The unmet health care needs of homeless adults: a national study

Continued Homelessness and Depressive Symptoms in Older Adults

Importance

Depression is common in adults experiencing homelessness. It is unclear whether continued homelessness is associated with more depressive symptoms.

Objective

To examine the association between residential status and depressive symptoms in adults aged 50 years or older experiencing homelessness at study entry.

Design, Setting, and Participants

This cohort study analyzed results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age (HOPE HOME) project, which in 2013 began enrolling adults aged 50 years or older experiencing homelessness in Oakland, California, and conducted structured interviews every 6 months for a mean duration of 5.5 years through 2023 (for this cohort study). Eligible participants included those aged 50 years or older, able to speak English, and experiencing homelessness at enrollment. We analyzed data collected from 2013 to 2023.

Exposures

The exposure of interest was residential status. At follow-up visits, residential status was categorized as (1) homelessness (meeting the HEARTH [Homeless Emergency Assistance and Rapid Transition to Housing] Act definition) or (2) housed (living in a noninstitutional environment and not meeting the HEARTH Act definition).

Main Outcomes and Measures

The primary outcome was moderate to severe depressive symptoms (with Center for Epidemiologic Studies-Depression [CES-D] scale score ≥22). The augmented inverse probability of treatment weighting (AIPTW) approach was used to examine the association between continued homelessness and depressive symptoms. The AIPTW adjusted for the following variables: number of chronic health conditions, age, sex, visiting a health care practitioner, receiving outpatient mental health treatment, receiving mental health medication, exposure to abuse, substance use disorder, and binge drinking.

Results

The cohort was composed of 450 participants, of whom 343 (76.2%) were males, and the mean (SD) age was 58.5 (5.2) years. Participants completed a median (IQR) of 8.9 (8-11) follow-up visits. With 1640 person-years of observation time, participants continued homelessness for 880 person-years (57.1%) and experienced being housed for 715 person-years (44.3%). Many participants (304 [78.0%]) were housed during at least 1 follow-up visit. The odds of a CES-D scale score of 22 or higher was significantly higher among participants who continued experiencing homelessness than among housed participants (marginal causal odds ratio, 1.08; 95% CI, 1.04-1.11; P < .001).

Conclusions and Relevance

This cohort study found that continued homelessness was associated independently with increased odds of depressive symptoms. Obtaining housing may have a favorable role in depression and overall well-being of older adults experiencing homelessness and may be considered as a mental health intervention.

The Impact of Race and Sex on the Clinical Outcomes of Homeless Patients With Alcoholic Liver Disease: Propensity Score Matched Analysis of US Hospitals

BACKGROUND

Among patients with alcoholic liver disease (ALD), homelessness poses significant medical and psychosocial risks; however, less is known about the effects of race and sex on the hospital outcomes of admitted homeless patients with ALD.

METHODS

The National Inpatient Sample database from 2012 to 2017 was used to isolate homeless patients with ALD, and the cohort was further stratified by race and sex for comparisons. Propensity score matching was utilized to minimize covariate confounding. The primary endpoints of this study include mortality, hospital length of stay, and hospital costs; secondary endpoints included the incidence of liver complications.

RESULTS

There were 3972 females/males postmatch, as well as 2224 Blacks/Whites and 4575 Hispanics/Whites postmatch. In multivariate, there were no significant differences observed in mortality rate, length of stay, and costs between sexes. Comparing liver outcomes, females had a higher incidence of hepatic encephalopathy [adjusted odds ratio (aOR) 1.02, 95% CI: 1.01-1.04, P <0.001]. In comparing Blacks versus Whites, Black patients had higher hospitalization costs (aOR 1.13, 95% CI: 1.03-1.24, P =0.01); however, there were no significant differences in mortality, length of stay, or liver complications. In comparing Hispanics versus Whites, Hispanic patients had longer length of hospital stay (aOR 1.12, 95% CI: 1.06-1.19, P <0.001), greater costs (aOR 1.15, 95% CI: 1.09-1.22, P <0.001), as well as higher prevalence of liver complications including varices (aOR 1.04, 95% CI: 1.02-1.06, P <0.001), hepatic encephalopathy (aOR 1.03, 95% CI: 1.02-1.04, P <0.001), and hepatorenal syndrome (aOR 1.01, 95% CI 1.00-1.01, P =0.03). However, there was no difference in mortality between White and Hispanic patients.

CONCLUSIONS

Black and Hispanic ALD patients experiencing homelessness were found to incur higher hospital charges; furthermore, Hispanic patients also had greater length of stay and higher incidence of liver-related complications compared with White counterparts.

The recovery experiences of homeless service users with substance use disorder: A systematic review and qualitative meta-synthesis

BACKGROUND

The relationship between homelessness and substance use disorder (SUD) is layered and complex. Adults pursuing recovery while dealing with homelessness and SUD face many challenges. Little research has inspected qualitative first-person accounts of recovery in the context of homelessness and SUD, and few studies have employed conceptualisations of recovery beyond abstinence. In this systematic review study, we examine the qualitative literature on the recovery experiences of adult homeless service users with SUD.

METHODS

2,042 records were identified via database and secondary searching strategy. After title and abstract and full text screening, 15 eligible studies remained. Critical Appraisal Skills Programme quality appraisal criteria was used to assess potential bias in the studies. Meta-ethnography was employed to synthesise extracted data.

RESULTS

Four themes were generated from the extracted data: Two sides of the Service Coin; Navigating Relationships; Recovery Practices and Personal Attributes; and Housing as Foundational for Recovery.

CONCLUSION

Unconditional housing, a broad array of supports, opportunities to contribute to society, and family reunification supports all facilitate the development of recovery for adults with SUD experiencing homelessness. Implications for policy are discussed.

Utilization and Perceived Need for Mental Health Services Among Homeless Seniors

Homeless seniors confront distinct challenges regarding their mental health needs and service access. This study aims to illuminate the mental health landscape of homeless seniors by examining the prevalence of mental illness, utilization of mental health services, and perceived need for mental health care. The study comprises 177 homeless seniors in New York, NY. Findings indicate 10.2% experiencing depression, 10.2% schizophrenia, and 5.7% bipolar disorder. Despite high prevalence, there is a significant gap between diagnosed mental health conditions and service utilization, with only 50% of those with depression seeking care. Perceived need for mental health services emerges as a critical aspect of the study, with over half of those suffering from depression (61.1%; n = 11), PTSD (75%; n = 3), schizophrenia (77.8%; n = 14), and other mental illnesses (100%; n = 1) expressing a need for mental health care. Also, mental health conditions, loneliness, and levels of social support play significant roles in a need for mental health services.

Adapting the serious illness conversation guide for unhoused older adults: a rapid qualitative study

BACKGROUND

Older adults experiencing homelessness (OAEH) age quickly and die earlier than their housed counterparts. Illness-related decisions are best guided by patients' values, but healthcare and homelessness service providers need support in facilitating these discussions. The Serious Illness Conversation Guide (SICG) is a communication tool to guide discussions but has not yet been adapted for OAEH.

METHODS

We aimed to adapt the SICG for use with OAEH by nurses, social workers, and other homelessness service providers. We conducted semi-structured interviews with homelessness service providers and cognitive interviews with OAEH using the SICG. Service providers included nurses, social workers, or others working in homeless settings. OAEH were at least 50 years old and diagnosed with a serious illness. Interviews were conducted and audio recorded in shelters, transitional housing, a hospital, public spaces, and over Zoom. The research team reviewed transcripts, identifying common themes across transcripts and applying analytic notetaking. We summarized transcripts from each participant group, applying rapid qualitative analysis. For OAEH, data that referenced proposed adaptations or feedback about the SICG tool were grouped into two domains: "SICG interpretation" and "SICG feedback". For providers, we used domains from the Toolkit of Adaptation Approaches: "collaborative working", "team", "endorsement", "materials", "messages", and "delivery". Summaries were grouped into matrices to help visualize themes to inform adaptations. The adapted guide was then reviewed by expert palliative care clinicians for further refinement.

RESULTS

The final sample included 11 OAEH (45% Black, 61 ± 7 years old) and 10 providers (80% White, 8.9 ± years practice). Adaptation themes included changing words and phrases to (1) increase transparency about the purpose of the conversation, (2) promote OAEH autonomy and empowerment, (3) align with nurses' and social workers' scope of practice regarding facilitating diagnostic and prognostic awareness, and (4) be sensitive to the realities of fragmented healthcare. Responses also revealed training and implementation considerations.

CONCLUSIONS

The adapted SICG is a promising clinical tool to aid in the delivery of serious illness conversations with OAEH. Future research should use this updated guide for implementation planning. Additional adaptations may be dependent on specific settings where the SICG will be delivered.

The Role of Street Medicine and Mobile Clinics for Persons Experiencing Homelessness: A Scoping Review

INTRODUCTION

An estimated 5800 to 46,500 lives are lost due to homelessness each year. Experiencing homelessness and poor health are cyclically related, with one reinforcing the other. Mobile programs, which include vehicles that travel to deliver care, and street medicine, the act of bringing care to spaces where PEH live, may play a role in alleviating this burden by providing trusted, affordable, and accessible care to this community.

