Health Outcomes of Obtaining Housing Among Older Homeless Adults

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Housing Status Changes Are Associated With Cancer Outcomes Among US Veterans

Cancer is a leading cause of death in older unhoused adults. We assessed whether being unhoused, gaining housing, or losing housing in the year after cancer diagnosis is associated with poorer survival compared with being continuously housed. We examined all-cause survival in more than 100,000 veterans diagnosed with lung, colorectal, and breast cancer during the period 2011-20. Five percent were unhoused at the time of diagnosis, of whom 21 percent gained housing over the next year; 1 percent of veterans housed at the time of diagnosis lost housing. Continuously unhoused veterans and veterans who lost their housing had poorer survival after lung and colorectal cancer diagnosis compared with those who were continuously housed. There was no survival difference between veterans who gained housing after diagnosis and veterans who were continuously housed. These findings support policies to prevent and end homelessness in people after cancer diagnosis, to improve health outcomes.

Aging in the Right Place for Older Adults Experiencing Housing Insecurity: An Environmental Assessment of Temporary Housing Program

Research on programs offering senior-specific housing supports and enabling "aging in the right place" (AIRP) for "older persons with experiences of homelessness" (OPEH) is limited. This paper presents an environmental assessment of a "transitional housing program" (THP) in Metro Vancouver, Canada, for OPEH to AIRP. Data were collected using Aging in the Right Place Environmental (AIRP-ENV) and Secondary Observation (AIRP-ENV-SO) audit tools designed to evaluate multi-unit housing for OPEH. The 241-item AIRP-ENV tool was used to assess the built environmental features of four multi-unit buildings of the THP. The AIRP-ENV-SO tool was used to collect contextual data on the function, safety, and land use of the surrounding neighborhood. Findings identified built environment and urban design features that support THP residents' safety, security, accessibility, functionality, social activity, autonomy, and identity. The THP buildings were rated 'Good' for accessibility, functionality, autonomy and identity, while 'Satisfactory' or 'Poor' for safety, security, and social activity. Findings point to the built environmental features (e.g., size and layout of spaces) required in the THP to create opportunities for increased social engagement among residents and enhanced safety and security. The AIRP-ENV and AIRP-ENV-SO audit tools can help inform programs across the housing continuum to develop supportive built environments that promote AIRP for OPEH.

A Scoping Review of the Health Impact of the COVID-19 Pandemic on Persons Experiencing Homelessness in North America and Europe

Persons experiencing homelessness (PEH) are at heightened risk for infection, morbidity, and mortality from COVID-19. However, health consequences of the pandemic extend far beyond those directly caused by the virus. This scoping review aimed to explore the impacts of the COVID-19 pandemic on the health and well-being of PEH in North America and Europe. A systematic search of academic and grey literature was conducted in September 2021. To be included, studies had to include primary data related to the impact of the pandemic on health or well-being of PEH and be written in English. All potentially relevant references were independently screened by two reviewers, and minor conflicts were settled with input of a third reviewer. A total of 96 articles met criteria for inclusion. Data extraction was completed for all included studies, and findings synthesised and presented thematically. Numerous health impacts of the pandemic on PEH were identified, including SARS-CoV-2 infection, morbidity, mortality, and hospitalisation, fear of infection, access to housing, hygiene, PPE, food, as well as mental health, substance use, other health-related outcomes and treatment services. Gaps in the literature relating to persons using alcohol, access to mental health support, and violence were also identified. Implications for future research are discussed.

The physical and mental health effects of housing homeless people: A systematic review

Housing is a significant determinant of health and is widely accepted as a key solution to address some of the health disparities that exist among the homeless. It is estimated that 150 million people worldwide are homeless, and approximately 1.8 billion lack adequate housing. However, understanding of how housing has a positive impact on the health of the homeless remains unclear and underdeveloped. This systematic review investigates intervention studies that report on the physical and mental health effects of housing homeless persons. A search of PubMed, PsycINFO, EBSCOHost-Academic Search Complete and the Cochrane Library was conducted for peer-reviewed articles published in English from 1999 to 2020 that had a combination of at least one housing intervention and health outcome, with a homeless sample. Three previous reviews and 24 studies were included for analysis. Most of the studies (n = 20) encompassed permanent supportive housing interventions that emphasised placing homeless people with mental illness directly into affordable housing with access to support services. The primary health outcomes reported were general physical and mental health, well-being, and quality of life. Despite inconsistent findings and significant issues identified in the reviewed literature, housing (in the short term) improves some aspects of health in homeless populations with human immunodeficiency virus, anxiety and depression.

