Characteristics of emergency department visits by older versus younger homeless adults in the United States

Predictors and consequences of homelessness in whole-population observational studies that used administrative data: a systematic review

BACKGROUND

Homelessness is a complex societal and public health challenge. Limited information exists about the population-level health and social care-related predictors and consequences of persons with lived experience of homelessness (PEH). Studies that focus on population subgroups or ad hoc questionnaires to gather data are of relatively limited generalisability to whole-population health surveillance and planning. The aim of this study was to find and synthesise information about the risk factors for, and consequences of, experiencing homelessness in whole-population studies that used routine administrative data.

METHOD

We performed a systematic search using EMBASE, MEDLINE, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO research databases for English-language studies published from inception until February 2023 that reported analyses of administrative data about homelessness and health and social care-related predictors and consequences. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Of the 1224 articles reviewed, 30 publications met the inclusion criteria. The included studies examined a wide range of topic areas, and the homelessness definitions used in each varied considerably. Studies were categorised into several topic areas: Mortality, morbidity and COVID-19; health care usage and hospital re-admission; care home admission and shelter stay; and other (e.g. employment, crime victimisation). The studies reported that that the physical and mental health of people who experience homelessness was worse than that of the general population. Homeless individuals were more likely to have higher risk of hospitalisation, more likely to use emergency departments, have higher mortality rates and were at greater risk of needing intensive care or of dying from COVID-19 compared with general population. Additionally, homeless individuals were more likely to be incarcerated or unemployed. The effects were strongest for those who experienced being homeless as a child compared to those who experienced being homeless later on in life.

CONCLUSIONS

This is the first systematic review of whole-population observational studies that used administrative data to identify causes and consequences associated with individuals who are experiencing homelessness. While the scientific literature provides evidence on some of the possible risk factors associated with being homeless, research into this research topic has been limited and gaps still remain. There is a need for more standardised best practice approaches to understand better the causes and consequences associated with being homeless.

Predictors and Consequences of Homelessness: Protocol for a Cohort Study Design Using Linked Routine Data

BACKGROUND

Homelessness is a global burden, estimated to impact more than 100 million people worldwide. Individuals and families experiencing homelessness are more likely to have poorer physical and mental health than the general population. Administrative data is being increasingly used in homelessness research.

OBJECTIVE

The objective of this study is to combine administrative health care data and social housing data to better understand the consequences and predictors associated with being homeless.

METHODS

We will be linking health and social care administrative databases from Northern Ireland, United Kingdom. We will conduct descriptive analyses to examine trends in homelessness and investigate risk factors for key outcomes.

RESULTS

The results of our analyses will be shared with stakeholders, reported at conferences and in academic journals, and summarized in policy briefing notes for policymakers.

CONCLUSIONS

This study will aim to identify predictors and consequences of homelessness in Northern Ireland using linked housing, health, and social care data. The findings of this study will examine trends and outcomes in this vulnerable population using routinely collected health and social care administrative data.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42404.

Homelessness and the use of Emergency Department as a source of healthcare: a systematic review

BACKGROUND

Persons experiencing homelessness (PEH) often use hospital Emergency Department (ED) as the only source of healthcare. The aim of this study was to undertake a systematic review to identify the prevalence, clinical reasons and outcomes in relation to ED visits by PEH.

METHODS

A protocol-led (CRD42020189263) systematic review was conducted using search of MEDLINE, EMBASE, CINAHL and Google Scholar databases. Studies that reported either the prevalence of homelessness in the ED or clinical reasons for presentation to ED by PEH and published in English language were included. Definitions of homelessness used by study authors were accepted.

RESULTS

From the screening of 1349 unique titles, a total of 36 studies were included. Wide variations in the prevalence and key cause of presentations were identified across the studies often linked to differences in country, study setting, disease classification and data collection methods. The proportion of ED visits contributed by PEH ranged from 0.41 to 19.6%. PEH made an average of 0.72 visits to 5.8 visits per person per year in the ED [rate ratio compared to non-homeless 1.63 to 18.75]. Up to a third and quarter of the visits were contributed by alcohol-related diagnoses and substance poisoning respectively. The percentage of PEH who died in the ED ranged from 0.1 to 0.5%.

CONCLUSIONS

Drug-, alcohol- and injury-related presentations dominate the ED visits by PEH. Wide variations in the data were observed in regard to attendance and treatment outcomes. There is a need for prevention actions in the community, integrated discharge and referral pathways between health, housing and social care to minimise frequent usage and improve attendance outcomes.

Barriers and Facilitators to Resolving Older Adult Homelessness through Stays with Family: Qualitative findings from the HOPE HOME Study

Living with family and friends is a common strategy used to prevent or exit homelessness, but little is known about structural barriers that impede family and friends' ability to provide temporary or permanent housing for older homeless adults. We conducted semi-structured interviews with 46 homeless participants from the HOPE HOME study, a cohort of 350 community-recruited homeless adults age 50 or older in Oakland, CA, who reported having stayed with housed family/friends for 1 or more nights in the prior 6 months. We conducted semi-structured interviews with 19 hosts of homeless participants and 11 stakeholders in housing and homelessness. We found that homeless older adults and hosts perceived staying with family or friends as a form of temporary housing rather than as a permanent exit to homelessness. Structural barriers to family and friends providing housing for temporary stays or permanent exits from homelessness included housing regulations restricting visitors and changing rent obligations; decreased eligibility and priority for shelter and permanent housing; geographic and transportation challenges; and environments inconducive to older adults. We suggest four areas for policy reform: providing subsidies to hosts and homeless individuals, removing disincentives for homeless older adults to stay with family, changing lease regulations, and expanding the supply of affordable housing.

Exploring Foot Care Conditions for People Experiencing Homelessness: A Community Participatory Approach

Introduction:

People experiencing homelessness are faced with complex challenges and are at high risk of illness due to inequities and disparities in access to health care services.

Objective:

To explore the health and foot care problems related to people experiencing homelessness in British Columbia.

Methods:

A community participatory research approach was used with a sample of 65 people experiencing homelessness. Data were collected using a survey questionnaire and face-to-face semistructured interviews.