METHODS

We conducted a scoping review of peer-reviewed literature on the role of mobile clinics and street medicine in providing care for PEH by searching PubMed, Embase, and Web of Science on 10 August 2023. Articles from 2013 to 2023 specific to programs in the United States were included. The protocol was developed following the PRISMA-ScR guidelines. The primary outcome was the role of mobile programs for persons experiencing homelessness.

RESULTS

A total of 15 articles were included in this review. The descriptive findings emphasized that street medicine and mobile clinics provide primary care, behavioral health, and social services. The utilization findings indicate that street medicine programs positively impact the health system through their ability to defer emergency department and hospital visits, providing financial benefits. The comparative findings between mobile programs and office-based programs indicate current successes and areas for improvement.

DISCUSSION

Mobile clinics and street medicine programs that serve PEH provide a wide range of services. While more significant structural change is needed to address healthcare costs and housing policies in the United States, mobile clinics and street medicine teams can improve healthcare access and the healthcare system.

Enablers and Inhibitors to Implementing Tobacco Cessation Interventions within Homeless-Serving Agencies: A Qualitative Analysis of Program Partners' Experiences

Despite the high tobacco use rates (~80%) and tobacco-related cancers being the second leading cause of death among people experiencing homelessness within the United States, these individuals rarely receive tobacco use treatment from homeless-serving agencies (HSAs). This qualitative study explored the enablers and inhibitors of implementing an evidence-based tobacco-free workplace (TFW) program offering TFW policy adoption, specialized provider training to treat tobacco use, and nicotine replacement therapy (NRT) within HSAs. Pre- and post-implementation interviews with providers and managers (n = 13) pursued adapting interventions to specific HSAs and assessed the program success, respectively. The organizational readiness for change theory framed the data content analysis, yielding three categories: change commitment, change efficacy and contextual factors. Pre- to post-implementation, increasing challenges impacted the organizational capacity and providers' attitudes, wherein previously enabling factors were reframed as inhibiting, resulting in limited implementation despite resource provision. These findings indicate that low-resourced HSAs require additional support and guidance to overcome infrastructure challenges and build the capacity needed to implement a TFW program. This study's findings can guide future TFW program interventions, enable identification of agencies that are well-positioned to adopt such programs, and facilitate capacity-building efforts to ensure their successful participation.

An Integrative Model of ENT Healthcare for the Homeless Population

OBJECTIVE

Our aim was to determine the need for otolaryngology care within the homeless population, identify barriers to access that the homeless population may face, and develop a model system which would address these needs with respect to the barriers.

METHODS

A retrospective chart review of 812 patients seen between 1/25/16-3/21/2020 was performed. Charts were obtained from homeless patients seen at free general clinics held shelters in Chicago, IL (781 charts) and in Champaign, IL (31 charts). Records reporting at least one otolaryngology disease in a patient experiencing homelessness were included in this study. Patients were considered homeless if they resided at the shelter at the time of their appointment. To determine common barriers to care, a simple yes/no questionnaire was administered to residents at west-side Chicago homeless shelters. Questions addressed barriers to health care access that had been mentioned by patients seen at free clinics.

RESULTS

Chart review findings demonstrated that 14.3% (n = 142) of all homeless patients seen at free in-shelter clinics were seen for ENT-related disorders. Survey results revealed that 76.3% (n = 71) of respondents believed that telemedicine services would be useful in shelters. 74.2% (n = 69) stated they were unable to afford prescribed medications. 93.5% (n = 87) stated that better access to transportation would increase their likelihood of seeking care.

CONCLUSIONS

In our attempt to bridge this inequity, we have launched a hybrid in-person/virtual care program to improve access to otolaryngology care for the homeless community.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:2705-2709, 2024.

Miracle friends and miracle money in California: a mixed-methods experiment of social support and guaranteed income for people experiencing homelessness

BACKGROUND

This paper describes the protocols for a randomized controlled trial using a parallel-group trial design that includes an intervention designed to address social isolation and loneliness among people experiencing homelessness known as Miracle Friends and an intervention that combines Miracles Friends with an economic poverty-reduction intervention known as Miracle Money. Miracle Friends pairs an unhoused person with a volunteer "phone buddy." Miracle Money provides guaranteed basic income of $750 per month for 1 year to Miracle Friends participants. The study will examine whether either intervention reduces social isolation or homelessness compared to a waitlist control group.

METHODS

Unhoused individuals who expressed interest in the Miracle Friends program were randomized to either receive the intervention or be placed on a waitlist for Miracle Friends. Among those randomized to receive the Miracle Friends intervention, randomization also determined whether they would be offered Miracle Money. The possibility of receiving basic income was only disclosed to study participants if they were randomly selected and participated in the Miracle Friends program. All study participants, regardless of assignment, were surveyed every 3 months for 15 months.

RESULTS

Of 760 unhoused individuals enrolled in the study, 256 were randomized to receive Miracle Friends, 267 were randomized to receive Miracle Money, and 237 were randomized to the waitlist control group. In the two intervention groups, 360 of 523 unhoused individuals were initially matched to a phone buddy. Of the 191 study participants in the Miracle Money group who had been initially matched to a volunteer phone buddy, 103 were deemed to be participating in the program and began receiving monthly income.

DISCUSSION

This randomized controlled trial will determine whether innovative interventions involving volunteer phone support and basic income reduce social isolation and improve housing outcomes for people experiencing homelessness. Although we enrolled unhoused individuals who initially expressed interest in the Miracle Friends program, the study team could not reach approximately 30% of individuals referred to the study. This may reflect the general lack of stability in the lives of people who are unhoused or limitations in the appeal of such a program to some portion of the unhoused population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05408884 (first submitted on May 26, 2022).

A scoping review examining patient experience and what matters to people experiencing homelessness when seeking healthcare

BACKGROUND

Homelessness is associated with significant health disparities. Conventional health services often fail to address the unique needs and lived experience of homeless individuals and fail to include participatory design when planning health services. This scoping review aimed to examine areas of patient experience that are most frequently reported by people experiencing homelessness when seeking and receiving healthcare, and to identify existing surveys used to measure patient experience for this cohort.

METHODS

A scoping review was undertaken reported according to the PRISMA-ScR 2020 Statement. Databases were searched on 1 December 2022: MEDLINE, EMBASE, APA PsychINFO and CINAHL. Included studies focused on people experiencing homelessness, healthcare services and patient experience, primary research, published in English from 2010. Qualitative papers and findings were extracted and synthesized against a modified framework based on the National Institute for Health and Care Excellence guidelines for care for people experiencing homelessness, the Institute of Medicine Framework and Lachman's multidimensional quality model. People with lived experience of homelessness were employed as part of the research team.

RESULTS

Thirty-two studies were included. Of these, 22 were qualitative, seven quantitative and three mixed methods, from the United States of America (n = 17), United Kingdom (n = 5), Australia (n = 5) and Canada (n = 4). Health services ranged from primary healthcare to outpatient management, acute care, emergency care and hospital based healthcare. In qualitative papers, the domains of 'accessible and timely', 'person-centred', and values of 'dignity and respect' and 'kindness with compassion' were most prevalent. Among the three patient experience surveys identified, 'accessible and timely' and 'person-centred' were the most frequent domains. The least frequently highlighted domains and values were 'equitable' and 'holistic'. No questions addressed the 'safety' domain.

CONCLUSIONS

The Primary Care Quality-Homeless questionnaire best reflected the priorities for healthcare provision that were highlighted in the qualitative studies of people experiencing homelessness. The most frequently cited domains and values that people experiencing homelessness expressed as important when seeking healthcare were reflected in each of the three survey tools to varying degrees. Findings suggest that the principles of 'Kindness and compassion' require further emphasis when seeking feedback on healthcare experiences and the domains of 'safety', 'equitable', and 'efficiency' are not adequately represented in existing patient experience surveys.

Mortal Systemic Exclusion Yielded Steep Mortality-Rate Increases In People Experiencing Homelessness, 2011-20

The number and percentage of people in the US dying while homeless has increased in recent years. However, information about the causes of death most prevalent among this population, and about how cause-specific mortality rates may be shifting over time, has been limited to locally specific data. Using a unique data set of 22,143 homeless decedents in twenty-two localities across ten states and Washington, D.C., from the period 2011-20, we found large increases in all-cause and cause-specific homeless mortality rates. The largest increases in cause-specific homeless mortality rates in the ten-year period were for deaths related to drug and alcohol overdose, diabetes, infection, cancer, homicide, and traffic injury. We discuss implications of these results and posit that people experiencing homelessness are systematically excluded from the life-affirming institutions of housing and health care, in an example of mortal systemic exclusion. The findings have important implications for existing local and federal policy approaches to homelessness.

A systematic review of approaches to improve medication adherence in homeless adults with psychiatric disorders

Introduction

Medication non-adherence is a significant problem among homeless individuals with psychiatric disorders in the United States. We conducted a systematic review to identify strategies to improve psychiatric medication adherence among homeless individuals with psychiatric disorders, including substance use disorders.