Housing conditions and long-term care needs of older adults in Ghana: Evidence from the WHO SAGE Ghana Wave 1

The present study examined the association between housing conditions and long-term care needs of older adults in Ghana. We used data from 4,920 adults aged ≥50 years that participated in the World Health Organisation's (WHO) Study on adult health and AGEing Ghana Wave 1. Housing conditions were assessed with drinking water, sanitation, cooking conditions and building materials, and long-term care needs were based on WHO Disability Assessment Schedule 2.0. Multivariable logistic regressions modelled the effect of housing conditions on long-term care needs. After full adjustment for all available potential confounders, older adults living in households with unimproved cooking conditions had higher odds of reporting long-term care needs (OR = 6.87, 95%CI: 5.04-9.37) compared to those in improved cooking condition households. Moreover, those in households with unimproved housing materials (OR = 1.27, 95%CI: 1.01-1.72) and those in unimproved sanitation households (OR = 1.26, 95%CI: 1.05-1.54) were more likely to experience long-term care needs after respectively controlling for demographic and health-related covariates. Poor housing conditions are risk factors of long-term care needs in Ghana. Efforts to improve housing conditions may benefit older age functional abilities and unmet long-term care needs.

Persistent Homelessness and Violent Victimization Among Older Adults in the HOPE HOME Study

The homeless population is aging; older homeless adults may be at high risk of experiencing violent victimization. To examine whether homelessness is independently associated with experiencing physical and sexual abuse, we recruited 350 adults, aged 50 and older in Oakland, California, who met criteria for homelessness between July 2013 and June 2014. We interviewed participants at 6-month intervals for 3 years in Oakland about key variables, including housing status. Using generalized estimating equations, we examined whether persistent homelessness in each follow-up period was independently associated with having experienced physical or sexual victimization, after adjusting for known risk factors. The majority of the cohort was men (77.4%) and Black American (79.7%). At baseline, 10.6% had experienced either physical or sexual victimization in the prior 6 months. At 18-month follow-up, 42% of the cohort remained homeless. In adjusted models, persistent homelessness was associated with twice the odds of victimization (adjusted odds ratio [AOR] = 2.01; 95% confidence interval [CI]: [1.41, 2.87]). Older homeless adults experience high rates of victimization. Re-entering housing reduces this risk. Policymakers should recognize exposure to victimization as a negative consequence of homelessness that may be preventable by housing.

A Community Partnership to House and Care for Complex Patients with Unstable Housing

Rising homelessness, especially among older adults, has significant ramifications for our health care system. People experiencing homelessness tend to experience worse health and poorer access to needed health care than people with stable housing. Commonwealth Care Alliance (CCA), a not-for-profit payer and provider that offers health plans to people dually eligible for Medicare and Medicaid, sought to address homelessness among its beneficiaries through a partnership with a local community-based housing organization, Hearth. This partnership led to many CCA members gaining access to permanent supportive housing in a setting in which CCA and Hearth could monitor and address their medical, social, and behavioral needs. It also provided an opportunity to examine health care utilization and cost trends associated with permanent supportive housing. Our experience demonstrates that a community-based partnership can effectively address homelessness among older adults with significant medical needs and may be associated with reduced health care expenditures.

Temporary Financial Assistance Decreased Health Care Costs For Veterans Experiencing Housing Instability

Compared with housed people, those experiencing homelessness have longer and more expensive inpatient stays as well as more frequent emergency department visits. Efforts to provide stable housing situations for people experiencing homelessness could reduce health care costs. Through the Supportive Services for Veteran Families program, the Department of Veterans Affairs partners with community organizations to provide temporary financial assistance to veterans who are currently homeless or at imminent risk of becoming homeless. We examined the impact of temporary financial assistance on health care costs for veterans in the Supportive Services for Veteran Families program and found that, on average, people receiving the assistance incurred $352 lower health care costs per quarter than those who did not receive the assistance. These results can inform national policy debates regarding the proper solution to housing instability.

