumatic brain injury (TBI). However, individuals experiencing homelessness are rarely represented in research that informs evidence-based rehabilitation guidelines even though TBI is disproportionately prevalent among this population. This protocol is for a scoping review to explore the extent to which rehabilitation, including the types of rehabilitation interventions, is available to, or used by, individuals who experience homelessness and TBI to inform (1) opportunities to integrate rehabilitation for individuals experiencing homelessness and TBI, (2) considerations for existing clinical and practice guidelines for rehabilitation and (3) recommendations for future research.

METHODS AND ANALYSIS

The scoping review will be guided by six stages described in scoping review methodology frameworks. Electronic databases (MEDLINE, Embase and Embase Classic, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Applied Social Sciences Index and Abstracts, and Nursing and Allied Health), reference list of included articles and scoping or systematic reviews identified from the search and grey literature, defined as reports from relevant brain injury, housing and rehabilitation organisations, will be searched. Two reviewers will independently screen all articles based on predetermined inclusion and exclusion criteria. A descriptive numerical summary of data items will be provided and qualitative content analytic techniques will be used to identify and report common themes. Preliminary findings will be shared with stakeholders to seek feedback on the implications of the results.

ETHICS AND DISSEMINATION

Ethics review will not be required, as only publicly available data will be analysed. Findings from the scoping review will be published in a peer-reviewed journal and presented at scientific meetings and to stakeholders, defined as service providers in the housing and TBI sectors; health professionals who provide care for individuals with TBI and/or homelessness; health administrators, decision-makers and policy-makers; researchers; and caregivers or family members of individuals with lived experience of TBI and homelessness.

Understanding Dermatologic Concerns Among Persons Experiencing Homelessness: A Scoping Review and Discussion for Improved Delivery of Care

There is a paucity of information surrounding dermatologic care for persons experiencing homelessness (PEH). This scoping review aims to map existing literature and provide a summary of the most common cutaneous manifestations among PEH, risk factors for dermatologic disease, describe any reported interventions, as well as identify research gaps for future studies. Search strategies developed for MEDLINE and hand searching yielded 486 articles. Out of the 486 articles screened, 93 articles met the inclusion criteria. The majority were cohort studies, cross-sectional studies, and case-control studies concentrated in North America and Europe. Excluding the pediatric population, the prevalence of dermatologic conditions ranged from 16.6% to 53.5%. Common skin conditions described in PEH were: acne, psoriasis, seborrheic dermatitis, atopic dermatitis, and lichen simplex chronicus. There were no studies comparing the extent or severity of these cutaneous diseases in PEH and the general population. PEH have a higher prevalence of skin infections and non-melanoma skin cancers. This scoping review has direct implications on public health interventions for PEH and highlights the need for evidence-based interventions to provide optimum and safe dermatologic healthcare for PEH. We propose several recommendations for improved care delivery, including addressing upstream factors and comorbidities impacting skin health, providing trauma informed care, reducing barriers to care, preventing and managing skin conditions, as well as including PEH in the planning and implementation of any proposed intervention.

Nowhere to go: exploring the social and economic influences on discharging people experiencing homelessness to appropriate destinations in Toronto, Canada

OBJECTIVES

A main component of discharging patients from hospital is identifying an appropriate destination to meet their post-hospitalization needs. In Canada, meeting this goal is challenged when discharging people experiencing homelessness, who are frequently discharged to the streets or shelters. This study aimed to understand why and how the ability of hospital workers to find appropriate discharge destinations for homeless patients is influenced by dynamic social and economic contexts.

METHODS

Guided by critical realism, we conducted semi-structured, in-depth interviews with 33 participants: hospital workers on general medicine wards at three urban hospitals; shelter workers; and researchers, policy advisors, and advocates working at the intersection of homelessness and healthcare.

RESULTS

Historical and contemporary social and economic contexts (e.g., shrinking financial resources) have triggered the adoption of efficiency and accountability measures in hospitals, and exclusion criteria and rules in shelters, both conceptualized as mechanisms in this article. Hospitals are pressured to move patients out as soon as they are medically stable, but they struggle to discharge patients to shelters: to prevent inappropriate discharges, shelters have adopted exclusion and eligibility rules and criteria. These mechanisms contribute to an explanation of why identifying an appropriate discharge destination for people experiencing homelessness is challenging.