Methods

We searched seven databases (MEDLINE, Embase, PsychInfo, Scopus, Web of Science, CDSR, and CENTRAL) and screened 664 studies by title and abstract followed by full-text review. Our inclusion criteria were studies that: involved an intervention for homeless adults with psychiatric disorders, reported a quantitative outcome of medication adherence, and were published in English in a peer-reviewed journal. We rated the relative effectiveness of strategies described in each study using a self-designed scale.

Results

Eleven peer-reviewed studies met criteria for inclusion in this review. Within these studies, there were seven different approaches to improve medication adherence in this population. Three studies were randomized controlled trials (RCTs) and the remaining were observational studies. Outpatient interventions included Assertive Community Treatment, Cell Phone-Assisted Monitoring, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Homeless-Designated Pharmacy Clinics. Residential, shelter-based, and inpatient interventions included use of the Housing First model, Modified Therapeutic Communities, and Homeless-Designated Inpatient Care. The approaches described in four of the eleven studies were rated as scoring a 3 or higher on a 5-point scale of effectiveness in improving medication adherence; none received 5 points.

Discussion

The interventions with the strongest evidence for improving medication adherence in this population were Assertive Community Treatment, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Housing First. Overall, studies on this topic required more rigor and focus on medication adherence as an outcome in this population. This review highlights several promising strategies and the need for larger RCTs to determine effective and diverse ways to improve medication adherence among homeless adults with psychiatric disorders.

How do health system factors (funding and performance) impact on access to healthcare for populations experiencing homelessness: a realist evaluation

BACKGROUND

People experiencing long-term homelessness face significant difficulties accessing appropriate healthcare at the right time and place. This study explores how and why healthcare performance management and funding arrangements contribute to healthcare accessibility or the lack thereof using long-term homeless adults as an example of a population experiencing social exclusion.

METHODS

A realist evaluation was undertaken. Thirteen realist interviews were conducted after which data were transcribed, coded, and analysed.

RESULTS

Fourteen CMOCs were created based on analysis of the data collected. These were then consolidated into four higher-level CMOCs. They show that health systems characterised by fragmentation are designed to meet their own needs above the needs of patients, and they rely on practitioners with a special interest and specialised services to fill the gaps in the system. Key contexts identified in the study include: health system fragmentation; health service fragmentation; bio-medical, one problem at a time model; responsive specialised services; unresponsive mainstream services; national strategy; short health system funding cycles; and short-term goals.

CONCLUSION

When health services are fragmented and complex, the needs of socially excluded populations such as those experiencing homelessness are not met. Health systems focus on their own metrics and rely on separate actors such as independent NGOs to fill gaps when certain people are not accommodated in the mainstream health system. As a result, health systems lack a comprehensive understanding of the needs of all population groups and fail to plan adequately, which maintains fragmentation. Policy makers must set policy and plan health services based on a full understanding of needs of all population groups.

Bringing Lived Experience to Research on Health and Homelessness: Perspectives of Researchers and Lived Experience Partners

Improving health and healthcare for people experiencing homelessness (PEH) has become a national research priority. It is critical for research related to homelessness to be guided by input from PEH themselves. We are a group of researchers and individuals who have personally experienced homelessness collaborating on a study focused on homelessness and housing. In this Fresh Focus, we describe our partnership, lessons learned from our work together, what we have gained from our collaboration, and considerations for future homelessness research-lived experience partnerships.

Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study

Background

There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services.

Objectives

This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants' use of health care and social care services over 12 months, and costs were calculated.

Design and setting

The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model.

Participants

People who had been homeless during the previous 12 months were recruited as 'case study participants'; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders.

Results

The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services.

Limitations

There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model.

Conclusions

Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, 'drop-in' services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (HSDR 13/156/03) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 16. See the NIHR Journals Library website for further project information.

A qualitative exploration of older people's lived experiences of homelessness and memory problems - stakeholder perspectives

BACKGROUND

The numbers of older people experiencing both homelessness and memory problems are growing, yet their complex health, housing and care needs remain undelineated and unmet. There is a critical gap in understanding what can improve the care, support and experiences of this group. In this qualitative study we explore how stakeholders understand memory problems among older people in the context of homelessness and consider what they judge gets in the way of achieving positive outcomes.

METHOD

We conducted reflexive thematic analysis of qualitative interviews (n = 49) using a semi-structured topic guide, with 17 older people (aged ≥ 50 years) experiencing memory problems and homelessness, 15 hostel staff and managers, and 17 health, housing and social care practitioners. We recruited participants from six homelessness hostels, one specialist care home and National Health and Local Authority Services in England.

RESULTS

We identified four overarching themes. The population is not taken seriously; multiple causes are hard to disentangle; risk of exploitation and vulnerability; and (dis)connection and social isolation. The transience and lack of stability associated with homelessness intensified the disorienting nature of memory and cognitive impairment, and those providing direct and indirect support required flexibility and persistence, with staff moving beyond traditional roles to advocate, provide care and safeguard individuals. Memory problems were perceived by frontline staff and older people to be overlooked, misinterpreted, and misattributed as being caused by alcohol use, resulting in pervasive barriers to achieving positive and desired outcomes.

CONCLUSIONS

Efforts to meet the needs of older people living with memory problems and experiencing homelessness and future interventions must reflect the complexity of their lives, often in the context of long-term alcohol use and current service provision and we make suggestions as to what could be done to improve the situation.

Contraception-related knowledge, attitude, belief contexts among US women experiencing homelessness: A scoping review

Contraception provision may help reduce undesired pregnancies, but women experiencing homelessness may have low health literacy, specific attitudes, and certain beliefs that influence contraception uptake. This scoping review identifies what is known about pregnancy prevention and contraception knowledge, attitudes, and beliefs among US women experiencing homelessness. This review examined English articles that measured the context of knowledge, attitudes, and beliefs related to contraceptive use for avoiding pregnancy among US women experiencing homelessness. Using PRISMA-ScR guidelines, articles published before May 2022 were located via PubMed, EBSCOhost, and Embase. The initial search identified 1204 articles, and 10 met the inclusion criteria. There were five quantitative, four qualitative, and one mixed-methods study, published between 2000 and 2022, with samples of 15-764 women ranging from ages 15-51. Contraception knowledge, attitudes, and beliefs related to pregnancy prevention suggested several knowledge gaps (e.g., contraception efficacy), contraception preferences and past experiences, interpersonal relationship influences, and vulnerability to clinic and shelter-specific barriers. These findings may ultimately inform contraception interventions in partnership with the community of US women who experience homelessness and the health care and social service organizations who serve them.

Health Care of People Experiencing Homelessness: Part II

Health Care of People Experiencing HomelessnessIn this second part of a two-part review of health care for people experiencing homelessness, Taylor and Munson discuss approaches to care that are tailored to this population.

The Association of Homelessness With Rates of Diabetes Complications: A Population-Based Cohort Study

OBJECTIVE

To estimate the rates of diabetes complications and revascularization procedures among people with diabetes who have experienced homelessness compared with a matched cohort of nonhomeless control subjects.

RESEARCH DESIGN AND METHODS

A propensity-matched cohort study was conducted using administrative health data from Ontario, Canada. Inclusion criteria included a diagnosis of diabetes and at least one hospital encounter between April 2006 and March 2019. Homeless status was identified using a validated administrative data algorithm. Eligible people with a history of homelessness were matched to nonhomeless control subjects with similar sociodemographic and clinical characteristics. Rate ratios (RRs) for macrovascular complications, revascularization procedures, acute glycemic emergencies, skin/soft tissue infections, and amputation were calculated using generalized linear models with negative binomial distribution and robust SEs.

RESULTS

Of 1,076,437 people who were eligible for inclusion in the study, 6,944 were identified as homeless. A suitable nonhomeless match was found for 5,219 individuals. The rate of macrovascular complications was higher for people with a history of homelessness compared with nonhomeless control subjects (RR 1.85, 95% CI 1.64-2.07), as were rates of hospitalization for glycemia (RR 5.64, 95% CI 4.07-7.81) and skin/soft tissue infections (RR 3.78, 95% CI 3.31-4.32). By contrast, the rates of coronary revascularization procedures were lower for people with a history of homelessness (RR 0.76, 95% CI 0.62-0.94).

CONCLUSIONS

These findings contribute to our understanding of the impact of homelessness on long-term diabetes outcomes. The higher rates of complications among people with a history of homelessness present an opportunity for tailored interventions to mitigate these disparities.

Health Care of People Experiencing Homelessness: Part I

Homelessness and Health CarePeople who experience homelessness have high rates of medical illness. They struggle with conditions associated with living in crowded shelters, trauma, and exposure to extreme weather. Here, Taylor and Munson review the care of this vulnerable population.