Association of Temporary Financial Assistance With Housing Stability Among US Veterans in the Supportive Services for Veteran Families Program

Importance

Temporary financial assistance (TFA) for housing-related expenses is a key component of interventions to prevent homelessness or to quickly house those who have become homeless. Through the US Department of Veterans Affairs (VA) Supportive Services for Veteran Families (SSVF) program, the department provides TFA to veterans in need of housing assistance.

Objective

To assess the association between TFA and housing stability among US veterans enrolled in the SSVF program.

Design, Setting, and Participants

This retrospective cohort study analyzed data on veterans who were enrolled in the SSVF program at 1 of 203 partner organizations in 49 US states and territories. Some veterans had repeat SSVF episodes, but only the first episodes were included in this analysis. An episode was defined as the period between entry into and exit from the program occurring between October 1, 2015, and September 30, 2018.

Exposures

Receipt of TFA.

Main Outcomes and Measures

The main outcome was stable housing, defined as permanent, independent residence with payment by the program client or housing subsidy after exit from the SSVF program. Covariates included demographic characteristics, monthly income and source, public benefits, health insurance, use of other VA programs for homelessness, comorbidities, and geographic location. Multivariable mixed-effects logistic regression, inverse probability of treatment weighting, and instrumental variable approaches were used.

Results

The overall cohort consisted of 41 969 veterans enrolled in the SSVF program, of whom 29 184 (mean [SD] age, 50.4 [12.9] years; 25 396 men [87.0%]) received TFA and 12 785 (mean [SD] age, 50.0 [13.3] years; 11 229 men [87.8%]) did not receive TFA. The mean (SD) duration of SSVF episodes was 90.5 (57.7) days. A total of 69.5% of SSVF episodes involved receipt of TFA, and the mean (SD) amount of TFA was $6070 ($7272). Stable housing was obtained in 81.4% of the episodes. Compared with those who did not receive TFA, veterans who received TFA were significantly more likely to have stable housing outcomes (risk difference, 0.253; 95% CI, 0.240-0.265). An association between the amount of TFA received and stable housing was also found, with risk differences ranging from 0.168 (95% CI, 0.149-0.188) for those who received $0 to $2000 in TFA to 0.226 (95% CI, 0.203-0.249) for those who received more than $2000 to $4000 in TFA.

Conclusions and Relevance

This study found that receipt of TFA through the SSVF program was associated with increased rates of stable housing. These results may inform national policy debates regarding the optimal solutions to prevent and reduce housing instability.

The Role of Self-Esteem in the Relationship Between Loneliness and Life Satisfaction in Late Adulthood: Evidence from Poland

Background

The life satisfaction of elderly persons has been extensively investigated and discussed. However, a literature review shows that relatively few studies have focused on the effect of loneliness on the life satisfaction of older adults. Some researchers have acknowledged that the character of the relationship between loneliness and life satisfaction is still unclear, and this association is much more complex that it appears to be. Therefore, the main purpose of the current study was to understand how loneliness is associated with satisfaction, and whether self-esteem and educational involvement in the University of the Third Age (U3A) courses can affect this relationship among elderly people.

Methods

The research was conducted on a group of 179 elderly adults (65% women). We measured loneliness, satisfaction, and self-esteem. The data were collected via the paper-and-pencil format through convenience sampling, just before the COVID-19 pandemic began.

Results

The results obtained show that loneliness correlated negatively with self-esteem and life satisfaction. Self-esteem was associated positively with life satisfaction. Self-esteem acted as a suppressor between loneliness and life satisfaction. The participation of older adults in U3A moderated the strength of the relationship between loneliness and life satisfaction (direct effect) and between loneliness and life satisfaction mediated by self-esteem (indirect effect).

Conclusion

The mediatory role of self-esteem and the moderating role of educational activities in the relationship between loneliness and life satisfaction in late adulthood have important developmental and social implications. It appears that although feelings of loneliness and social isolation have a negative association on the life satisfaction of older adults, this relationship may be altered by empowering seniors’ self-esteem through their involvement in lifelong learning. Such a solution supports the functioning of older people also at the social level.