CONCLUSION

Our results point to a systems gap in this discharge pathway where there is nowhere for people experiencing homelessness to go who no longer need acute care, but whose needs are too complex for shelters. Systemic changes are needed to better support hospital and shelter frontline workers to improve discharge processes.

Multimorbidity among People Experiencing Homelessness-Insights from Primary Care Data

Background: Although the poor health of people experiencing homelessness is increasingly recognised in health discourse, there is a dearth of research that has quantified the nature and magnitude of chronic health issues and morbidity among people experiencing homelessness, particularly in the Australian context. Methods: Analysis of the medical records of 2068 “active” patients registered with a specialist homeless health service in Perth, Western Australia as of 31 December 2019. Results: Overall, 67.8% of patients had at least one chronic physical health condition, 67.5% had at least one mental health condition, and 61.6% had at least one alcohol or other drug (AOD) use disorder. Nearly half (47.8%) had a dual diagnosis of mental health and AOD use issues, and over a third (38.1%) were tri-morbid (mental health, AOD and physical health condition). Three-quarters (74.9%) were multimorbid or had at least two long-term conditions (LTCs), and on average, each patient had 3.3 LTCs. Conclusions: The study findings have substantial implications from both a health risk and healthcare treatment perspective for people experiencing homeless. The pervasiveness of preventable health conditions among people experiencing homelessness also highlights the imperative to improve the accessibility of public health programs and screening to reduce their morbidity and premature mortality.

A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness

Background

Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness.

Objectives

The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness.

Search Methods

In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies.

Selection Criteria

Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income.

Data Collection and Analysis

Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model.

Main Results

The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services.

Authors' Conclusions

PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.

Characteristics of Departments That Provided Primary Support for Households with Complex Care Needs in the Community: A Preliminary Cross-Sectional Study

To prevent emergency admissions and save medical costs, support should be provided to households that include people with complex care needs to allow them to continue living in their own homes. This community-based, cross-sectional study was conducted to (1) identify which departments that public health nurses (PHNs) worked have been the primary providers of support for households with complex care needs and (2) clarify the length of time required by each department to resolve primary health problems. We analyzed 148 households with complex care needs that were registered in City A from April 2018 to July 2019. Four types of departments were the primary support providers for complex care households: the department supporting persons with disabilities (n = 54, 36.5%), public/community health centers (n = 47, 31.8%), department of older adults (n = 29, 19.6%), and welfare offices (n = 18, 12.2%). The Mantel–Cox test showed that welfare offices mainly supported households in economic distress and needed significantly less time to resolve their primary health issues than other departments. For early detection and resolution of primary health problems for households with complex care needs, PHNs and healthcare professionals should focus on their economic distress and enhanced multidisciplinary approaches.

Understanding the health and housing experiences of refugees and other migrant populations experiencing homelessness or vulnerable housing: a systematic review using GRADE-CERQual

BACKGROUND

A growing number of migrants experience precarious housing situations worldwide, but little is known about their health and housing experiences. The objective of this study was to understand the enablers and barriers of accessing fundamental health and social services for migrants in precarious housing situations.

METHODS

We conducted a systematic review of qualitative studies. We searched the databases of MEDLINE, PsycINFO, CINAHL, Scopus, Web of Science, Social Sciences, Canadian Business & Current Affairs and Sociological Abstracts for articles published between Jan. 1, 2007, and Feb. 9, 2020. We selected studies and extracted data in duplicate, and used a framework synthesis approach, the Bierman model for migration, to guide our analysis of the experiences of migrant populations experiencing homelessness or vulnerable housing in high-income countries. We critically appraised the quality of included studies using the Critical Appraisal Skills Programme checklist and assessed confidence in key findings using the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach.

RESULTS

We identified 1039 articles, and 18 met our inclusion criteria. The studies focused on migrants from Asia and Africa who resettled in Canada, Australia, the United States, the United Kingdom and other European countries. Poor access to housing services was related to unsafe housing, facing a family separation, insufficient income assistance, immigration status, limited employment opportunities and lack of language skills. Enablers to accessing appropriate housing services included finding an advocate and adopting survival and coping strategies.

INTERPRETATION

Migrants experiencing homelessness and vulnerable housing often struggle to access health and social services; migrants may have limited proficiency with the local language, limited access to safe housing and income support, and ongoing family insecurities. Public health leaders could develop outreach programs that address access and discrimination barriers.

PROSPERO REGISTRATION

CRD42018071568.

Emergency department interventions for homelessness: a systematic review

BACKGROUND

The social determinants of health are economic and social conditions that contribute to health. Access to housing is a major social determinant of health and homeless patients often rely on emergency departments (EDs) for their healthcare. These patients are frequently discharged back to the street which further perpetuates the cycle of homelessness and negatively affects their health. Previous work has described the financial and systems implications of ED-housed interventions for homeless patients; this review summarizes ED-based interventions that seek to improve the social determinants of health of homeless patients.

METHODS

We conducted a search of multiple databases and gray literature for studies investigating interventions for homelessness that were initiated in the ED. Studies had to use a control group or use a pre/post-intervention design and measure outcomes that demonstrate an effect on health or the social determinants of health.

RESULTS

Thirteen studies were identified that met the inclusion criteria. Two studies were housing first interventions and were effective in providing housing and improving health. Seven studies used variations of case management and were able to address many of the social needs of people who are homeless.

CONCLUSION

This review demonstrated that ED interventions can be effective in improving the social determinants of health of homeless individuals and can be the place to initiate housing interventions. ED providers must advocate for the resources necessary to properly address the social needs of this marginalized population. Equipped with the proper resources, EDs can be one place where the cycle of homelessness is broken.

Evidence-informed interventions and best practices for supporting women experiencing or at risk of homelessness: a scoping review with gender and equity analysis

INTRODUCTION

While much of the literature on homelessness is centred on the experience of men, women make up over one-quarter of Canada's homeless population. Research has shown that women experiencing homelessness are often hidden (i.e. provisionally housed) and have different pathways into homelessness and different needs as compared to men. The objective of this research is to identify evidence-based interventions and best practices to better support women experiencing or at risk of homelessness.

METHODS

We conducted a scoping review with a gender and equity analysis. This involved searching MEDLINE, CINAHL, PsycINFO and other databases for systematic reviews and randomized trials, supplementing our search through reference scanning and grey literature, followed by a qualitative synthesis of the evidence that examined gender and equity considerations.

RESULTS

Of the 4102 articles identified on homelessness interventions, only 4 systematic reviews and 9 randomized trials were exclusively conducted on women or published disaggregated data enabling a gender analysis. Interventions with the strongest evidence included post-shelter advocacy counselling for women experiencing homelessness due to intimate partner violence, as well as case management and permanent housing subsidies (e.g. tenant-based rental assistance vouchers), which were shown to reduce homelessness, food insecurity, exposure to violence and psychosocial distress, as well as promote school stability and child well-being.

CONCLUSION

Much of the evidence on interventions to better support women experiencing homelessness focusses on those accessing domestic violence or family shelters. Since many more women are experiencing or at risk of hidden homelessness, population-based strategies are also needed to reduce gender inequity and exposure to violence, which are among the main structural drivers of homelessness among women.

Getting Unstuck: Challenges and Opportunities in Caring for Patients Experiencing Prolonged Hospitalization While Stable for Discharge

Many physicians care for patients who remain in the hospital for prolonged periods despite being "medically ready" or stable for discharge. However, this phenomenon is not well-defined, and optimal strategies to address the problem are not known. A prolonged hospitalization past the point of medical necessity can harm patients, frustrate care teams, and is costly for the health care system. In this perspective, we describe opportunities to improve value of care for these patients through the lens of the Quadruple Aim, a common framework used to guide health care transformation efforts. We then offer recommendations, including some employed by our hospitals, for clinicians, researchers, and health care systems to improve the care for patients who are "stuck" in the hospital.