Precarious Housing Associated with Unsuppressed Viral load, sub-optimal Access to HIV Treatment and Unmet Health care Needs, Among Women Living with HIV in Metro Vancouver, Canada

We investigated associations between (1) housing status (four categories measuring housing stability) and outcomes along the HIV care continuum (not currently on antiretroviral therapy [ART]; sub-optimal ART adherence [< 95% in the last 3-4 weeks]; unsuppressed viral load [> 200 copies/ml], median CD4 < 200 in the last six months), and (2) housing status and unmet primary, dental and mental health care needs in the last six months among WLWH. Housing status was defined according to the Canadian Definition of Homelessness and had four categories: unsheltered (i.e., living in ≥ 1 unsheltered location [e.g., street, abandoned buildings]), unstable (i.e., living in ≥ 1 unstable location [e.g., shelter, couch surfing]), supportive housing (i.e., only living in supportive housing), and stable housing (i.e., only living in one's own housing; reference). At baseline, in the last six months, 47.3% of participants reported unstable housing, followed by 24.4% unsheltered housing, 16.4% stable housing, and 11.9% supportive housing. Overall, 19.1% of the full sample (N = 336, 2010-2019) reported not currently on ART; among participants on ART, 28.0% reported sub-optimal ART adherence. Overall, 32.1% had recent unsuppressed viral load. Among a subsample (n = 318, 2014-2019), 15.7% reported unmet primary care needs, 26.1% unmet dental care needs, and 16.4% unmet mental health care needs. In adjusted models, being unsheltered (vs. stable housing) was associated with not currently on ART, unsuppressed viral load, and unmet primary and dental care needs. Housing and health services need to be developed with and for WLWH to address structural inequities and fulfill basic rights to housing and health.

Burden of long COVID among adults experiencing sheltered homelessness: a longitudinal cohort study in King County, WA between September 2020-April 2022

BACKGROUND

People experiencing homelessness (PEH) are at increased risk for acquiring SARS-CoV-2, but the burden of long COVID in this population is unknown.

METHODS

We conducted a matched prospective cohort study to assess the prevalence, characteristics, and impact of long COVID among sheltered PEH in Seattle, WA between September 2020-April 2022. Adults ≥ 18 years, residing across nine homeless shelters with active respiratory virus surveillance, were eligible to complete in-person baseline surveys and interval follow-up phone surveys. We included a subset of 22 COVID-19-positive cases who tested positive or inconclusive for SARS-CoV-2 and 44 COVID-19-negative controls who tested negative for SARS-CoV-2, frequency matched on age and sex. Among controls, 22 were positive and 22 were negative for one of 27 other respiratory virus pathogens. To assess the impact of COVID-19 on the risk of symptom presence at follow-up (day 30-225 post-enrollment test), we performed log-linear regression with robust standard errors, adjusting for confounding by shelter site and demographic variables determined a priori.

RESULTS

Of 53 eligible COVID-19 cases, 22 (42%) completed ≥ 1 follow-up survey. While five (23%) cases reported ≥ 1 symptom at baseline, this increased to 77% (10/13) between day 30-59 and 33% (4/12) day 90 + . The most commonly reported symptoms day 30 + were fatigue (27%) and rhinorrhea (27%), with 8 (36%) reporting symptoms that interfered with or prevented daily activities. Four (33%) symptomatic cases reported receiving medical care outside of a medical provider at an isolation facility. Of 44 controls, 12 (27%) reported any symptoms day 90 + . Risk of any symptoms at follow-up was 5.4 times higher among COVID-19 cases compared to controls (95% CI: 2.7-10.5).

CONCLUSIONS

Shelter residents reported a high prevalence of symptoms 30 + days after their SARS-CoV-2 detection, though few accessed medical care for persistent illness. The impact of COVID-19 extends beyond acute illness and may exacerbate existing challenges that marginalized populations face in maintaining their health and wellbeing.

Wound healing in the vulnerable: A novel case of postauricular wounds caused by mask ties

Background

The COVID-19 pandemic has made facial masks an essential part of daily life. While protective facial masks are crucial to help the spread of viral infections, they are common causes of facial skin breakdown, acne, and superficial injuries. Masks with elastic ear loops are also particularly likely to cause ear pressure injuries.

Case report

Herein, we present a case of a patient experiencing homelessness found to have significant postauricular wounds due to prolonged mask use in the context of the Covid-19 pandemic. These injuries led to bilateral erosion of the helix with partial avulsion of the ear and mask ear loops eroding into cartilage.

Why should an emergency physician be aware of this?

We describe a rare complication of mask use and highlight the difficulties the COVID pandemic has made in providing adequate care for chronic head and neck wounds amongst the homeless population. While PPE remains an important part of decreasing the risk of the spread of infections, it is important to recognize the vulnerabilities of the homeless population during the COVID pandemic and how best to care for novel auricular wounds.

Opportunities and challenges in involving people with lived experience of inclusion health as co-researchers in palliative and end of life research: a rapid review and thematic synthesis

BACKGROUND

Co-research is a collaborative approach to research, promoting involvement of individuals with lived experience of a research area as experts by experience. Recently, the importance of co-research within palliative and end of life care (PEoLC) has been highlighted, yet few recommendations exist regarding best practice for involving inclusion health groups (i.e., groups that are socially excluded, typically experiencing multiple disadvantages that contribute to poor health outcomes).

AIMS

To identify and synthesise qualitative literature outlining barriers and facilitators for involving four inclusion health groups (individuals with lived experience of: homelessness, substance use disorder, incarceration or exchanging sex for money) in PEoLC research, from the perspectives of both the researchers and individuals with lived experience.

METHODS

This report is a rapid review with thematic synthesis methodology. Three electronic databases were searched (2012-30th August 2022). Thematic synthesis was used to generate themes across qualitative studies.

RESULTS

Three qualitative studies were eligible for inclusion. Two involved individuals with lived experience of incarceration, and one lived experience of homelessness. No papers outlined best-practice guidance for co-research; all offered reflections on the co-research process. Challenges for involvement included: facilitating appropriate reimbursement; overcoming stigma; fear of tokenism; pre-conceived views and the emotional burden of research. Successes and benefits included: advanced level of insight, a two-way learning opportunity and relatability of lived experience co-researchers.

CONCLUSIONS

This review did not identify any best-practice guidance for co-production of PEoLC research with inclusion health groups. There are few, good quality, qualitative studies offering insight into challenges and facilitators for lived experience co-researcher involvement. Further research and formal policy development is required to produce formal best-practice guidance to support safe, impactful inclusion in PEoLC research. It is important that researchers work together with people who have lived experience of the topic they are researching. Palliative care is specialised medical care for people living with a terminal illness. There is some collaboration between researchers and people with lived experience in palliative and end-of-life care research. However, some groups of people have been excluded. This includes people experiencing homelessness, or people with drug or alcohol addictions. This review aimed to understand what works and what doesn't work when involving four excluded groups in palliative and end-of-life research. These groups were people experiencing homelessness, those who had spent time in prison, people with drug or alcohol disorders, and people who exchanged sex for money. This review used a shortened methodology, which allowed it to be done quickly. Three online academic databases (Medline, PubMed, PsychINFO) were searched for research projects: three papers were included in the review. No clear guidance for working with these groups was found. Analysis identified themes across papers. Challenges for collaboration included: appropriate payment methods; overcoming stigma; fear of being talked down to,; assumptions made before meeting people, and the potential of becoming upset. Successes and benefits included: better understanding of the research topic, the opportunity to learn from one another, and how research participants could relate to lived experience co-researchers. There are few, good quality papers, but more research is needed to produce guidance to support safe, impactful collaboration.

A Network Analysis of the Relationship Between Mental and Physical Health in Unsheltered Homeless Persons in Los Angeles County

Homelessness is a public health crisis both nationally, in the United States, and internationally. Nevertheless, due to the hidden vulnerabilities of persons who are without shelter, little is known about their experiences during periods of homelessness. The present research adopts a network approach that conceptualizes how the major risk factors of homelessness interact, namely substance abuse problems, poor mental health, disability, and exposure to physical or sexual violence by an intimate partner. Our analysis draws on a large demographic survey of over 5,000 unsheltered homeless persons conducted in 2017 by the Los Angeles Homeless Services Authority. We estimated a network structure for 12 survey items tapping individual risk using the graphical least absolute shrinkage and selection operator algorithm. We then examined network centrality metrics and implemented a community detection algorithm to detect communities in the network. Our results indicated that mental illness and intimate partner violence (IPV) are central measures that connect all other mental and physical health variables together and that post-traumatic stress disorder and IPV are both highly affected by changes in any part of the network and, in turn, affect changes in other parts of the network. A community detection analysis derived four communities characterized by disability, sexual victimization and health, substance use, and mental health issues. Finally, a directed acyclic graph revealed that drug abuse and physical disability were key drivers of the overall system. We conclude with a discussion of the major implications of our findings and suggest how our results might inform programs aimed at homelessness prevention and intervention.