Housing Stability and Hepatitis C Infection for Young Adults Who Inject Drugs: Examining the Relationship of Consistent and Intermittent Housing Status on HCV Infection Risk

Housing status affects drug using behaviors, but less is known about the relationship between housing patterns and hepatitis C virus (HCV) infection. HCV-negative young people who inject drugs (PWID) were enrolled into a prospective cohort (2003-2019) with quarterly study visits. We used Cox regression to estimate the independent association of recent housing status (housed vs. unhoused, housing stability, and housing trajectory) on HCV incidence. Among 712 participants, 245 incident HCV infections occurred over 963.8 person-years (py) (cumulative incidence 24.4/100 py). An inverse relationship between time housed and HCV incidence was observed (always unhoused 45.0/100 py, 95% confidence interval (CI) 37.1, 54.5; variably housed 18.0/100 py, 95% CI 15.0, 21.3; and always housed 7.0/100 py, 95% CI 3.0, 17.3). In Cox regression models controlling for confounders, those unhoused versus housed at baseline had a 1.9-fold increased infection risk (95% CI 1.4, 2.6). Those always unhoused versus always housed had a 1.5 times greater risk of HCV (95% CI 1.0, 2.3), and those spending a portion of time in stable housing a lower risk (adjusted relative hazard 0.05, 95% CI 0.3, 0.9) with a similar trend for those being housed for less time. Young adult PWID experiencing both recent and chronic states of being unhoused are at elevated risk for HCV infection. Importantly for this group of PWID, our findings indicate that some frequency of residential housing significantly reduces HCV infection risk.

"They don't know who they have in here": Sense of community in budget hotels

The purpose of this study was to understand older residents descriptions of socio-spatial guest interactions and sense of community in budget hotels. Due to financial vulnerability, some people move into budget hotels when other housing options are unavailable. Little is known about how older residents perceive other hotel guests who frequent the commercial establishment and how a mix of various consumer interactions can potentially influence health. Theoretically framing this inquiry with sense of community constructs, we conducted a secondary data analysis of 20 interviews with residents aged 50 and older. Through thematic analysis strategies, we identified temporal and socio-spatial interactions of hotel guests, then discussed sense of community based on these insider/outsider relationships. We conclude with research, policy, and practice implications of our findings.

Positive health among older Traveller and older homeless adults: A scoping review of life-course and structural determinants

Concepts related to positive health in later life are increasingly prevalent within community-based health and social care policy. With a greater emphasis on inclusion health for older populations, there is a critical need to understand the determinants of such states for those most at risk of societal disadvantage. Focusing on two such groups, the aim of this article is to synthesise international research on the life-course and structural determinants of positive subjective health for older homeless people and older Irish Travellers. Two scoping reviews were conducted (one for each group) to capture state-of-the art knowledge published from 1998 to 2020. The reviews were completed from July to December 2018, and repeated from March to April 2020. Thirty-eight publications were included in the final sample (older Travellers: 10 sources; older homeless: 28 sources). Specific life-course and structural factors were evident for both groups, as well as commonalities with respect to: accumulated exclusions; complexity of needs; accommodation adequacy/stability and independence and resilience. Research gaps are identified concerning: lack of conceptualisation of positive health; the application of life-course perspectives and the absence of an environmental gerontological analysis of the situations of both groups.

Homelessness and rates of physical dysfunctions characteristic of premature geriatric syndromes: systematic review and meta-analysis

BACKGROUND

Homeless adults may experience accelerated aging, presenting earlier with geriatric syndromes such as falls and functional limitations. Though homelessness is surging in United States, data are scarce regarding rates of physical dysfunctions characteristic of geriatric syndromes experienced in this underserved population.

PURPOSE

Examine associations between homelessness, premature geriatric syndromes, and functional limitations.

METHODS

Two reviewers independently searched PubMed, CINAHL, and PEDro databases for prognostic studies reporting rates of geriatric syndromes in homeless adults aged 40 years and older. Two reviewers independently performed study selection. Data were extracted for homeless adults and community-dwelling controls regarding age, demographic information, limitations of activities of daily living (ADL) and instrumental ADL (IADL), frailty, and falls the past year. Risk ratio (RR) and 95% confidence interval (CI) were calculated across studies to compare groups.

RESULTS

Five studies met predetermined criteria. Meta-analysis revealed greater rates in homeless adults (average age 56) compared to housed adults (average age 78) for ADL limitation (RR = 1.50, 95% CI = 1.37-1.64) and IADL limitation (RR = 1.36, 95% CI = 1.28-1.45). Falls were three times more prevalent in homeless individuals (RR = 3.42, 95% CI = 3.16-3.70). Heterogeneous frailty data did not reach significance (RR = 2.59, 95% CI = 0.90-7.46).