Results:

Thematic findings shows risk of foot injuries, lack of foot care resources, and absence of family support. Barriers to equitable access to services for most participants experiencing homelessness were lack of housing (76.92%), inability to work (72.31%), and inability to afford the cost of living on their own (63.08%).

Conclusions:

There is a pressing need for early screening and detection by health care professionals and enhanced foot care services to reduce foot problems and improve foot care wellness of homeless people. Addressing foot-related care are necessary steps in promoting health, preventing illness, and improving access to health services among people experiencing homelessness.

Assessment and Diagnosis of Mental Illness in EDs Among Individuals Without a Home: Findings from the National Hospital Ambulatory Care Survey

INTRODUCTION

Homeless individuals lack resources for primary healthcare and as a result use the emergency department (ED) as a social safety net. Our primary objective in this study was to identify the differences between features of visits to United States (US) EDs made by patients without a home and patients who live in a private residence presenting with mental health symptoms or no mental health symptoms at triage.

METHODS

Data for this study come from the 2009-2017 National Health and Ambulatory Medical Care Survey, a nationally representative cross-sectional survey of ED visits in the US. We examined differences in waiting time, length of visit, and triage score among homeless patients, and privately housed and nursing home residents. We used logistic regression to determine the odds of receiving a mental health diagnosis. Residence, age, gender, race, urgency, and whether the person was seen in the ED in the previous 72 hours were controlled.

RESULTS

Homeless individuals made up less than 1% of all ED visits during this period. Of these visits, 47.2% resulted in a mental health diagnosis compared to those who live in a private residence. Adjusting for age, race, gender, triage score, and whether the person had been seen in the prior 72 hours, homeless individuals were still six times more likely to receive a mental health diagnosis despite reporting no mental health symptoms compared to individuals who lived in a private residence. Homeless individuals reporting mental health symptoms were two times more likely to receive a mental health diagnosis compared to privately housed and nursing home residents.

CONCLUSIONS

Homeless individuals are more likely to receive a mental health diagnosis in the ED whether or not they present with mental health symptoms at triage. This study suggests that homelessness as a status impacts how these individuals receive care in the ED. Community coordination is needed to expand treatment options for individuals experiencing emergent mental health symptoms.

Trends in homelessness and injection practices among young urban and suburban people who inject drugs: 1997-2017

BACKGROUND

Among young people who inject drugs (PWID) homelessness is associated with numerous adverse psychosocial and health consequences, including risk of relapse and overdose, psychological distress and suicidality, limited treatment access, and injection practices that increase the risk of HIV and hepatitis C (HCV) transmission. Homeless PWID may also be less likely to access sterile syringes through pharmacies or syringe service programs.

METHODS

This study applied random-effects meta-regression to examine trends over time in injection risk behaviors and homelessness among young PWID in Chicago and surrounding suburban and rural areas using data from 11 studies collected between 1997 and 2017. In addition, subject-level data were pooled to evaluate the effect of homelessness on risk behaviors across all studies using mixed effects logistic and negative binomial regression with random study effects.

RESULTS

There was a significant increase in homelessness among young PWID over time, consistent with the general population trend of increasing youth homelessness. In mixed-effects regression, homelessness was associated with injection risk behaviors (receptive syringe sharing, syringe mediated sharing, equipment sharing) and exchange sex, though we detected no overall changes in risk behavior over time.

CONCLUSIONS

Increases over time in homelessness among young PWID highlight a need for research to understand factors contributing to youth homelessness to inform HIV/STI, HCV, and overdose prevention and intervention services for this population.

Characteristics of Emergency Department Visits by Homeless Young Adults in the U.S

PURPOSE

Homeless young adults often seek health care at emergency departments (EDs) after they are no longer able to ignore a pressing health problem. However, a dearth of literature examines homeless young adults' ED visits. This study aimed to increase understanding of ED visits among homeless young adults within the U.S.

METHODS

Data for this study were obtained from the 2011-2015 National Hospital Ambulatory Medical Care Survey. The sample for this study included all ED visits made by homeless and housed young adults aged 18-29 years (unweighted N = 25,068).

RESULTS

ED visits by homeless young adults were distinguished in terms of gender, region, payment sources, and triage level. Furthermore, ED visits made by homeless young adults were more likely related to mental health and suicide. Homeless young adults' ED visits were characterized by a longer average length of stay and were less likely to be referred to a physician or clinic for follow-up, given medication, or have a procedure performed in the ED.

CONCLUSIONS

This study highlighted differences in ED utilization for homeless young adults. The findings of this study suggest a need to further examine the characteristics of ED services received by homeless young adults to better understand differences in ED service receipt related to housing status. This knowledge can inform efforts to reduce costs through improving access to housing and outpatient mental health care and reducing stigma among health care professionals to ensure continuity of care.

Typology of Currently or Formerly Homeless Individuals Based on Their Use of Health and Social Services

This study identified profiles among 455 currently or formerly homeless individuals in Quebec (Canada), based on health and social service use. Using latent class analysis, four profiles were identified that grouped individuals with: (1) few health problems, and using few case managers and family doctors, but with high frequency of psychiatric consultations, emergency department (ED) visits and hospitalizations; (2) chronic physical illnesses, having case managers and family doctors, but low frequency of ED visits and hospitalizations; (3) moderate health problems and little service use; and (4) multiple and complex health problems and high frequency of service use. These profiles suggest the following recommendations to more adequately meet patient needs: regarding Class 1, improved outreach services, more ED liaison nurses and peer navigation; Class 2: more family doctors and case managers; Class 3: higher family doctors; and Class 4: more assertive or intensive case management, harm reduction and permanent housing resources.

Determinants of suicidal ideation and suicide attempt among former and currently homeless individuals

PURPOSES

This study identified determinants associated with suicidal ideation, suicide attempt and no suicidal behavior in a 12-month period among 455 former or currently homeless individuals in Quebec (Canada).

METHODS

Study recruitment took place in 27 organizations located in two major Quebec urban areas, where services for homelessness are offered. Independent variables including clinical, socio-demographic, and service use/outcome variables were measured with eight standardized instruments. Significant associations between these variables and suicidal ideation or attempt in bivariate analyses were produced to build a multinomial logistic regression model using a block approach.