The Impact of COVID-19 on Access to Resources among Individuals Experiencing Homelessness and Traumatic Brain Injury

The rates of traumatic brain injury (TBI) are higher among individuals experiencing homelessness compared with the general population. Individuals experiencing homelessness and a TBI may experience barriers to care. COVID-19 may have further impacted access to basic resources, such as food, shelter, and transportation for individuals experiencing homelessness. This study aimed to answer the following research question: What is the impact of COVID-19 on access to resources among individuals experiencing homelessness and TBI? A cross-sectional study design and purposive sampling were utilized to interview 38 English-speaking adults experiencing homelessness and who had sustained a TBI (ages 21–73) in one Colorado city. Qualitative questions related to the impact of COVID-19 were asked and qualitative analysis was used to analyze the responses. Three primary themes emerged regarding the types of resources that were restricted by COVID-19: basic/biological needs, financial needs, and a lack of connection. COVID-19 has shown the social work field the need for continued innovation and better practice standards for individuals who are not housed. For those living with a reported TBI history and experiencing homelessness, COVID-19 made it difficult to access basic services for survival.

Soft tissue infection and follow-up for an unsheltered patient: the role of Street Medicine providers in bridging gaps in care

Street Medicine is a volunteer-run initiative for low-resource healthcare settings. Formed to bridge gaps in care for persons experiencing homelessness, these organisations work to provide preventative medicine through maintenance care and follow-up. However, there are limits to what Street Medicine can accomplish given the geographical radius covered, lack of available transportation options and vulnerable sleeping locations night to night for the patients served. The subject of this case report is a middle-aged Spanish-speaking unsheltered man who began his care with a Street Medicine team. He was unable to attend medical appointments due to relocation, complicating his disease course and resulting in hospital intervention for cellulitis. Post-discharge, he stayed within radius and was treated by the street team. Increased emphasis on the effects of housing insecurity and addressing social determinants of health could prevent deterioration of manageable diseases and should be an area of active interest for Street Medicine team expansion.

Identifying the Group Vulnerable to Unmet Medical Needs Due to Food Security: According to Children in the Household

OBJECTIVE

Adults may experience unmet medical needs for various reasons. The purpose of this study was to examine the effect of food security on unmet medical needs according to the presence of children in the household of adults, as well as to identify the medically vulnerable group considering individual and household characteristics.

METHODS

This study was conducted using data from the National Health and Nutrition Examination Survey for 2013-2015 and 2019-2020. The subjects of the study were 23,069 adults 19 years of age or older, and were divided into two groups according to whether or not children were included in the household. In order to observe the association between food security and unmet medical needs, multiple logistic regression analysis was performed. In addition, a subgroup analysis was performed in consideration of individual and household characteristics.

RESULTS

When food security was unstable for households with children, or without children, there was a high correlation with unmet medical needs. Considering individual and household characteristics, in groups with lower age and household income level, or higher number of members in household and subjective health status, food security was strongly correlated with unmet medical needs in households with children. Contrarily, households without children showed a high correlation in the opposite characteristics of households with children, excluding household income level.

CONCLUSION

Food security was highly correlation with unmet medical needs regardless of whether or not children were included in the household. However, according to the individual and household characteristics of households with and without children, the relationship between food security and unmet medical needs was found to be different. Therefore, it is necessary to prepare a health policy that can increase access to medical services in consideration of food security and individual and household characteristics depending on whether or not children are included in the household.

Unmet needs of homeless U.S. veterans by gender and race/ethnicity: Data from five annual surveys

There has been insufficient research on gender, race, and ethnic differences in unmet needs of homeless populations. This study analyzed 5 years of data collected by Project Community Homelessness Assessment, Local Education, and Networking Groups (CHALENG) surveys from 2012 to 2016 to examine gender, race, and ethnic differences in "literally homeless" veterans (i.e., veterans living in the streets, shelters, vehicles, or any other place not meant for habitation). Of 7,040 participants, there were 6,335 male and 705 female literally homeless veterans from 4 self-identified racial/ethnic categories (White, Black, Hispanic, and Other). The results showed that homeless female veterans were significantly more likely to report unmet needs related to emergency shelter, transitional housing, and dental care than male veterans. Among men, White veterans reported greater unmet needs in housing, healthcare, basic needs, and specialized needs than racial/ethnic minority veterans. Among women, veterans who were racial/ethnic minorities reported greater unmet needs than their White counterparts. These findings suggest programmatic attention to gender, race, and ethnicity is important in addressing diverse needs of homeless veterans and specialized services may be needed to address their specific and consistent unmet needs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Risk of delivery complications among pregnant people experiencing housing insecurity

BACKGROUND

Housing insecurity is increasingly being recognized as an important social determinant of health. Pregnant individuals experiencing housing insecurity may represent a particularly vulnerable subset of this population, but few studies have examined this population nationally. In particular, racial and ethnic minority individuals may be at risk for poor outcomes within this group because of structural racism and discrimination. The introduction of the International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes related to social determinants of health represent a new opportunity to identify patients with housing insecurity nationally.

OBJECTIVE

This study aimed to evaluate the prevalence of and delivery outcomes for pregnant people experiencing housing insecurity, both nationally and by race and ethnicity.

STUDY DESIGN

This was a retrospective cohort study using data from the 2016 to 2018 National Inpatient Sample. Delivery hospitalizations for people experiencing housing insecurity were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code Z59. Among hospitals that coded at least 1 delivery for a patient with housing insecurity, logistic regression models were used to assess the odds of severe maternal morbidity associated with housing insecurity, adjusting for clinical risk and pregnancy characteristics.

RESULTS

Of 539,950 delivery hospitalizations, 1820 hospitalizations (0.3%) were for patients with housing insecurity. Compared to deliveries for patients with housing security, deliveries for patients with housing insecurity were more likely for patients who identified as Black (34.8% vs 18.1%; P<.001) and who had Medicaid insurance (83.5% vs 46.2%; P<.001). People with housing insecurity were more likely to have comorbidities and higher-risk pregnancies, including higher rates of substance use disorders (54.0% vs 6.9%), major mental health disorders (37.5% vs 8.7%), preeclampsia with severe features (7.4% vs 4.3%), and preterm birth <37 weeks gestation (23.7% vs 11.6%) (all P<.001). In regression analyses, patients with housing insecurity had more than twice the odds of severe maternal morbidity than patients with housing security during the delivery hospitalization (odds ratio, 2.17; 95% confidence interval, 1.75-2.68). After adjusting for clinical risk and pregnancy characteristics, the differences were attenuated overall (adjusted odds ratio, 1.17; 95% confidence interval, 0.94-1.47) and among racial and ethnic groups (White patients: adjusted odds ratio, 1.39; 95% confidence interval, 0.95-2.03; Black patients: adjusted odds ratio, 1.05; 95% confidence interval, 0.73-1.52; Hispanic patients: adjusted odds ratio, 1.04; 95% confidence interval, 0.59-1.84; Asian or Pacific Islander or Native American or other race patients: adjusted odds ratio, 1.08; 95% confidence interval, 0.45-2.58).

CONCLUSION

Pregnant individuals experiencing housing insecurity were more likely to be from groups that have been marginalized historically, had higher rates of comorbidities, and worse delivery outcomes. After risk adjustment, differences in the odds of severe maternal mortality were attenuated. Screening for housing insecurity may identify these patients earlier and connect them to services that could improve disparities in outcomes.

Cancer Diagnoses and Use of Radiation Therapy Among Persons Experiencing Homelessness

PURPOSE

Persons experiencing homelessness (PEH) have low rates of cancer screening and worse cancer mortality compared with persons not experiencing homelessness. Data regarding cancer diagnosis and treatment in PEH are limited. We investigated cancer prevalence and use of radiation therapy (RT) in PEH.

METHODS AND MATERIALS

Patients presenting between January 1, 2014, and September 27, 2021, at a large metropolitan hospital system were assessed for homelessness via intake screening or chart search. PEH data were cross-referenced with the institution's cancer database to identify PEH with cancer diagnoses. Demographic, clinical, and treatment variables were abstracted.

RESULTS

Of a total of 9654 (9250 evaluable) PEH with a median age of 42 years, 81 patients (0.88%) had at least 1 cancer diagnosis and 5 had multiple diagnoses, for a total of 87 PEH with at least 1 cancer diagnosis. The median age at diagnosis was 60 years. In total, 43% were female and 51% were Black, and 43% presented with advanced or metastatic disease. Lung (17%), prostate (15%), leukemia/lymphoma (13%), and head/neck (9%) were the most common diagnoses. In total, 17% of patients underwent surgery alone, 13% received chemotherapy alone, 14% received RT alone, and 6% received hormone therapy alone. A total of 8% of patients underwent no treatment, and 43% underwent multimodality therapy. In total, 58% of treated patients never achieved disease-free status. Of the 31 patients who received RT, 87% received external beam RT. Most patients (70%) received hypofractionated regimens. For patients who had multifraction treatment, the treatment completion rate was 85%, significantly lower than the departmental completion rate of 98% (P < .00001).

CONCLUSIONS

In a large cohort of PEH in a metropolitan setting, cancer diagnoses were uncommon and were frequently in advanced stages. Most patients underwent single-modality treatment or no treatment at all. Despite the use of hypofractionation, the RT completion rate was low, likely reflecting complex barriers to care. Further interventions to optimize cancer diagnosis and treatment in PEH are urgently needed.