CONCLUSION

Homeless adults have increased risk of premature geriatric syndromes. Limitations in ADL and IADL rates were 30-50% higher than adults with stable housing averaging 20 years older, and fall rates were three times higher than controls averaging 4.5 years older. These results underscore the need for healthcare providers such as physical therapists to address physical dysfunction in homeless adults.

Homeless Shelter Characteristics and Prevalence of SARS-CoV-2

INTRODUCTION

The unfolding COVID-19 pandemic has predictably followed the familiar contours of well established socioeconomic health inequities, exposing and often amplifying preexisting disparities. People living in homeless shelters are at higher risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) compared to the general population. The purpose of this study was to identify shelter characteristics that may be associated with higher transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

METHODS

We conducted a cross-sectional assessment of five congregate shelters in Rhode Island. Shelter residents 18 years old and older were tested for SARS-CoV-2 from April 19-April 24, 2020. At time of testing, we collected participant characteristics, symptomatology, and vital signs. Shelter characteristics and infection control strategies were collected through a structured phone questionnaire with shelter administrators.

RESULTS

A total of 299 shelter residents (99%, 299/302) participated. Thirty-five (11.7%) tested positive for SARS-CoV-2. Shelter-level prevalence ranged from zero to 35%. Symptom prevalence did not vary by test result. Shelters with positive cases of SARS-CoV-2 were in more densely populated areas, had more transient resident populations, and instituted fewer physical distancing practices compared to shelters with no cases.

CONCLUSION

SARS-CoV-2 prevalence varies with shelter characteristics but not individual symptoms. Policies that promote resident stability and physical distancing may help reduce SARS-CoV-2 transmission. Symptom screening alone is insufficient to prevent SARS-CoV-2 transmission. Frequent universal testing and congregate housing alternatives that promote stability may help reduce spread of infection.

Characteristics of health care related to mental health and substance use disorders among Community Health Centre clients in Ontario: a population-based cohort study

BACKGROUND

Community Health Centre (CHC) client populations with a history of mental illness or substance use disorders, or both, are not described well in the literature. We identified CHC clients in Ontario with a history of health care related to mental health or substance use disorders, or both, and describe their demographic characteristics, health system use and related health risks in comparison to other people in the province with similar diagnoses who did not use CHC services.

METHODS

We conducted a population-based cohort study using provincial health administrative data among Ontario residents aged 21-105 years with a previously established medical history of a mental illness or substance use disorder, or both. We examined 3 groups: clients of CHC sites that serve at-risk priority populations (PPCHCs) who presented for care at a CHC between Apr. 1, 2014, and Mar. 31, 2015, clients of CHC sites that serve nonpriority populations (NPPCHCs) who presented for care at a CHC over the same period, and a community control group of patients with a history of health care use related to mental illness or substance use disorders, or both, in the 2 years before the index date who were not CHC clients. We used descriptive statistics and multivariable logistic regression to estimate the odds of psychiatric care and emergency department use within 1 year of the index date.

RESULTS

Compared to the community control patients (n = 1 673 200), clients of PPCHCs (n = 6575) and NPPCHCs (n = 15 208) were younger, experienced more residential instability and had an increased prevalence of medical comorbidities; they had higher odds of receiving care from a psychiatrist (adjusted odds ratio [OR] 1.26, 95% confidence interval [CI] 1.20-1.33, and 1.47, 95% CI 1.41-1.53, respectively) and visiting an emergency department (adjusted OR 1.15, 95% CI 1.10-1.20, and 1.13, 95% CI 1.09-1.17, respectively) in the 1-year follow-up period.

INTERPRETATION

Ontario CHC clients with mental health or substance use disorders had medically complex needs and were intensive users of the health care system. Specific interventions should be developed to better serve this vulnerable population.