RESULTS

Of 455 participants, 72 (15.8%) reported suicidal ideation and 30 (6.6%) suicide attempt, while 353 (77.6%) had not experienced suicidal behavior. Suicide ideation was particularly high among those with generalized anxiety disorder and substance use disorders, and suicide attempt even higher. Participants with higher functional disability and hospitalizations had a higher incidence of suicide attempt, whereas participants with schizophrenia spectrum and other psychotic disorders, those placed in foster care during childhood and with higher stigma scores experienced more suicidal ideation.

CONCLUSIONS

Suicidal ideation and suicide attempt among currently or recently homeless individuals were both strongly associated with clinical variables. Based on the study results, specific interventions may be promoted to improve screening of homeless individuals with suicidal behavior and prevent hospitalization such as training programs and brief care management interventions, addiction liaison nurses, improved access to primary or specialized ambulatory services, and further development of case management and outreach programs for homeless individuals, especially those with functional disabilities.

The Efficacy of the Geriatric Model of Care in Emergency Housing Programs for Homeless Veterans

INTRODUCTION

The aging homeless population currently makes up half the general homeless population. However, there are few homeless emergency shelters that can address their needs. This results in an overutilization of inpatient admissions and emergency room services.

METHODS

Homeless service staff from VA Palo Alto Health Care System partnered with a local homeless emergency housing provider, Compassion Residio Services Inc., to implement this new model of care for aging, medically fragile homeless Veterans. This emergency housing model utilizes practices done in geriatric settings. This model aimed to help decrease the utilization of emergency departments and inpatient admissions.

RESULTS

The average cost of emergency department visits and inpatient admissions was $127,314 per Veteran 6 months before admission. Six months after discharge, the average cost of treatment from emergency department visits and inpatient admissions was roughly $59,546 after discharge, a 53% decrease. Emergency department visits decreased from an average of 5.6 visits per Veteran 6 months before admission to 2.65 visits after 6 months discharge. The number of inpatient nights decreased from an average of 15 days per admission in the 6 months before the program to 13 days. Total admissions decreased by nearly half from 48 the previous 6 months to 25 after 6 months.

DISCUSSION

Overall, as residents settled into stable environments tailored around geriatric care, the utilization of emergency department visits and inpatient services decreased. Furthermore, the complexity (eg, cost per encounter) also decreased.

Physical and Behavioral Health Characteristics of Aging Homeless Women in the United States: An Integrative Review

Background: The average age of the homeless population is and will continue to rise. Although women comprise a significant and growing percentage of this vulnerable population, their age- and sex-specific health characteristics are poorly understood. Materials and Methods: This integrative review appraises published research addressing the physical and behavioral health characteristics of aging homeless women (≥50 years) in the United States (2000-2019). The authors searched six electronic databases to identify eligible studies. Studies were screened for methodological quality by using the Johns Hopkins Nursing Evidence-Based Practice model. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results: Ten primary studies met the review eligibility criteria. All were level III (non-experimental); nine appraised as "good" quality (level B), and one as "lower" quality (level C). Aging homeless women demonstrate elevated rates of physical health conditions, related to suboptimal nutrition, lower than expected preventive health screening uptake, and geriatric concerns. Disproportionate rates of mental health conditions are compounded by substance use and interpersonal trauma. Familial and social dynamics and socioeconomic disadvantage contribute to social health concerns. Spiritual health is a critically important yet underexplored protective factor. Conclusions: Studies are limited, though collective findings suggest that aging homeless women endure a disproportionate physical, behavioral, and social health burden compared with aging non-homeless women and aging homeless men. Implications for research on early aging, preventative health strategies, and homelessness among women, and clinical practice in the context of geriatric and women's health are described.

Homeless people under the influence of alcohol admitted to hospital emergency departments in Poland

Aim:

To assess the incidence of diagnoses related to alcohol use in the population of homeless people admitted to hospital emergency departments (EDs).

Material and method:

Data were analysed from three hospitals concerning stays of homeless people in three EDs in Bydgoszcz, Poland, in 2013–2015; 3133 stays were identified. The data were compiled using Microsoft Excel and Statistica 10 statistical software.

Results:

At the time of admission to EDs, 31% of homeless people were considered to be under the influence of alcohol. Diagnoses related to alcohol use accounted for 25% of all diagnoses. The average blood alcohol concentration in the patients was 2.97 per mille. The average blood alcohol concentration in the group of men was significantly higher than that in the group of women (p = 0.015). The average length of stay in the ED of patients under the influence of alcohol was significantly longer (p < 0.0001) than among sober patients.

Conclusions:

Homeless people under the influence of alcohol account for a third of the population of homeless patients admitted to hospital emergency departments, while alcohol-related ICD-10 diagnoses account for a fourth of all diagnoses in these patients. Homeless patients under the influence of alcohol stay longer in hospital emergency departments than do sober homeless people, which may translate into more frequent acts of aggression towards medical personnel. In Poland there are no systemic ED-level solutions as regards dealing with homeless patients for whom alcohol dependence is in many cases a reality.

Exploring the Association of Community Integration in Mental Health among Formerly Homeless Individuals Living in Permanent Supportive Housing

Supportive housing has been widely used among persons experiencing chronic homelessness and/or mental health conditions. While it has been demonstrated to be effective in addressing homelessness among populations with complex needs, community integration remains a challenge. Community integration is the extent to which individuals live, participate, and socialize in their community and consists of three aspects: physical, social, and psychological. The study utilized data from the Transitions to Housing project that followed formerly homeless individuals (N = 383) throughout their first year of residence in permanent supportive housing (PSH). The study set out to examine which aspects of community integration are associated with mental health symptoms in this population. Five nested multivariate linear regression models were conducted and then compared. The model that accounted for demographics, substance use, neighborhood quality, and all three aspects of community integration simultaneously was the best fit and explained the most variance in mental health symptoms (24%). The complete model suggested higher levels of psychological integration were significantly associated with decreased mental health symptoms in this sample. This finding suggests fostering a sense of belonging among PSH residents could improve mental health outcomes. Implications for practice and future research are discussed.

Le soutien postlogement transitoire auprès des femmes en situation d’itinérance : besoins, implantation et impact d’une étude pilote

Objectifs Les dispositifs de soutien en logement sont parmi les solutions soutenues pour contrer l’itinérance. Le logement transitoire (LT) offre une trajectoire séquentielle d’accès à la stabilité résidentielle : des refuges au LT, au logement permanent avec ou sans soutien. Le suivi post-LT permettrait d’améliorer la stabilité résidentielle et l’intégration communautaire. Néanmoins, peu d’informations sont disponibles sur les conditions de succès et la capacité du suivi post-LT à améliorer la stabilité résidentielle et l’intégration communautaire des personnes itinérantes, en particulier les femmes. Cette étude de cas pilote visait à identifier les besoins de femmes recevant du suivi post-LT, l’implantation des activités de suivi et ses conditions de succès, ainsi que son impact en réponse aux besoins exprimés.

Méthode Deux organismes à but non lucratif ont été sélectionnés à Montréal. Une étude de cas à partir de méthodes mixtes a permis de trianguler les données provenant de femmes en situation d’itinérance, de leurs intervenantes et des gestionnaires de ressources de suivi post-LT. Deux entretiens ont été menés à un intervalle de 6 mois avec ces femmes (n = 10). Les besoins et l’impact du suivi post-LT ont été mesurés grâce à un questionnaire (questions ouvertes et fermées). Pour documenter l’implantation du suivi, des informations ont été colligées auprès des intervenantes (n = 2) sur les activités et l’intensité des services offerts à l’aide de fiches de contact. Des facteurs facilitant et entravant le suivi post-LT ont également été identifiés lors d’une entrevue de groupe avec les intervenantes (n = 2) et les gestionnaires (n = 4).

Résultats Les usagères ont identifié des besoins liés à la santé, aux activités quotidiennes et à l’intégration sociale. La plupart des femmes étaient satisfaites des activités et de la fréquence du suivi, de la facilité d’accès des intervenantes et de la capacité du suivi à répondre à leurs besoins. L’intensité du suivi, l’alliance thérapeutique usagère/intervenante et la motivation des usagères ont été identifiées comme des facteurs facilitants. Les facteurs entravants comprenaient : la durée limitée de l’insertion préalable en LT, particulièrement chez les usagères ayant subi un traumatisme majeur ; les comportements réfractaires ; la réticence à prendre des médicaments et la dépendance à des substances psychoactives ; les problèmes d’accès aux services, dont les services de santé mentale spécialisés ; et pour les intervenantes, les contraintes de temps, les difficultés logistiques, et le manque de logements permanents abordables adéquats. Après six mois, 80 % des usagères avaient conservé le même logement, et leur intégration communautaire n’avait pas changé.

Conclusion Le suivi post-LT semble adapté pour promouvoir la stabilité résidentielle chez les femmes en situation d’itinérance chronique et ayant des problèmes de santé mentale ou de dépendance, première étape essentielle vers l’intégration communautaire. L’étude a souligné l’importance d’offrir des modalités de services adaptés aux besoins des usagères. Un meilleur financement du suivi post-LT, une collaboration plus étroite avec d’autres services publics, une formation accrue des intervenantes et une augmentation du nombre de logements permanents abordables et adéquats favoriseraient un déploiement plus efficace du suivi post-LT.

Trauma in adults experiencing homelessness

BACKGROUND

Homeless individuals suffer a greater burden of health problems than the general population. This study aimed to describe the epidemiology of physical trauma among homeless patients presenting to an urban major trauma center and to ascertain any differences in the nature, injury severity and outcomes among homeless compared to domiciled patients.

METHODS

A retrospective matched cohort study that included adults who met inclusion criteria for The Alfred Hospital Trauma Registry between 01 July 2010 and 31 March 2017 was conducted. Primary homelessness was identified using the International Statistical Classification of Diseases, 10th Revision Coding Z59.0 and/or 'No fixed abode' address data. Homeless and domiciled patients were matched at a 1:2 ratio on age, sex, month and year of injury. The primary outcome variable was the Injury Severity Score (ISS). Secondary outcomes were hospital length of stay (LOS), mortality, emergency department (ED) disposition, hospital disposition, discharge processes and trauma registry recidivism.

RESULTS

Of 25,920 cases in the trauma registry, 147 (0.6%) were identified as homeless, comprising 131 unique homeless individuals who were matched with 262 domiciled patients. The median (Inter-Quartile Range) ISS among homeless patients was 5(2-10), compared to 9(4-17) for domiciled patients (p < 0.001). Homeless patients had significantly lower odds of sustaining an injury with ISS>12 (OR 0.5, 95% CI: 0.3-0.8, p = 0.001). Homeless patients were treated more often than domiciled patients for assault (32.1% vs 9.5%), intentional self-harm (10.7% vs 2.7%), and penetrating injury (16.0% vs 6.5%). Homeless patients had higher rates of psychiatry admissions (9.2% vs 0.8%), positive blood alcohol concentration (30.5% vs 13.7%), and higher odds of discharging against medical advice (DAMA)(OR 2.0, 95% CI: 1.1-3.6 p = 0.02). There were no differences in LOS (p = 0.51), mortality (p = 0.19), ED disposition (p = 0.64) or trauma registry recidivism (p = 0.09).

CONCLUSION

Among injured patients who presented at an urban trauma center, homelessness was associated with higher odds of assault, intentional self-harm, penetrating injury, psychiatry admissions, DAMA but lower ISS than domiciled patients. Variable definitions of homelessness and lack of standardized documentation in the medical record should be addressed to ensure these vulnerable patients are identified and linked with peripheral services.

Severity of Injury and Associated Factors among Injured Patients Who Visited the Emergency Department at Wolaita Sodo Teaching and Referral Hospital, Ethiopia

Background

An injury is a physical damage that occurs when the body is exposed to an excessive amount of energy. Physical agents, radiation, chemical agents, biological agents and physiological needs deprivation can cause injury. The study was aimed at assessing the severity of injury and identifying the factors associated with it among injured patients.

Methods

A cross-sectional study was conducted among patients who visited the emergency department of Wolaita Sodo Teaching and Referral Hospital from January 1, 2012 – January 1, 2017. A total of 320 patient records were included in the study and selected using simple random sampling. Statistical association was done for categorical variables using Chi-square. Rank correlation was done for three ordered options independent variables, Chi-squared test for trend used for two options independent variables, and General Chi-square test of independence used for independent variables with not ordered three and above options. Multivariate multinomial logistic regression was conducted. A P-value <0.05 was taken as a significant association.

Results

The study indicated that the majority (45.3%), 128(40%) and 47(14.7%) had minor, moderate and severe injury, respectively. Residence (AOR 0.462; 95%CI 0.268, 0.798), cause of injury (AOR 3.602; 95%CI 1.336, 9.714), night time injury (AOR 4.895; 95%CI 1.472, 16.277), afternoon time injury (AOR 8.776; 95%CI 2.699, 28.537), and chest injury (AOR 2.391; 95%CI 1.048, 5.454) were significant predictors of moderate injury. Afternoon time of injury (AOR; 4.683; 95%CI 1.137, 19.296) and head, neck and spinal cord injury (AOR; 4.933; 95%CI 1.945, 12.509) were predictors of severe injury.

Mental and behavioral disorders in the population of homeless patients admitted to hospital emergency departments

The aim of the study is to identify the most common mental and behavioral disorders diagnosed in homeless patients admitted to hospital emergency departments and to identify performed medical procedures including diagnostic and therapeutic measures in this range.

Material and Method:Data from information systems of three hospitals concerning stays of homeless people in ED in Bydgoszcz in 2013-2015 were analyzed. As any as 3133 stays were identified. The data was compiled using the Microsoft Excel spreadsheet and Statistica 10 statistical software package.

Results: Diagnoses in the category of mental disorders and behavioral disorders constituted 23.3% of diagnoses made in the studied population, of which two thirds were psychiatric disorders and behavioral disorders caused by alcohol use. Specific personality disorders (5.84%), schizophrenia (3.82%), and mild mental retardation (2.24%) were diagnosed in patients. One tenth of all the ICD-9 procedures performed were the procedures of the category 94- Procedures related to mental condition

Conclusions: Mental and behavioral disorders are one of the main reasons for admission of homeless people to hospital emergency departments. Most diseases is diagnosed in facilities where psychiatric consultation is possible, as well as where the number of procedures related to mental condition performed is the highest. Homeless patients suffering from mental and behavioral disorders are rarely admitted to hospital wards for hospitalization. Psychiatric care for homeless patients admitted to emergency departments is an ad hoc intervention and depends on the availability of a psychiatrist. Providing homeless patients with access to a psychiatric diagnosis at ED level would affect the quality of psychiatric care and would contribute to the improvement of mental health of homeless people.

Health Care Needs of Homeless Older Adults:: Examining the Needs of a Senior Center Cohort

Objectives

To assess the medical status and health care needs of Wilmington’s largest accessible group of homeless elders located at St. Patrick’s Center in order to identify areas for improvement of medical screening, preventive health care delivery, and disease management.

Methods

A cross sectional study was conducted between December 2016 and August 2018 at St. Patrick’s center in Wilmington, DE. Utilizing a structured health needs assessment, 64 unique individuals aged 50 years and older were interviewed. Descriptive statistics were used to compare data from homeless older adults with data from non-homeless older adults.

Results

Of the 64 total subjects, 17 self-reported as homeless at the time of interviewing. High rates of depressive and cognitive impairment symptoms were self-reported in both homeless and non-homeless participants. When compared to the non-homeless group at St. Patrick’s Center, the homeless cohort was less likely to have received a non-acute assessment (such as a routine physical exam/well check-up) or a routine dental cleaning/x-ray within the past year. Tobacco and alcohol use and were frequently self-reported by homeless and non-homeless respondents and were more frequent in the homeless group. The homeless individuals were more likely to have engaged in illicit drug use. Overall, more than 90% of the subjects had some form of health insurance coverage. The most frequently cited reasons for lack of healthcare were inability to afford co-payments/deductibles and lack of transportation.

Conclusions

To address the health care needs of this population, new programs to improve care should focus on facilitating access to services which address areas of deficiency. This group of older adults has benefited from a range of available services that reflect the work of a staff aware of their medical needs, as indicated by the high rate of insured individuals. Licit and illicit substance use assessment and treatment and dental screening remain areas of need for the homeless older adults interviewed in this study. The high rates of depression and cognitive impairment in both the homeless and non-homeless older adult groups suggest the need for further services in these areas as well. Access to care may be improved by addressing concerns regarding co-payments, deductibles, and transportation to care.

Homelessness Among Patients in a Southeastern Safety Net Emergency Department

OBJECTIVES

Emergency departments (EDs) are important providers for homeless individuals, providing vital health care and meeting the subsistence needs of many homeless patients (eg, food, water, shelter). Studies that have examined the proportion of patients in the ED setting who experience homelessness have been conducted primarily in the northeastern United States. We hypothesized that findings from prior studies, conducted primarily in the Northeast, would not generalize to other regions of the United States. We conducted a direct patient survey to describe the proportion and demographics of ED patients who have experienced homelessness within the past 12 months in an urban safety net hospital in Atlanta, Georgia.

METHODS

A cross-sectional survey of a convenience sample of patients presenting to the ED from September to December 2016. A team of trained research assistants administered a structured survey instrument to patients who were 18 years old, English speakers, not incarcerated, and able to provide informed consent. Questions were based on the US Department of Health and Human Services definition of homelessness.

RESULTS

A total of 923 ED patients (55.1% male; median age 44 years) completed the survey. Of the ED patients surveyed, 51.5% reported some measure of homelessness in the past 12 months: lived with others but did not pay rent (n = 279, 30.2%), skipped mortgage or rent payment (n = 111, 12%), experienced eviction (n = 74, 8%), lived in a hotel or motel (n = 196, 21.2%), lived in a place not meant for human habitation (n = 76, 8.2%), slept in a shelter (n = 131, 14.2%), and slept on the street (n = 115, 12.5%). Men (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.17-2.09), patients who completed some school (OR 2.85, 95% CI 1.72-4.71), and patients who completed high school (OR 2.32, 95% CI 1.53-3.52) were more likely to have experienced homelessness in the 12 months preceding their ED visit.

CONCLUSIONS

The rate of patients experiencing homelessness at our hospital is substantially greater than those reported in prior surveys of ED patients. More research is needed on homelessness and its implications for ED patients.

Self-reported health, healthcare service use and health-related needs: A comparison of older and younger homeless people

The number of older homeless people with a limited life expectancy is increasing. European studies on their health-related characteristics are lacking. This study compared self-reported health, healthcare service use and health-related needs of older and younger homeless people in the Netherlands. It is part of a cohort study that followed 513 homeless people in the four major Dutch cities for a period of 2.5 years, starting from the moment they registered at the social relief system in 2011. Using cross-sectional data from 378 participants who completed 2.5-year follow-up, we analysed differences in self-reported health, healthcare service use, and health-related needs between homeless adults aged ≥50 years (N = 97) and <50 years (N = 281) by means of logistic regression. Results show that statistically significantly more older than younger homeless people reported cardiovascular diseases (23.7% versus 10.3%), visual problems (26.8% versus 14.6%), limited social support from family (33.0% versus 19.6%) and friends or acquaintances (27.8% versus 14.6%), and medical hospital care use in the past year (50.5% versus 34.5%). Older homeless people statistically significantly less often reported cannabis (12.4% versus 45.2%) and excessive alcohol (16.5% versus 27.0%) use in the past month and dental (20.6% versus 46.6%) and mental (16.5% versus 25.6%) healthcare use in the past year. In both age groups, few people reported unmet health-related needs. In conclusion, compared to younger homeless adults, older homeless adults report fewer substance use problems, but a similar number of dental and mental problems, and more physical and social problems. The multiple health problems experienced by both age groups are not always expressed as needs or addressed by healthcare services. Older homeless people seem to use more medical hospital care and less non-acute, preventive healthcare than younger homeless people. This vulnerable group might benefit from shelter-based or community outreach programmes that proactively provide multidisciplinary healthcare services.

A Portrait of Late Life Homelessness in Calgary, Alberta

Le présent article vise à évaluer les problèmes de santé des Calgariens de plus de 50 ans en situation d’itinérance chronique, à identifier les manques en matière de services pour cette population et à cerner les prédicteurs de l’itinérance chronique, tels que les traumatismes durant l’enfance, qui pourraient être atténués par des modifications touchant les politiques ou la prestation de services. Des personnes en situation d’itinérance, dont trois cents provenaient de refuges d’urgence, ont été recrutées à Calgary (Canada) à hiver 2016. Les logiciels Excel et SPSS ont été utilisés pour l’analyse des statistiques descriptives des participants qui ont été séparés en deux groupes, soit les répondants de 50 ans et plus (n = 142) et ceux de moins de 50 ans (n = 158). Plus de la moitié des participants étaient en situation d’itinérance continue depuis plus de dix ans. Les personnes plus âgées ont fait état de problèmes de santé complexes et d’obstacles importants pour l’accès aux soins de santé, associés notamment à leurs problèmes financiers, aux listes d’attente et au fait de ne pas recevoir d’aide malgré leurs demandes. Les répondants plus âgés ont rapporté des taux de traumatismes durant l’enfance inférieurs à ceux des répondants plus jeunes, bien que la moyenne de ces taux soit 2,5 fois supérieure à celle de la population générale. La reconnaissance des effets croisés et cumulatifs de l’itinérance de long terme et de l’âge pourrait guider la modification des politiques visant à réduire les cloisonnements entre les services publics. Étant donné que les personnes âgées en situation d’itinérance sont plus à risque de mourir prématurément, elles devraient être priorisées par les programmes d’aide au logement. Des interventions adaptées au contexte culturel et tenant compte des traumatismes seraient nécessaires pour répondre aux besoins à la fois variés et complexes de ce groupe vulnérable.

Home Safety Fall and Accident Risk Among Prematurely Aging, Formerly Homeless Adults

OBJECTIVE

Homelessness prematurely ages people. A large subgroup of formerly homeless adults between ages 40 and 64 yr have health conditions similar to or worse than people categorized as elderly. Little is known about the impact of this group's chronic health conditions on their ability to safely function in supportive housing.

METHOD

Home safety visits were carried out with 25 formerly homeless adults, ages 40-64 yr, now residing in supportive housing.

RESULTS

Participants had physical, cognitive, and mental health problems that significantly interfered with their ability to perform daily life skills, safely function in an apartment, and manage chronic health conditions. Home safety hazards included cluttered walking paths, the presence of steps, and the lack of grab bars and nonskid flooring.

CONCLUSION

The homeless population would benefit from aging specialists, such as occupational therapists, who could help people to maintain and function more safely in their homes. Without such services, this population may be at risk for home safety events leading to hospitalization and mortality.

Sick and unsheltered: Homelessness as a major risk factor for emergency care utilization

OBJECTIVE

Homelessness is a critical public health issue and socioeconomic epidemic associated with a disproportionate burden of disease and significant decrease in life expectancy. We compared emergency care utilization between individuals with documented homelessness to those enrolled in Medicaid without documented homelessness.

METHODS

We conducted a retrospective cohort study consisting of electronic medical record review of demographics, chief complaints, and health care utilization metrics of adults with homelessness compared to a group enrolled in Medicaid without identified homelessness. The chart review spanned two years of emergency visits at a single urban, academic, tertiary care medical center. Descriptive statistics, bivariate and multivariate analyses were utilized.

RESULTS

Over the study period, 986 patients experiencing homelessness accounted for 7532 ED visits, with a mean of 7.6 (SD 19.9) and max of 316 visits. The control group of 3482 Medicaid patients had 5477 ED visits, with a mean of 1.6 visits (SD 2.1) and max of 49 visits. When controlling for age, sex, race, ethnicity, and ESI, those living with homelessness were 7.65 times more likely to return to the ED within 30 days of their previous visit, 9.97 times more likely to return within 6 months, 10.63 times more likely to return within one year, and 11 times more likely to return within 2 years.

CONCLUSIONS

Compared to non-homeless Medicaid patients, patients with documented homelessness were over seven times more likely to return to the ED within 30 days and over eleven times more likely to return to the ED in two years.

Homelessness and Emergency Medicine: A Review of the Literature

OBJECTIVES

We aimed to synthesize the available evidence on the demographics, prevalence, clinical characteristics, and evidence-based management of homeless persons in the emergency department (ED). Where appropriate, we highlight knowledge gaps and suggest directions for future research.

METHODS

We conducted a systematic literature search following databases: PubMed, Ovid, and Google Scholar for articles published between January 1, 1990, and December 31, 2016. We supplemented this search by cross-referencing bibliographies of the retrieved publications. Peer-reviewed studies written in English and conducted in the United States that examined homelessness within the ED setting were included. We used a qualitative approach to synthesize the existing literature.

RESULTS

Twenty-eight studies were identified that met the inclusion criteria. Based on our study objectives and the available literature, we grouped articles examining homeless populations in the ED into four broad categories: 1) prevalence and sociodemographic characteristics of homeless ED visits, 2) ED utilization by homeless adults, 3) clinical characteristics of homeless ED visits, and 4) medical education and evidence-based management of homeless ED patients.

CONCLUSION

Homelessness may be underrecognized in the ED setting. Homeless ED patients have distinct care needs and patterns of ED utilization that are unmet by the current disease-oriented and episodic models of emergency medicine. More research is needed to determine the prevalence and characteristics of homelessness in the ED and to develop evidence-based treatment strategies in caring for this vulnerable population.

Material Needs of Emergency Department Patients: A Systematic Review

BACKGROUND

Interest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States.

METHODS

We followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles.

RESULTS

Forty-three articles were eligible for inclusion. There was heterogeneity in study methods; single-center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs.

CONCLUSIONS

Despite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.

Mental disorders and the use of primary health care services among homeless shelter users in the Helsinki metropolitan area, Finland

Background

Homelessness is associated with increased morbidity, mortality and health care use. The aim of this study was to examine the role of mental disorders in relation to the use of 1) daytime primary health care services and 2) after hours primary health care emergency room (PHER) services among homeless shelter users in the Helsinki Metropolitan Area, Finland.

Methods

The study cohort consists of all 158 homeless persons using the four shelters operating in the study area during two selected nights. The health records were analyzed over a period of 3 years prior to the sample nights and data on morbidity and primary health care visits were gathered. We used negative binomial regression to estimate the association between mental disorders and daytime visits to primary health care and after hours visits to PHERs.

Results

During the 3 years the 158 homeless persons in the cohort made 1410 visits to a physician in primary health care. The cohort exhibited high rates of mental disorders, including substance use disorders (SUDs); i.e. 141 persons (89%) had a mental disorder. We found dual diagnosis, defined as SUD concurring with other mental disorder, to be strongly associated with daytime primary health care utilization (IRR 11.0, 95% CI 5.9–20.6) when compared with those without any mental disorder diagnosis. The association was somewhat weaker for those with only SUDs (IRR 4.9, 95% CI 2.5–9.9) or with only other mental disorders (IRR 5.0, 95% CI 2.4–10.8). When focusing upon the after hours visits to PHERs we observed that both dual diagnosis (IRR 14.1, 95% CI 6.3–31.2) and SUDs (11.5, 95% CI 5.7–23.3) were strongly associated with utilization of PHERs compared to those without any mental disorder. In spite of a high numbers of visits, we found undertreatment of chronic conditions such as hypertension and diabetes.

Conclusions

Dual diagnosis is particularly strongly associated with primary health care daytime visits among homeless persons staying in shelters, while after hours visits to primary health care level emergency rooms are strongly associated with both dual diagnosis and SUDs. Active treatment for SUDs could reduce the amount of emergency visits made by homeless shelter users.

On the Frontlines: Perspectives of Providers Working With Homeless Women

Homeless service providers (HSPs) are on the frontlines of caring for the most vulnerable populations to help them navigate out of homelessness and access health and social services. The purpose of this qualitative study was to understand, from the perspectives of HSPs ( N = 19; age range, 27-58 years; SD = 10.37), their account and experiences in working with homeless women (HW), and opportunities for intervention development and integration. Five focus groups were conducted with HSPs in Central City East, Los Angeles. Five main themes emerged which included (a) seeking to establish a therapeutic relationship, (b) internal and external drivers of change, (c) navigating systems, (d) targeted outreach, and (e) program design recommendations. Within these themes, individual- and structural-level characteristics emerged. To better equip HW, HSPs' perspectives need to be considered in future interventions to aid women traverse homelessness.

Characteristics of the old and homeless: identifying distinct service needs

OBJECTIVES

Research suggests that being older and homeless is associated with unique characteristics and potential barriers to improved living conditions. Additional research is needed to better understand the vulnerabilities associated with this population. The purpose of this study was to identify characteristics related to aging and homelessness. It was hypothesized that older adults would exhibit more vulnerability compared to other age groups related to health, social support proximity, occupational perceptions, and recent living conditions prior to seeking assistance at an emergency shelter. It was also hypothesized that these age-related characteristics would predict the amount of time that individuals resided in the emergency shelter.

METHOD

A cross-sectional sample of young, middle-aged, and older homeless adults seeking shelter at two emergency homeless shelters was utilized for this study. Data included information obtained during a structured interview after participants arrived at the shelter and the number of days that were spent at the shelter.

RESULTS

Older adults were more likely to exhibit several characteristics (i.e., poorer health, being further from social support, longer durations of homelessness, lack of employment area, prior residence types, and mental health treatment) potentially contributing to and/or recovering from homelessness. Duration of homelessness, reports of having no career area, and age were predictive of the amount of time spent at the shelter.

CONCLUSIONS

The various characteristics that differentiate older homeless populations (e.g., health, social support, homelessness duration, and employment) could create potential barriers to overcoming homelessness that should be considered when serving this population.

Factors associated with substance use in older homeless adults: Results from the HOPE HOME study

BACKGROUND

The median age of the single adult homeless population is 50 and rising. Although the prevalence of substance use decreases as individuals age, older adults now have a higher prevalence of substance use than older adults did 10 years ago. Homeless individuals have a higher prevalence of substance use disorders than the general population. However, little is known about substance use in older homeless adults.

METHODS

The objective of the study was to examine prevalence of and factors associated with substance use in a population-based sample (N = 350) of homeless individuals aged 50 and older in Oakland, California. Dependent variables included moderate or greater severity illicit drug symptoms (Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) score >3) and moderate or greater alcohol symptoms (Alcohol Use Disorders Identification Test (AUDIT) score >7). Independent variables included demographics, mental health problems, and negative life course events such as physical and sexual abuse, school expulsion, and onset of homelessness.

RESULTS

Almost two thirds of participants, 64.6%, had moderate or greater severity symptoms for at least 1 illicit drug; 25.8% had moderate or greater severity alcohol symptoms. History of psychiatric hospitalization was associated with moderate or greater illicit drug symptoms (adjusted odds ratio [AOR] = 1.9, 1.0-3.6). The presence of major depressive symptoms was associated with moderate or greater severity alcohol symptoms (AOR = 1.8, 1.1-3.0).

CONCLUSIONS

In this sample of older homeless adults, substance use is common. There is a need for substance use treatment programs, integrated with mental health services, which are targeted towards the needs of older homeless adults.

The Frequent Fliers of New Mexico: Hospital Readmissions among the Homeless Population

It is estimated that there are 1.7 million homeless individuals in the United States; 36% are families with children under the age of 18. Due to lack of resources, individuals who are homeless frequent emergency departments for immediate health care needs. The aim of this study was to examine a homeless population over a 3-year time period who were admitted to an Albuquerque area hospital at any time during the time period. A comparison of demographic characteristics as well as hospitalization characteristics between two populations was analyzed: individuals who were homeless and had a 30-day readmission compared to those that did not have a 30-day readmission. There were 850 unique homeless patients that were admitted to an Albuquerque area hospital during the 3-year time period. The mean age was 43.8 years with the majority of the population being male. The 3-year average 30-day readmission rate was 30.1%. Multivariate regression analysis indicated that homeless patients older than 19 years, individuals with more than 1 admission during the time period, and individuals who left against medical advice had increased odds of a 30-day readmission. Individuals who were homeless who were admitted for respiratory conditions or cardiovascular disease had decreased odds of a 30-day readmission compared to patients admitted for neuropsychiatric conditions. In New Mexico, patients who were homeless experienced a high 30-day readmission rate. These results suggest a need for further research into the healthcare needs of this population and how to improve discharge protocols to prevent future readmissions.

Emergency Care for Homeless Patients: A French Multicenter Cohort Study

OBJECTIVES

To determine whether homeless patients experience suboptimal care in the emergency department (ED) by the provision of fewer health care resources.

METHODS

We conducted a prospective multicenter cohort study in 30 EDs in France. During 72 hours in March 2015, all homeless patients that visited the participating EDs were included in the study. The primary health care service measure was the order by the physician of a diagnostic investigation or provision of a treatment in the ED. Secondary measures of health care services included ED waiting time, number and type of investigations per patient, treatment in the ED, and discharge disposition.

RESULTS

A total of 254 homeless patients and 254 nonhomeless patients were included. After excluding homeless patients that attended the ED for the sole purpose of housing, we analyzed 214 homeless and 214 nonhomeless. We found no significant difference between the 2 groups in terms of health care resource consumption, and for our secondary endpoints.

CONCLUSIONS

We did not find significant differences in the level of medical care delivered in French EDs to homeless patients compared with matched nonhomeless patients.

Health Outcomes of Obtaining Housing Among Older Homeless Adults

OBJECTIVES

We determined the impact of obtaining housing on geriatric conditions and acute care utilization among older homeless adults.

METHODS

We conducted a 12-month prospective cohort study of 250 older homeless adults recruited from shelters in Boston, Massachusetts, between January and June 2010. We determined housing status at follow-up, determined number of emergency department visits and hospitalizations over 12 months, and examined 4 measures of geriatric conditions at baseline and 12 months. Using multivariable regression models, we evaluated the association between obtaining housing and our outcomes of interest.

RESULTS

At 12-month follow-up, 41% of participants had obtained housing. Compared with participants who remained homeless, those with housing had fewer depressive symptoms. Other measures of health status did not differ by housing status. Participants who obtained housing had a lower rate of acute care use, with an adjusted annualized rate of acute care visits of 2.5 per year among participants who obtained housing and 5.3 per year among participants who remained homeless.

CONCLUSIONS

Older homeless adults who obtained housing experienced improved depressive symptoms and reduced acute care utilization compared with those who remained homeless.

Injury-related visits and comorbid conditions among homeless persons presenting to emergency departments

OBJECTIVES

The authors examined the clinical characteristics of homeless patients presenting to emergency departments (EDs) in the United States, with a focus on unintentional and intentional injury events and related comorbid conditions.

METHODS

The study included a nationally representative sample of patients presenting to EDs with data obtained from the 2007 through 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS). Descriptive and analytical epidemiologic analyses were employed to examine injuries among homeless patients.

RESULTS

Homeless persons made 603,000 visits annually to EDs, 55% of which were for injuries, with the majority related to unintentional (52%) and self-inflicted (23%) injuries. Multivariate logistic regression analyses revealed that homeless patients had a higher odds of presenting with injuries related to unintentional (odds ratio [OR]=1.4. 95% confidence interval [CI]=1.1 to 1.9), self-inflicted (OR=6.0, 95% CI=3.7 to 9.5), and assault (OR=3.0, 95% CI=1.5 to 5.9) injuries.

CONCLUSIONS

A better understanding of the injuries affecting homeless populations may provide medical and public health professionals insight into more effective ways to intervene and limit further morbidity and mortality related to specific injury outcomes.

Meeting the Housing and Care Needs of Older Homeless Adults: A Permanent Supportive Housing Program Targeting Homeless Elders

The homeless population is aging faster than the general population in the United States. As this vulnerable population continues to age, addressing complex care and housing needs will become increasingly important. This article reviews the often-overlooked issue of homelessness among older adults, including their poor health status and unique care needs, the factors that contribute to homelessness in this population, and the costs of homelessness to the U.S. health care system. Permanent supportive housing programs are presented as a potential solution to elder homelessness, and Hearth, an outreach and permanent supportive housing model in Boston, is described. Finally, specific policy changes are presented that could promote access to housing among the growing older homeless population.