Psychometric properties of the measure of achieved capabilities in homeless services

BACKGROUND

Purposeful participation in personally meaningful life tasks, enjoyment of positive reciprocal relationships, and opportunities to realize one's potential are growth-related aspects of a meaningful life that should be considered important dimensions of recovery from homelessness. The extent to which homeless services support individuals to achieve the capabilities they need to become who they want to be and do what they want to do is, in turn, an important indicator of their effectiveness. In this study, we developed a measure of achieved capabilities (MACHS) for use in homeless services settings, and assessed its construct and concurrent validity.

METHODS

We analysed data collected from homeless services users at two time points in eight European countries to assess the factor structure and psychometric properties of the new measure. Participants were adults engaged with either Housing First (n = 245) or treatment as usual (n = 320).

RESULTS

Exploratory and confirmatory factor analyses yielded a four-factor structure of the capabilities measure: community integration, optimism, safety, and self-determination. We obtained evidence for construct validity through observed correlations between achieved capabilities and recovery, working alliance and satisfaction with services. Moreover, we obtained evidence of the measure's concurrent validity from its positive association between HF and personal recovery, which was fully mediated by achieved capabilities.

CONCLUSIONS

Findings demonstrate that the MACHS is a valid and reliable measure that may be used to assess the extent to which homeless services support their clients to develop capabilities needed for growth-related recovery. Implications for practice and future research directions are discussed.

Peer support and whole health coaching to address the healthcare needs of homeless veterans: a pilot study

BACKGROUND

Homelessness is a robust social determinant of acute care service utilization among veterans. Although intensive outpatient programs have been developed for homeless veterans who are high utilizers of acute care ("super utilizers"), few scalable programs have been implemented to address their needs.

OBJECTIVE

Describe the development and pilot testing of a novel intervention that integrates the roles of a peer and whole health coach ("Peer-WHC") in coordination with primary care teams to reduce homeless veterans' frequent use of acute care.

DESIGN

Single-arm trial in three outpatient primary care clinics at a Veterans Health Administration (VHA) medical center; pre/post design using mixed-methods.

PARTICIPANTS

Twenty veterans from VHA's homeless registry who were super-utilizers of acute care and enrolled in primary care.

INTERVENTION

Weekly health coaching sessions with a peer over 12 weeks, including discussions of patients' health care utilization patterns and coordination with primary care.

MAIN MEASURES

Rates of session attendance and intervention fidelity, patient-reported satisfaction and changes in patient engagement and perceptions of health, pre/post utilization of acute and supportive care services, and qualitative interviews with multiple stakeholders to identify barriers and facilitators to implementation.

KEY RESULTS

On average, patients attended 6.35 sessions (SD = 3.5, Median = 7). Satisfaction scores (M = 28.75 out of 32; SD = 2.79) exceeded a priori benchmarks. Patients' perceptions of health improved from pre to post [t(df)=-2.26(14), p = 0.04]. In the 3-months pre/post, 45% (n = 9) and 15% (n = 3) of patients, respectively, were hospitalized. Qualitative feedback from patients, providers, and peers and fidelity metrics suggested value in increasing the length of the intervention to facilitate goal-setting with patients and coordination with primary care.

CONCLUSION

Findings support the feasibility, acceptability, and utility of Peer-WHC to address the healthcare needs of homeless veterans. A future trial is warranted to test the impact of Peer-WHC on reducing these patients' frequent use of acute care.

Identifying Risk Factors for Hospitalization with Behavioral Health Disorders and Concurrent Temperature-Related Illness in New York State

Extreme temperature events are linked to increased emergency department visits, hospitalizations, and mortality for individuals with behavioral health disorders (BHD). This study aims to characterize risk factors for concurrent temperature-related illness among BHD hospitalizations in New York State. Using data from the NYS Statewide and Planning Research and Cooperative System between 2005-2019, multivariate log binomial regression models were used in a population of BHD hospitalizations to estimate risk ratios (RR) for a concurrent heat-related (HRI) or cold-related illness (CRI). Dementia (RR 1.65; 95% CI:1.49, 1.83) and schizophrenia (RR 1.38; 95% CI:1.19, 1.60) were associated with an increased risk for HRI among BHD hospitalizations, while alcohol dependence (RR 2.10; 95% CI:1.99, 2.22), dementia (RR 1.52; 95% CI:1.44, 1.60), schizophrenia (RR 1.41; 95% CI:1.31, 1.52), and non-dependent drug/alcohol use (RR 1.20; 95% CI:1.15, 1.26) were associated with an increased risk of CRI among BHD hospitalizations. Risk factors for concurrent HRI among BHD hospitalizations include increasing age, male gender, non-Hispanic Black race, and medium hospital size. Risk factors for concurrent CRI among BHD hospitalizations include increasing age, male gender, non-Hispanic Black race, insurance payor, the presence of respiratory disease, and rural hospital location. This study adds to the literature by identifying dementia, schizophrenia, substance-use disorders, including alcohol dependence and non-dependent substance-use, and other sociodemographic factors as risk factors for a concurrent CRI in BHD hospitalizations.

Housing Status as a Predictor for Outpatient Care Following an Emergency or Urgent Care Encounter with a Behavioral Health Diagnosis: A Multivariable Analysis

Individuals without stable housing experience high rates of mental illness and seek behavioral health care in emergency care settings. Little is known about the effect of homelessness on outpatient follow-up after utilizing emergency or urgent care for behavioral health care. Patient encounters with behavioral health diagnoses among 7 emergency department (ED) or urgent care (UC) locations over 4 years were used to determine the correlation between housing status and outpatient follow-up within 90 days. Of 1,160,386 visits by 269,615 unique patients, 55,738 (23%) encounters included a behavioral health diagnosis. Patients with stable housing were twice as likely to follow up with a primary care provider (PCP) and with an outpatient behavioral health provider than patients without housing (aOR 2.60; aOR 2.00, p < 0.0001). Homelessness is associated with difficulty in accessing follow-up behavioral health care. UCs and EDs may use specific interventions to improve outpatient follow-up.

Engaging health professions students in community-based service learning through the design of a needs assessment survey

Background: Interprofessional student participation in community-based service learning projects is critically important for the preparation of future health professionals to care for underserved and vulnerable populations. Oftentimes, there is a disconnect between existing community services and the actual needs of individuals being served, such as those experiencing homelessness. A best practice of launching a new service learning project is to begin with a needs assessment. This study describes the stepwise approach taken to guide students launching a new street medicine program in developing and administering a needs assessment survey and is generalizable to other student-led service learning outreaches. Methods: We conducted a needs assessment from April-June 2018 on 144 unsheltered homeless individuals in metro Phoenix, Arizona. The 16-question survey investigated perceptions of priority needs, sources of medical care, health literacy, and health status. Survey results were analyzed using Wilcoxon Rank Sum Test, chi-squared analysis, and multivariable logistic regression. Results: Most respondents (91.6%) identified food as a top need. The majority (64.1%) utilized emergency departments as their primary source of care, and 40.1% reported suboptimal health. Suboptimal health was more likely to be reported in those who expressed transportation (OR 3.03, 95% CI: 1.30-7.07) as a top priority need. Health illiteracy (OR 3.68, 95% CI: 0.76-17.9) was associated with suboptimal health, as was obtaining care at an Emergency Department (OR 2.05, 95% CI: 0.81-5.25). Conclusions: Pairing healthcare with meals and other primary needs may be an effective strategy to increase service utilization by this population. Future needs assessments should consider implementing open-ended questions to better assess the holistic needs of study populations and match community partner organization services with these needs. Needs assessments provide an opportunity for health professional students to learn about social needs and more effectively connect patients with services from community agencies and healthcare organizations.

Disruptions to U.S. local public health’s role in population-based substance use prevention and response during COVID-19

Background

COVID-19 dramatically limited the scale and scope of local health department (LHD) work, redirecting resources to the response. However, the need for essential public health services—including substance use prevention—was not reduced.

Methods

We examined six quantitative data sources, collected between 2016 and 2021, to explore the impact of the COVID-19 pandemic on LHD substance use-related services.

Results

Before the pandemic, the proportion of LHDs providing some level of substance use prevention services was increasing, and many were expanding their level of provision. During the pandemic, 65% of LHDs reduced their level of substance use-related service provision, but the proportion of LHDs providing some level of services remained steady from prior to COVID-19.

Conclusion

We discuss policy recommendations to mitigate the risk of service disruptions during future public health emergencies, including direct and flexible funding for LHDs and federal directives declaring substance use prevention services as essential.