Comparing Unsheltered and Sheltered Homeless: Demographics, Health Services Use and Predictors of Health Services Use

Secondary data obtained through the 2015 point-in-time homelessness count and an administrative health care utilization database was used to identify differences in demographic characteristics, health service use, and predictors of health service use among people experiencing unsheltered and sheltered homelessness. Compared to sheltered participants, unsheltered participants had higher proportions of males and Caucasians, were younger, were more likely to use any type of health service and ED services, and used significantly more of any health service and ED and outpatient services. Results also confirm that health services utilization is a complex phenomenon predicted by a variety of predisposing, enabling, and need-related factors, including mental health problems. Together, these findings demonstrate important differences between people living unsheltered and those residing in shelters and they inform local health policy and program initiatives tailored towards these homeless populations.

Integrating social and behavioral determinants of health into patient care and population health at Veterans Health Administration: a conceptual framework and an assessment of available individual and population level data sources and evidence-based measurements

The premise of this project was that social and behavioral determinants of health (SBDH) affect the use of healthcare services and outcomes for patients in an integrated healthcare system such as the Veterans Health Administration (VHA), and thus individual patient level socio-behavioral factors in addition to the neighborhood characteristics and geographically linked factors could add information beyond medical factors mostly considered in clinical decision making, patient care, and population health. To help VHA better address SBDH risk factors for the veterans it cares for within its primary care clinics, we proposed a conceptual and analytic framework, a set of evidence-based measures, and their data source. The framework and recommended SBDH metrics can provide a road map for other primary care-centric healthcare organizations wishing to use health analytic tools to better understand how SBDH affect health outcomes.

Duration of homelessness and its relationship to use of hospital and emergency department services in Helsinki, Finland

Aims: Homelessness is associated with poor health outcomes and increased use of hospital and emergency department (ED) services. Little is known about the duration of homelessness in relation to health care service use. The aim of this study was to examine the use of hospital and ED services among the homeless in Helsinki, Finland, and for the first time, to examine the relationship between service use and duration of homelessness. Methods: Six hundred and eighty-three persons staying at least one night in a shelter between September 2009 and September 2010 were followed until the end of 2014. Using negative binominal regression analysis we calculated the use of hospital and ED services and compared the use with that of a matched control group (N = 1361). We also analyzed service use in relation to the time spent homeless during follow-up. Results: The mean time spent homeless during the follow-up was 8.5 months, one third was temporarily homeless (less than 2% of the follow-up time), but recurrent episodes of homelessness were also common. The study group's incidence rate ratios for medical-surgical hospital days was 6.23 (95% CI: 4.73 to 8.21), for psychiatric hospital days 43.11 (95% CI: 23.02 to 80.74) and for ED visits 10.21 (95% CI: 8.77 to 11.90), compared with controls. The number of medical-surgical hospital days and ED visits/person-year increased as homelessness was prolonged, but the pattern was opposite for psychiatric hospital days. Conclusions: Homeless persons are heavy users of hospital and ED services, and there is also increased use among those temporarily homeless.

Determinants of Tenancy Sustainment Following Homelessness: A Systematic Review

BACKGROUND

Tenancy sustainment-maintenance of a tenancy to avoid a premature end of tenure-is fundamental to prevention of homelessness. Understanding what enables a successful tenancy is essential in informing interventions designed to support people in leaving homelessness.

OBJECTIVES

To conduct a systematic review identifying determinants associated with tenancy sustainment following homelessness.

SEARCH METHODS

A detailed search of 12 electronic databases, as well as gray literature sources, was conducted in 2015 and updated in 2016.

SELECTION CRITERIA

We included all study designs with a population of homeless or formerly homeless individuals in which tenancy sustainment was the primary outcome. Two reviewers independently carried out abstract and full-text reviews. QualSyst, a validated quality appraisal tool, was used in assessing the methodological quality of articles.

DATA COLLECTION AND ANALYSIS

A data extraction form was developed for the review and was completed by a pair of reviewers to ensure accuracy. The heterogeneity of the studies included indicated that a narrative overview of the results was most appropriate.

MAIN RESULTS

Forty-three articles reporting 38 studies were included. Determinants were categorized at 4 levels: individual, interpersonal, community, and structural. Participation in specific programs (e.g., Housing First), receipt of social support, and older age were identified as positive determinants of tenancy sustainment.

CONCLUSIONS

This systematic review is the first, to our knowledge, to focus solely on tenancy sustainment as a primary outcome. Although a range of determinants associated with tenancy sustainment were identified, it was difficult to draw strong conclusions owing to the heterogeneity of the studies. Despite being a fundamental concept in homelessness research, tenancy sustainment is poorly defined and conceptualized. A deeper understanding of tenancy sustainment will inform the development and evaluation of interventions that support people in leaving homelessness and maintaining tenancies. Public Health Implications. Housing stability is central to preventing homelessness and addressing the numerous public health concerns that can co-occur with homelessness. Our review highlights that a standardized approach to measuring housing stability and more high-quality intervention studies are essential.

'The Thing that Really Gets Me Is the Future': Symptomatology in Older Homeless Adults in the HOPE HOME Study

CONTEXT

The homeless population is aging. Older homeless adults experience premature development of age-related conditions and an elevated symptom burden. Little is known about symptom experience among older homeless adults.

OBJECTIVES

To characterize the experience, understanding, and management of physical, psychological, social (e.g., loneliness), and existential (e.g., regret, loss of dignity) symptoms among older homeless adults.

METHODS

We conducted semistructured interviews from June 2016 to March 2017 with a purposive sample of participants from the Health Outcomes of People Experiencing Homelessness in Older Middle Age cohort, a longitudinal study of homeless adults aged 50 and older. We analyzed data between June 2016 and December 2017 using thematic analysis.

RESULTS

We found four main themes: 1) nonphysical symptoms are interwoven with, and as distressing as, physical symptoms; 2) individuals attribute symptoms to childhood abuse, manual labor, the conditions of homelessness, and aging; 3) symptoms interfere with daily functioning, causing negative changes in personality, energy, and motivation; and 4) individuals cope with symptoms through religion, social support, and substance use.

CONCLUSION

Homelessness causes and exacerbates physical and psychological distress. Interventions should address multiple interconnected dimensions of suffering. Health systems that care for homeless patients should adapt palliative care practices using a stepwise approach. Homeless shelters should adopt policies and modifications that increase privacy and autonomy while promoting community building. Housing interventions should promote community building. All who work with people experiencing homelessness should avoid stigmatizing language and recognize homeless individuals' sources of strength and coping.

Comprehensive services delivery and emergency department use among chronically homeless adults

Homeless adults use emergency department (ED) services more frequently than other adults, but the relationships between homelessness, health status, outpatient service use, and ED utilization are poorly understood. Data from the Collaborative Initiative to Help End Chronic Homelessness (CICH) were used to compare ED use among chronically homeless adults receiving comprehensive housing, case management, mental health, addiction, and primary care services through CICH at 5 U.S. sites (n = 274) and ED use among comparison group clients receiving generally available community services (n = 116) at the same sites. Multiple imputation was used to account for missing data and differential rates of attrition between the cohorts. Longitudinal models were constructed to compare ED use between the 2 groups during the first year after initiation of CICH services. A mediation analysis was performed to determine the relative contributions of being housed, the receipt of outpatient services, and health status to group differences in ED utilization. Participants receiving CICH services were significantly less likely to report ED use (odds ratio = 0.78, 95% confidence interval [0.65, 0.93]) in the year after program entry. Decreased ED use was primarily mediated by decreased homelessness-not by increased access to other services or health status. This suggests that becoming housed is a key driver of reduced ED utilization and that efforts to provide housing for homeless adults may result in significantly decreased ED use. Further research is needed to determine the long-term effects of housing on health status and to develop services to improve health outcomes. (PsycINFO Database Record

Aging on the Street: Homeless Older Adults in America

Older adults are at greater risk for homelessness today than at any time in recent history. Approximately one half of homeless individuals in America are older than 50, which has created serious challenges for how cities, governments, and health care providers care for homeless populations. Systems established in the 1980s to help care for homeless individuals were not designed to address problems of aging. It is critical that nurses and all health professionals have a better understanding of the unique needs and concerns of homeless older adults. Nurses can be an important part of the solution, not only through direct patient care but by advocating for improvements in care for this vulnerable population. [Journal of Psychosocial Nursing and Mental Health Services, 54(9), 25-29.].

Concurrent Disorders and Health Care Utilization Among Homeless and Vulnerably Housed Persons in Canada

OBJECTIVE

Individuals who are homeless or vulnerably housed have a higher prevalence of concurrent disorders, defined as having a mental health diagnosis and problematic substance use, compared to the general housed population. The study objective was to investigate the effect of having concurrent disorders on health care utilization among homeless or vulnerably housed individuals, using longitudinal data from the Health and Housing in Transition Study.