Melanoma Identification and Management in an Unsheltered Male Using Teledermatology: Street Medicine Perspective

Skin cancers are concerning for unsheltered people experiencing homelessness because of their high levels of sun exposure. Currently, there is little data on the prevalence of skin cancers in people experiencing homelessness. Skin diseases are often untreated in people experiencing homelessness due to a lack of access to specialized care. Miami Street Medicine (MSM) is an organization that provides people experiencing homelessness in the Miami Health District with medical care in a nonclinical street setting, near overpasses, sidewalks, and encampments. We present a case of an unsheltered 59-year-old male with a pigmented, 2 cm × 2 cm facial lesion that developed over several years. Through a teledermatology consultation, his lesion was highly suspicious of melanoma and further evaluation was recommended. Due to a lack of insurance, he could not be treated at any dermatology clinic. Coincidentally, 2 weeks later, he developed cellulitis of his lower extremity and was admitted to the local safety-net hospital through the emergency department. By coordinating with his primary inpatient team, MSM was able to include a biopsy of the lesion as part of his hospital stay. The results demonstrated melanoma in situ. The vital course of action was to ensure treatment before metastasis. After registration for insurance and follow-up with a surgical oncology team, he is weeks away from excision and reconstruction surgery. His unsheltered status made follow-up difficult, but MSM bridged the gap from the street to the clinical setting by incorporating teledermatology into patient evaluations and leveraging connections with community shareholders such as charitable clinics and volunteer physicians. This case also represents the barriers to care for cancer-based dermatologic outreach among people experiencing homelessness.

Scoping review: Scope of practice of nurse-led services and access to care for people experiencing homelessness

AIMS

To investigate the scope of practice of nurse-led services for people experiencing homelessness, and the influence on access to healthcare.

DESIGN

A scoping review.

DATA SOURCES

On 20 November 2020, the following databases were searched: CINAHL, Embase, MEDLINE, PubMed and Scopus.

REVIEW METHODS

Included studies focused on people experiencing homelessness aged 18 years and over, nurse-led services in any setting and described the nursing scope of practice. Studies were peer-reviewed primary research, published in English from the year 2000. Three authors performed quality appraisals using the mixed methods assessment tool. Results were synthesized and discussed narratively and reported according to the PRISMA-ScR 2020 Statement.

RESULTS

Nineteen studies were included from the United States (n = 9), Australia (n = 4), United Kingdom (n = 4) and Canada (n = 2). The total participant sample size was n = 6303. Studies focused on registered nurses (n = 10), nurse practitioners (n = 5) or both (n = 4), in outpatient or community settings. The nursing scope of practice was broad and covered a range of skills, knowledge and attributes. Key skills identified include assessment and procedural skills, client support and health education. Key attributes were a trauma-informed approach and building trust through communication. Important knowledge included understanding the impact of homelessness, knowledge of available services and the capacity to undertake holistic assessments. Findings suggest that nurse-led care facilitated access to healthcare through building trust and supporting clients to access services.

CONCLUSION

Optimized nursing scope of practice can facilitate access to healthcare for people experiencing homelessness. Key factors in enabling this include autonomy in nursing practice, organizational support and education.

IMPACT

The broad range of skills, knowledge and attributes reported provide a foundation from which to design an educational framework to optimize the nursing scope of practice, thereby increasing access to healthcare for people experiencing homelessness.

Providers' reflections on infrastructure and improvements to promote access to care for Veterans experiencing housing instability in rural areas of the United States: A qualitative study

Veterans in rural areas of the United States face barriers to accessing healthcare and other services, which are intensified for those experiencing housing instability. Recent legislative acts have the potential to address obstacles faced by rural patients in the U.S. This study explores how infrastructure-including features related to the physical and digital environment-impacts the ability of rural Veterans experiencing housing instability to access healthcare and related services from the perspective of homeless service providers within the Veterans Health Administration (VHA). We conducted semi-structured telephone interviews (n = 22) with providers in high/low performing and/or resourced communities across the U.S. in May and June 2021 and analysed transcripts using template analysis. Themes described by providers highlight how infrastructure limitations in rural areas can exacerbate health disparities for Veterans experiencing housing instability, the impact of COVID-19 on service access, and recommendations to enhance service delivery. Providers suggested that VHA reconfigure where and how staff work, identify additional resources for transportation and/or alternative transportation models, and increase Veterans' access to technology and broadband Internet. Federal infrastructure investments should address challenges faced by Veterans experiencing housing instability in rural areas and the concerns of providers connecting them with care.

Addressing health needs of the homeless in Delhi: Standardising on the issues of Street Medicine practice

Due to barriers in accessing and using healthcare services, a large proportion of the care homeless populations receive comes from informal providers. In Delhi, one such informal programme, called Street Medicine, provides healthcare outreach to homeless communities. Clinical practice guidelines are set to be developed for Street Medicine teams in India and form the object of this research. This study uses a social-ecological model to understand the barriers facing Street Medicine teams and the homeless as they attempt to address the latter's healthcare needs; coupling it with an analytical approach which situates these barriers as the issues within practice through which standardisation can take place. A qualitative inquiry, comprising three months of observations of Street Medicine outreach and interviews with over 30 key informants, was conducted between April and July 2018. The analysis identified novel barriers to addressing the needs of homeless individuals, which bely a deficit between the design of health and social care systems and the agency homeless individuals possess within this system to influence their health outcomes. These barriers - which include user-dependent technological inscriptions, collaborating with untargeted providers and the distinct health needs of homeless individuals - are the entry points for standardising, or opening up, Street Medicine practices .

What do Veterans with homeless experience want us to know that we are not asking? A qualitative content analysis of comments from a national survey of healthcare experience

Surveys of people who experience homelessness can portray their life and healthcare experiences with a level of statistical precision; however, few have explored how the very same surveys can deliver qualitative insights as well. In responding to surveys, people experiencing homelessness can use the margins to highlight health and social concerns that investigators failed to anticipate that standard question batteries miss. This study describes the unprompted comments of a large national survey of Veterans with homeless experiences. The Primary Care Quality-Homeless Services Tailoring (PCQ-HOST) survey presented 85 close-ended items to solicit social and psychological experiences, health conditions, and patient ratings of primary care. Amongst 5377 Veterans responding to the paper survey, 657 (12%) offered 1933 unprompted comments across nearly all domains queried. Using a team-based content analysis approach, we coded and organised survey comments by survey domain, and identified emergent themes. Respondents used comments for many purposes. They noted when questions called for more nuanced responses than those allowed, especially 'sometimes' or 'not applicable' on sensitive questions, such as substance use, where recovery status was not queried. On such matters, the options of 'no' and 'yes' failed to capture important contextual and historical information that mattered to respondents, such as being in recovery. Respondents also elaborated on negative and positive care experiences, often naming specific clinics or clinicians. This study highlights the degree to which members of vulnerable populations, who participate in survey research, want researchers to know the reasons behind their responses and topics (like chronic pain and substance use disorders) that could benefit from open-ended response options. Understanding patient perspectives can help improve care. Quantitative data from surveys can provide statistical precision but may miss key patient perspectives. The content that patients write into survey margins can highlight shortfalls of a survey and point towards future areas of inquiry. Veterans with homeless experience want to provide additional detail about their lives and care experiences in ways that transcend the boundaries of close-ended survey questions. Questions on substance use proved especially likely to draw comments that went beyond the permitted response options, often to declare that the respondent was in recovery. Respondents frequently clarified aspects of their care experiences related to pain, pain care, transportation and experiences of homelessness.

Association of Social Needs and Housing Status Among Urban Emergency Department Patients

Introduction

People experiencing homelessness have high rates of social needs when presenting for emergency department (ED) services, but less is known about patients with housing instability who do not meet the established definitions of homelessness.

Methods

We surveyed patients in an urban, safety-net ED from June–August 2018. Patients completed two social needs screening tools and responded to additional questions on housing. Housing status was determined using validated questions about housing stability.

Results

Of the 1,263 eligible patients, 758 (60.0%) completed the survey. Among respondents, 40% identified as Latinx, 39% Black, 15% White, 5% Asian, and 8% other race/ethnicities. The median age was 42 years (interquartile range [IQR]: 29–57). and 54% were male. Of the 758 patients who completed the survey, 281 (37.1%) were housed, 213 (28.1%) were unstably housed, and 264 (34.8%) were homeless. A disproportionate number of patients experiencing homelessness were male (63.3%) and Black (54.2%), P <0.001, and a disproportionate number of unstably housed patients were Latinx (56.8%) or were primarily Spanish speaking (49.3%), P <0.001. Social needs increased across the spectrum of housing from housed to unstably housed and homeless, even when controlling for demographic characteristics.

Conclusion

Over one in three ED patients experience homelessness, and nearly one in three are unstably housed. Notable disparities exist by housing status, and there is a clear increase of social needs across the housing spectrum. Emergency departments should consider integrating social screening tools for patients with unstable housing.

[Analysis of the homeless population health in a disadvantaged district of Barcelona: ESSELLA study]

Objetivo

Conocer el estado de salud de la población sin hogar.

Diseño

Estudio descriptivo transversal.

Emplazamiento

Centro de Salud de Atención Primaria de Raval Sud (Barcelona).

Participantes

Personas mayores de edad en situación de sinhogarismo que han pernoctado en la calle en algún momento.

Mediciones principales

Datos sociodemográficos y tiempo en situación de sinhogarismo. Patologías crónicas, enfermedades infecciosas transmisibles, enfermedades mentales y trastornos por uso de sustancias adictivas. Cuestionario HAD sobre ansiedad y depresión. Cuestionario CVRS EQ-5D-3L. Estadística descriptiva.

Resultados

Se analizó la información de 146 pacientes con una media de edad de 51,6 años (DE = 12,8), 87% de sexo masculino y una media de 12 años (DE = 11,9) en situación de sinhogarismo. Se comparó la carga de enfermedad entre el perfil CAS Drogodependencias (Baluard) y el perfil sociosanitario (Arrels Fundació). Los usuarios del CAS presentaron mayores porcentajes de trastornos por uso de sustancias, enfermedades mentales y enfermedades infecciosas transmisibles. Las personas de perfil sociosanitario presentaron en mayor porcentaje enfermedades crónicas (respiratorias, cardiovasculares y oncológicas) y más de la mitad presentaron un trastorno por uso de alcohol y un mayor porcentaje de enfermedad asociada a su consumo.

Conclusiones

La población sin hogar presenta una elevada carga de enfermedad especialmente para enfermedad mental, adicciones y enfermedades infecciosas transmisibles. Creemos que son necesarios estudios para evaluar el exceso de enfermedad respecto a la población general con sus costes derivados y el diseño de nuevas estrategias para atender dicha carga de enfermedad y su especificidad.

Differences in disease prevalence among homeless and non-homeless veterans at an urban VA hospital

OBJECTIVES

Approximately 10% of homeless adults in the US are veterans and that number is increasing. Veterans who experience homelessness tend to do so for longer periods compared to non-veterans; and homelessness is associated with more chronic disease complications. We compared the prevalence of five chronic, ambulatory-care sensitive conditions in homeless and domiciled individuals who received primary care at an urban VA hospital.

METHODS

Data were obtained from the Veteran's Hospital Administration clinical data warehouse. Differences in disease prevalence were compared between the two groups using chi-square analyses and then adjusted for age, gender, race/ethnicity, BMI, and other risk factors where appropriate, using logistic regression. All analyses were conducted using SAS version 9.4.

RESULTS

Homeless individuals were 46% more likely to have asthma (OR 1.46, 95% CI 1.16-1.84) and 40% more likely to have COPD (OR 1.40, 95% CI 1.14-1.73) after adjustment for age, gender, race/ethnicity, BMI, and tobacco use status. After adjustment for covariates, there was no difference between homeless and domiciled veterans in the prevalence of diabetes, hypertension, or congestive heart failure.

DISCUSSION

Future quality improvement projects should identify social-environmental risk factors like employment characteristics, and housing quality that can impact chronic respiratory illness prevalence and associated complications.

Chronic diseases and multi-morbidity in persons experiencing homelessness: results from a cross-sectional study conducted at three humanitarian clinics in Germany in 2020

Background

Persons experiencing homelessness (PEH) suffer a high burden of chronic diseases and multi-morbidity, yet face significant barriers in accessing healthcare services. These health inequalities were further aggravated during the COVID-19 pandemic. While there is a lack of comprehensive health data on PEH, even less is known about populations experiencing housing exclusion, a hidden form of homelessness. This study examines and compares chronic diseases and multi-morbidity in PEH, persons experiencing housing exclusion, and persons with secure housing who lacked access to regular healthcare services in the wake of the COVID-19 pandemic in Germany.

Methods

Study participants were adults who sought medical care at clinics of the humanitarian organisation “Ärzte der Welt” in Munich, Hamburg and Berlin in 2020. The patients were categorised into three housing groups according to the ETHOS classification of homelessness and housing exclusion. Socio-demographic characteristics, self-rated health, chronic diseases and multi-morbidity were described in each group. Logistic regression analysis was used to identify socio-demographic factors associated with higher odds of chronic diseases and multi-morbidity in each housing group.

Results

Of the 695 study participants, 333 experienced homelessness, 292 experienced housing exclusion and 70 had secure housing. 92.3% of all patients had either no or limited health coverage, and 96.7% were below the poverty line. Males and EU/EEA citizens were highly represented among PEH (74.2% and 56.8% respectively). PEH had lower self-rated health (47.8%, p = 0.04), and a higher prevalence of psychiatric illness (20.9%, p = 0.04). In adjusted analyses, belonging to the age group 35–49 and ≥ 50 years were associated with greater odds of chronic disease (AOR = 2.33, 95% CI = 1.68–3.24; AOR = 3.57, 95% CI = 2.55–5.01, respectively) while being ≥ 50 years old was associated with multi-morbidity (AOR = 2.01, 95% CI = 1.21, 3.33). Of the 18 participants tested for SARS-COV-2, 15 were PEH, 1 of whom tested positive.

Conclusions

Housing status was not an independent risk factor for chronic disease and multi-morbidity in our study population. However, PEH reported poorer self-rated and psychiatric health. Strategies to improve access to healthcare services amongst persons experiencing homelessness and housing exclusion are needed in Germany.

A qualitative investigation of organizational challenges and facilitators to screening individuals experiencing homelessness for hepatitis C virus (HCV) in Houston, Texas

Background

Individuals experiencing homelessness may be at a disproportionately high risk for hepatitis C (HCV) because they may be more likely to engage in HCV risk behaviors. Community organizations that provide services to these vulnerable individuals can effectively screen, diagnose, and navigate them into HCV care. However, screening people experiencing homelessness for HCV at such organizations is limited by various challenges that remain understudied, including budgetary considerations and strategies to improve teamwork and communication. Accordingly, this study investigated the organizational challenges and facilitators to HCV screening of individuals experiencing homelessness as reported by homeless services providers.

Methods

Staff (N = 21) at two community organizations in Houston, Texas, completed an interviewer-administered survey and a semi-structured interview in August 2020 to assess the challenges and facilitators to screening people experiencing homelessness for HCV. Interviews were coded, and a thematic analysis was conducted to identify challenges as well as facilitators to HCV screening among individuals experiencing homelessness.

Results

Almost half of participants were employed in social services (42.86%; n = 9), while the remainder were employed in management/administration and health services. Barriers to HCV screening included funding, logistics, and resource-related challenges; and limited communication and collaboration around HCV screening. Facilitators to HCV screening included providing HCV education and training for all staff; and incentivizing, formalizing, and funding HCV screening.

Conclusions

Community organizations can help minimize barriers to HCV screening among individuals experiencing homelessness by providing staff with training specific to HCV, client education around HCV and the screening process, and providing clients with incentives for participation, as well as by maximizing community and clinic partnerships to provide linkage to care and services to this high-risk population.

Counter-Narratives of Structural Oppressions, Stigma and Resistance, and Reproductive and Sexual Health Among Youth Experiencing Homelessness

Youth experiencing homelessness (YEH) face myriad injustices regarding their reproductive and sexual health and rights. Reproductive and sexual health research with YEH often explores condom-use and sexually transmitted infections, potentially contributing to narrow conceptualizations of YEH as "unclean" or in need of disease-screening. A narrative theory perspective was applied to this study, which allowed for the emergence of alternative storylines, or counter-narratives, which attend to manifestations of power and oppression within the lives of marginalized individuals. Qualitative interviews engaged 30 young people (ages 18-21) accessing shelter services. Narrative analyses identified YEHs' documentations of dominant narratives related to structural oppressions, stigma, and numerous dimensions of reproductive and sexual health including how they create, through their resistance, counter-narratives that include their preferred futures. YEH emphasized systemic sources of stigma and outlined their criticisms of the state. Within-group stigma emerged as a noteworthy theme, with YEH showing both empathy and ambivalence towards other YEH, along with internalization of stigmatizing narratives about pregnancy and homelessness. Approaches to service provision that further amplify youths' voices in naming and challenging the many oppressions and stigmas they face should be prioritized. Moreover, policies should be implemented to dismantle the actual root causes of challenges faced by YEH, rather than perpetuating them through measures rooted in interlocking oppressions of discrimination, inequity, and judgment.

Health Care Needs of Young Adults Who Have Experienced Homelessness

INTRODUCTION

Young adults experiencing homelessness have poorer overall health compared with the general population. However, not much is known about how health care needs may change in the transition from homelessness to supportive housing. This study utilizes the Gelberg-Andersen Behavioral Model for Vulnerable Populations to examine unmet health care needs among young adults currently experiencing homelessness and formerly homeless young adults living in supportive housing.

METHODS

This study includes data from 192 young adults who were either residing in a supportive housing program (n=103) or were "unhoused" (eg, residing on the street, staying in emergency shelters; n=89) in Los Angeles, CA, between 2017 and 2019. Hierarchical modeling examined unmet health care needs and factors that may enable those needs to be met, controlling for predisposing and other need factors.

RESULTS

Controlling for predisposing and other need characteristics, this study identified increased enabling factors among those residing in supportive housing, the most widely applied intervention for homelessness. Participants who resided in supportive housing were more likely to report at least 1 type of unmet need than youth who did not have access to housing. Additional findings regarding the association of enabling factors and unmet need yield mixed results based on the type of unmet need.

DISCUSSION

The acknowledgment of unmet needs may, in fact, be a byproduct of shifting priorities, which often occurs in the transition from homelessness to housing. Understanding the unmet need and health implications of this transition has relevance for practice as we work to better support formerly homeless young adults in meeting the needs that they identify.