METHODS

In 2009, 1190 homeless or vulnerably housed adults were recruited in Ottawa, Toronto, and Vancouver, Canada. Participants completed baseline interviews and four annual follow-up interviews, providing data on sociodemographics, housing history, mental health diagnoses, problematic drug use with the Drug Abuse Screening Test (DAST-10), problematic alcohol use with the Alcohol Use Disorders Identification Test (AUDIT), chronic health conditions, and utilization of the following health care services: emergency department (ED), hospitalization, and primary care. Concurrent disorders were defined as the participant having ever received a mental health diagnosis at baseline and having problematic substance use (i.e., DAST-10 ≥ 6 and/or AUDIT ≥ 20) at any time during the study period. Three generalized mixed effects logistic regression models were used to examine the independent association of having concurrent disorders and reporting ED use, hospitalization, or primary care visits in the past 12 months.

RESULTS

Among our sample of adults who were homeless or vulnerably housed, 22.6% (n = 261) reported having concurrent disorders at baseline. Individuals with concurrent disorders had significantly higher odds of ED use (adjusted odds ratio [AOR] = 1.71; 95% confidence interval [CI], 1.4-2.11), hospitalization (AOR = 1.45; 95% CI, 1.16-1.81), and primary care visits (AOR = 1.34; 95% CI, 1.05-1.71) in the past 12 months over the four-year follow-up period, after adjusting for potential confounders.

CONCLUSIONS

Concurrent disorders were associated with higher rates of health care utilization when compared to those without concurrent disorders among homeless and vulnerably housed individuals. Comprehensive programs that integrate mental health and addiction services with primary care as well as community-based outreach may better address the unmet health care needs of individuals living with concurrent disorders who are vulnerable to poor health outcomes.

Adverse Childhood Experiences and Substance Use History among Vulnerable Older Adults Living in Public Housing

Previous research shows strong correlations between adverse childhood experiences (ACE) and later life health. The current study examines the relationship between ACEs and substance use among older adults living in public housing. Results show that about one-third of participants had four or more ACEs, and ACE score predicted likelihood of substance use history. Over half of older adults with four or more ACEs experienced substance abuse in their lifetime compared to one out of ten older adults with less than four ACEs. Findings shed light on a vulnerable group and point to next steps in research and practice.

HUD Housing Assistance Associated With Lower Uninsurance Rates And Unmet Medical Need

To investigate whether receiving US Department of Housing and Urban Development (HUD) housing assistance is associated with improved access to health care, we analyzed data on nondisabled adults ages 18-64 who responded to the 2004-12 National Health Interview Survey that were linked with administrative data from HUD for the period 2002-14. To account for potential selection bias, we compared access to care between respondents who were receiving HUD housing assistance at the time of the survey interview (current recipients) and those who received HUD assistance within twenty-four months of completing the survey interview (future recipients). Receiving assistance was associated with lower uninsurance rates: 31.8 percent of current recipients were uninsured, compared to 37.2 percent of future recipients. Rates of unmet need for health care due to cost were similarly lower for current recipients than for future recipients. No effect of receiving assistance was observed on having a usual source of care. These findings provide evidence that supports the effectiveness of housing assistance in improving health care access.

Joint replacement surgery in homeless veterans

Total joint arthroplasty (TJA) in a homeless patient is generally considered contraindicated. Here, we report our known medical and social (housing and employment) results of homeless veterans who had TJA. Thirty-seven TJAs were performed on 33 homeless patients (31 men) at our hospital between November 2000 and March 2014. This was 1.2% of all TJAs. Average age was 54 years. Average hospital stay was 4.1 days. There were no major inpatient complications. Thirty-four cases had at least 1-year follow-up in any clinic within the Veterans Affairs health care system. There were no known surgery-related reoperations or readmissions. At final follow-up, 24 patients had stable housing and 9 were employed. The extensive and coordinated medical and social services that were provided to veterans from the Department of Veterans Affairs contributed to our positive results.

Emergency Department Use in a Cohort of Older Homeless Adults: Results From the HOPE HOME Study

OBJECTIVE

The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older.

METHODS

We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use.

RESULTS

In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates.

CONCLUSIONS

A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness.