Improving Health Care Management in Primary Care for Homeless People: A Literature Review

Supporting the nutrition-related health and well-being of people experiencing socio-economic disadvantage: Findings from a national survey

BACKGROUND

People experiencing socio-economic disadvantage face significantly higher rates of diet-related health inequities. This study aimed to explore barriers, opportunities and potential solutions in providing food and nutrition services to people experiencing socio-economic disadvantage from the perspective of services providers. The present study is part of a broad co-design model to improve service provision for people experiencing socio-economic disadvantage.

METHODS

A cross-sectional online survey involving 33 open and closed-ended questions was distributed to Australian governmental and non-governmental organisations providing nutrition-related support to people experiencing socio-economic disadvantage aged 16 years and over. Data were analysed using frequency distributions and conceptual content analyses.

RESULTS

Sixty-eight responses were analysed. Services are predominantly offered by charitable organisations (90%), funded through private donations (66%) and reliant on volunteers (100%). Barriers to supporting clients' nutrition needs include financial constraints, limited community engagement, understaffing, insufficient resources and knowledge gaps. Opportunities and solutions for enhancing support include increasing government funding, advocacy initiatives, stronger community collaboration and more holistic, customised services. Proposed recommendations include establishing purpose-built facilities or wrap-around services to expand access to health services, life skills, training and educational programs.

CONCLUSIONS

Services face challenges including volunteer reliance, limited resources and inadequate government support, hindering food provision. Client barriers include transportation costs and lack of social support. With dedicated financial support, services can offer comprehensive assistance, including community spaces, staffing, health and social services and training. Community partnerships can maximise funding impact. Solutions must address overall well-being and broader social determinants such as income inequality and housing.

Describing the Medical Needs of Hawai'i's Houseless Population During COVID at Free Student Run Outpatient Clinics (Hawai'i HOME Project)

Hawai'i experiences some of the highest rates of houselessness per capita in the country. COVID-19 has exacerbated these disparities and made it difficult for these individuals to seek medical care. Hawai'i's Houseless Outreach in Medical Education (HOME) clinic is the largest student run free clinic in the state, which provides medical services to this patient population. This article reports the demographics, medical needs, and services provided to patients of Hawai'i's HOME clinic during the era of COVID-19. From September 2020 to 2021, the HOME clinic saw 1198 unique visits with 526 distinct patients. The most common chief complaints included wound care (42.4%), pain (26.9%), and skin complaints (15.7%). A large portion of the population suffered from comorbidities including elevated blood pressure (66%), a formal reported history of hypertension (30.6%), diabetes (11.6%), and psychiatric concerns including schizophrenia (5.2%) and generalized anxiety (5.1%). Additionally, a large portion of patients (57.2%) were substance users including 17.8% of patients endorsing use of alcohol, 48.5% tobacco and 12.5% marijuana. The most common services provided were dispensation of medication (58.7%), wound cleaning/dressing changes (30.7%), and alcohol or other drug cessation counseling (25.2%). This study emphasizes that the houseless are a diverse population with complex, evolving medical needs and a high prevalence of chronic diseases and comorbidities.

Multilayer depressive symptom networks in adults with bodily pain living in precarious housing or homelessness

Housing insecurity is associated with co-occurring depression and pain interfering with daily activities. Network analysis of depressive symptoms along with associated risk or protective exposures may identify potential targets for intervention in patients with co-occurring bodily pain. In a community-based sample of adults (n = 408) living in precarious housing or homelessness in Vancouver, Canada, depressive symptoms were measured by the Beck Depression Inventory; bodily pain and impact were assessed with the 36-item Short Form Health Survey. Network and bootstrap permutation analyses were used to compare depressive symptoms endorsed by Low versus Moderate-to-Severe (Mod + Pain) groups. Multilayer networks estimated the effects of risk and protective factors. The overall sample was comprised of 78% men, mean age 40.7 years, with 53% opioid use disorder and 14% major depressive disorder. The Mod + Pain group was characterized by multiple types of pain, more persistent pain, more severe depressive symptoms and a higher rate of suicidal ideation. Global network connectivity did not differ between the two pain groups. Suicidal ideation was a network hub only in the Mod + Pain group, with high centrality and a direct association with exposure to lifetime trauma. Antidepressant medications had limited impact on suicidal ideation. Guilt and increased feelings of failure represented symptoms from two other communities of network nodes, and completed the shortest pathway from trauma exposure through suicidal ideation, to the non-prescribed opioid exposure node. Interventions targeting these risk factors and symptoms could affect the progression of depression among precariously housed patients.

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.

Behavioral Health Care Delivery Through Street Medicine Programs in California

Mental health and substance use disorders are prevalent among people experiencing homelessness. Street Medicine can reach unhoused people who face barriers to accessing healthcare in more traditional medical settings including shelter-based clinics. However, there is little guidance on best practices for mental health and substance use treatment through Street Medicine. The aim of the study was to describe behavioral health care through Street Medicine by analyzing data from the California Street Medicine Landscape survey and follow-up qualitative interviews. Most street medicine programs utilize non-psychiatrists to diagnose and treat mental health and substance use disorders, though the capacity to provide the level of care needed varies. There is a lack of street-based psychiatric clinicians and programs have difficulty making referrals to mental health and addiction services. This report shows that Street Medicine could serve as a strategy to expand access to behavioral health care for the unhoused.

Short Interpregnancy Intervals Among Women Experiencing Homelessness in Colorado

Importance

Short interpregnancy intervals (SIPIs) are associated with increased risk of adverse maternal and neonatal outcomes. Disparities exist across socioeconomic status, but there is little information on SIPIs among women experiencing homelessness.

Objective

To investigate (1) differences in rates and characteristics of SIPIs between women experiencing homelessness and domiciled women, (2) whether the association of homelessness with SIPIs differs across races and ethnicities, and (3) whether the association between SIPIs of less than 6 months (very short interpregnancy interval [VSIPIs]) and maternal and neonatal outcomes differs between participant groups.

Design, Setting, and Participants

This cohort study used a Colorado statewide database linking the Colorado All Payer Claims Database, Homeless Management Information System, death records, and infant birth records. Participants included all women who gave birth between January 1, 2016, and December 31, 2021. Data were analyzed from September 1, 2022, to May 10, 2023.

Exposures

Homelessness and race and ethnicity.

Main Outcomes and Measures

The primary outcome consisted of SIPI, a binary variable indicating whether the interval between delivery and conception of the subsequent pregnancy was shorter than 18 months. The association of VSIPI with maternal and neonatal outcomes was also tested.

Results

A total of 77 494 women (mean [SD] age, 30.7 [5.3] years) were included in the analyses, of whom 636 (0.8%) were women experiencing homelessness. The mean (SD) age was 29.5 (5.4) years for women experiencing homelessness and 30.7 (5.3) years for domiciled women. In terms of race and ethnicity, 39.3% were Hispanic, 7.3% were non-Hispanic Black, and 48.4% were non-Hispanic White. Associations between homelessness and higher odds of SIPI (adjusted odds ratio [AOR], 1.23 [95% CI, 1.04-1.46]) were found. Smaller associations between homelessness and SIPI were found among non-Hispanic Black (AOR, 0.59 [95% CI, 0.37-0.96]) and non-Hispanic White (AOR, 0.57 [95% CI, 0.39-0.84]) women compared with Hispanic women. A greater association of VSIPI with emergency department visits and low birth weight was found among women experiencing homelessness compared with domiciled women, although no significant differences were detected.

Conclusions and Relevance

In this cohort study of women who gave birth from 2016 to 2021, an association between homelessness and higher odds of SIPIs was found. These findings highlight the importance of conception management among women experiencing homelessness. Racial and ethnic disparities should be considered when designing interventions.

Exploring Frontline Shelter Staff Perspectives on the Healthcare Needs of Clients Experiencing Homelessness

PURPOSE

To examine healthcare service development needs for persons experiencing homelessness from the perspective of frontline staff at a homeless shelter in Montreal, Quebec.

DESIGN

Qualitative descriptive design.

METHODS

Purposive sampling, semi-structured interviews with frontline shelter staff (n = 8), and thematic analysis.

FINDINGS

Themes included: 1) Challenges meeting healthcare service needs in a shelter environment. 2) Visions for improving healthcare services while accounting for health issues and barriers to care. 3) Participants' own knowledge gaps around health and healthcare services.

CONCLUSIONS

Future research should emphasize this group's crucial role in homelessness healthcare services development.

Community-Based Wound Care Programs for Unhoused Individuals

Wound care management for unhoused individuals is challenging due to the lack of healthcare infrastructure to handle the unique needs of this population. Therefore, we aimed to obtain insights for best practices and to establish a care clinic that is low threshold, community-based and meets the needs of unhoused people. We employed two approaches: (1) conduct a targeted narrative review of the literature of existing or proposed community-based program models that can address the wound care needs of unhoused individuals, and (2) assess cost-effectiveness and describe the results of a survey administered to unhoused clients and their health care providers at a community-based wound care program in Honolulu, Hawai'i. The literature search and screening yielded 11 articles relevant to the topic. Per the literature, existing community-based healthcare programs were successful when: (1) wound care services were incorporated into a broader social/health program, (2) cost-effective, and (3) comprehensive services were provided. Survey results in Honolulu found that the wound care program matched the needs of the targeted population and was cost-effective. Difficulty in following clients until wound closure and the sustainability of the program, particularly the lack of insurance reimbursement for street-based services, were perceived challenges. Additionally, the lack of insurance reimbursement for street-based wound care services continues to impact sustainability. Community-based programs can be successful in addressing the wound care needs of unhoused individuals if they address complex fundamental issues. This paper highlights existing gaps in logistics and policies that must be addressed to meet the specific medical needs of these vulnerable individuals.

Analysis of older adult blood pressure readings and hypertension treatment rates among the unsheltered population of Miami-Dade County

Objective

To assess prevalence of elevated blood pressure readings, rates of established hypertension diagnosis, and blood pressure control medication prescription rates in a cohort of older people experiencing unsheltered homelessness presenting to a Street Medicine clinic in Miami-Dade County, Florida. In addition, we will compare outcomes found in the study cohort to that of the general population.

Methods

Demographic information, clinical history, blood pressure control medication prescription, and blood pressure measurements were taken by a Street Medicine team of medical providers. The team routinely provides medical evaluations and care for people experiencing unsheltered homelessness who reside in rough sleeper tent encampments located on the street. Clinical information and vitals were recorded in REDCap. De-identified data from patients 65 years and above were downloaded and compared to a general population data set-the Centers for Disease Control National Health and Nutrition Examination Survey (CDC NHANES) 2017-2020 Pre-pandemic cohort. Data analysis was performed using R Studio version 4.3.2.

Results

Blood pressure was reported in 120 distinct interactions with older people experiencing homelessness. Compared to the age-matched NHANES data, older people experiencing unsheltered homelessness were at significantly increased relative risk for elevated blood pressure within the range of Stage 1 Hypertension (RR: 3.914, 95% CI: 2.560-5.892, P < 0.001), and within range of Stage 2 Hypertension (RR: 5.550, 95% CI: 4.272-7.210, P < 0.001). According to NHANES, 49.6% of adults over 60 with diagnosed hypertension receive treatment. Of study participants, 69% of those with elevated blood pressure had previously received a diagnosis of hypertension and 15.9% on medication to control blood pressure.

Conclusion

Our cohort of older people experiencing unsheltered homelessness had higher rates of elevated blood pressure and reduced rates of hypertension diagnosis and treatment as compared to the general population. Older people experiencing unsheltered homelessness are a growing population, and future research should seek to evaluate and understand older adult care vulnerabilities, including chronic disease management, to improve health outcomes for those who are aging, hypertensive, and unhoused.

The views of people using homeless services about learning disability

AIMS

People with a learning disability are at increased risk of becoming homeless, but little is known about how learning disability is viewed by people accessing homeless services. This study aimed to obtain the views of people experiencing homelessness about learning disability, in the context of a project that was exploring how to increase identification of learning disability.

METHODS

A qualitative approach was used, and 19 adults were interviewed who were receiving support from homeless services in the North-East of England. Information from the interviews was analysed using thematic analysis.

RESULTS

Four themes were identified relating to understanding of learning disability, the role of identification, day-to-day challenges, and experiences of services.

CONCLUSION

There is a need to: promote better understanding of learning disability; for early identification processes that involve the person in a meaningful way; and the provision of support that is non-stigmatising, practical and which addresses health concerns.

Implementation and Impacts of California Senate Bill 1152 on Homeless Discharge Protocols

Introduction

In recent decades, there has been a growing focus on addressing social needs in healthcare settings. California has been at the forefront of making state-level investments to improve care for patients with complex social and medical needs, including patients experiencing homelessness (PEH). Examples include Medicaid 1115 waivers such as the Whole Person Care pilot program and California Advancing and Innovating Medi-Cal (CalAIM). To date, California is also the only state to have passed a legislative mandate to address concerns related to the hospital discharge of PEH who lack sufficient resources to support self-care. To this end, California enacted Senate Bill 1152 (SB 1152), a unique legislative mandate that requires hospitals to standardize comprehensive discharge processes for PEH by providing (and documenting the provision of) social and preventive services. Understanding the implementation and impact of this law will help inform California and other states considering legislative investments in healthcare activities to improve care for PEH.

Methods

To understand health system stakeholders' perceived impact of SB 1152 on hospital discharge processes and key barriers and facilitators to SB 1152's implementation, we conducted 32 semi-structured interviews with key informants across 16 general acute care hospitals in Humboldt and Los Angeles counties. Study data were coded and analyzed using thematic analysis informed by the Consolidated Framework for Implementation Research.

Results

Participants perceived several positive impacts of SB 1152, including streamlined services, increased accountability, and more staff awareness about homelessness. In parallel, participants also underscored concerns about the law's limited scope and highlighted multiple implementation challenges, including lack of clarity about accountability measures, scarcity of implementation supports, and gaps in community resources.

Conclusion

Our findings suggest that SB 1152 was an important step toward the goal of more universal safe discharge of PEH. However, there are also several addressable concerns. Recommendations to improve future legislation include adding targeted funding for social care staff and improving implementation training. Participants' broader concerns about the parallel need to increase community resources are more challenging to address in the immediate term, but such changes will also be necessary to improve the overall health outcomes of PEH.

Medical centres for the homeless in Hamburg - consultation reasons and diagnoses compared to primary care patients in the regular health care system

BACKGROUND

In Germany, homeless people are entitled to health care within the regular health care system. However, due to their specific living conditions they make little use of these services. In 2013, three Medical centres for the homeless (MCH) were opened in Hamburg to provide general health care. This study aims to analyse the consultation reasons and diagnoses prevalent among the homeless in comparison to regular primary care patients. It also examines the means and obstacles of integrating the homeless into Germany's regular health care system.

METHODS

From 2013 to 2014, routine medical data of all patients of the MCH consenting to participate in the study were analysed descriptively, in particular consultation reasons (categorised by ICPC-2), ICD-10 diagnoses and data on health insurance status and the use of the regular health care system. Consultation reasons and diagnoses of homeless patients were compared descriptively with data from regular general practices. Additionally, anonymous data on patient numbers, gender and insurance status was exported from the MCH's software and analysed descriptively for the years 2013 to 2020.

RESULTS

A total of 840 homeless patients in 2013 and 2014 gave consent to the evaluation of consultation reasons and diagnoses. The most frequent consultation reasons in the MCH in 2013 were skin conditions (24%), musculoskeletal conditions (16%) and psychological disorders (14%), in GP practices these were musculoskeletal conditions (22%), conditions affecting the digestive system (14%) and skin conditions (12%). Essential (primary) hypertension, diabetes mellitus type 2 and back pain are among the top-10-diagnoses in GP practices, as well as in MCH. With regard to the other top-10-diagnoses, there are clear differences between GP practices and MCH: "Psychological behavioural disorder due to alcohol" and diagnoses in connection with trauma, skin infections and acute respiratory infections stand out in MCH. 35% of the homeless patients reported a lack of health insurance as the reason for "not making use of" the regular health care system, while 10% reported they were unable to visit a regular general practitioner due to physical or psychological reasons. In the years 2013-2020 46% to 73% of the 8.380 MCH patients had no health care insurance.

CONCLUSION

Patients consulting the MCH suffer from medical conditions typical for the homeless, namely skin diseases, wounds, injuries and behavioural disorders due to alcohol abuse, but also from "typical" symptoms in regular GP care as cough or lower back symptoms. Consultation reasons mostly are acute illnesses. Chronic diseases are equally present in regular GP and MCH patients, but pose a great challenge for the homeless among other things due to their irregular contact with the health care system. The lack of health insurance poses the greatest hurdle to the integration of the homeless into the regular health care system.

Barriers and facilitators to health care access for people experiencing homelessness in four European countries: an exploratory qualitative study

BACKGROUND

People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context.

METHODS

We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically.

RESULTS

Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers.

CONCLUSIONS

The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH's access to mainstream primary care. This can also be further complemented by investment in 'in-reach' services and other tailored and person-centred forms of health care.

TRIAL REGISTRATION

This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687.

Results of a Peer Navigator Program to Address Chronic Illness Among Persons Experiencing Homelessness

People who are homeless disproportionately experience the burdens of chronic disease, have limited access to preventive care, and may be less trusting of healthcare agencies. The Collective Impact Project created and evaluated an innovative model designed to increase chronic disease screening and referral to healthcare and public health services. Trained Peer Navigators (PNs), who were paid staff with lived experiences similar to the clients served, were embedded in five agencies serving people experiencing homelessness or at risk for homelessness. Over two years, PNs engaged 1071 individuals. Of those, 823 were screened for chronic diseases and 429 were referred to healthcare services. Alongside screening and referrals, the project demonstrated the value of convening a coalition of community stakeholders, experts, and resources to identify service gaps and how PN functions might complement existing staffing roles. Project findings add to a growing literature documenting unique PN roles that potentially reduce health inequities.

A systematic scoping review of primary health care service outreach for homeless populations

BACKGROUND

Homeless populations (HPs) have difficulties obtaining necessary medical care, and primary health care service outreach (PHSO) might be useful to bridge this gap.

OBJECTIVE

Using the Centre for Evidence-Based Management Critically Appraised Topics framework, to provide systematic evidence of the usefulness of PHSO interventions for HPs.

METHODS

A systematic search was conducted in 4 electronic databases: PubMed, Web of Science, CINAHL, and Cochrane (publication dates between January 1980 and November 2020). In total, 2,872 articles were identified. Primary research about PHSO for HPs in high-income countries were included. Data were extracted from eligible studies, summarized, and collated into a narrative account.

RESULTS

Twenty-four studies that described and evaluated PHSO interventions for adults experiencing homelessness were selected in the final synthesis. Most studies had a nonrandomized design. PHSO was found to successfully address some barriers to health care access for HPs through flexible appointments in convenient locations, fostering an understanding relationship between doctor and patients, and provision of additional basic necessities and referrals. Outreach was provided for a range of health care concerns, and several solutions to engage more HPs in primary care, improve continuity of care and to decrease the running costs were identified. Outreach also helped to implement preventative measures and reduced emergency service admissions.

CONCLUSION

Our review adds to the evidence that PHSO likely improves health care access for HPs. Further studies over longer time periods, involving collaborations with experts with lived experience of homelessness, and utilizing randomized study designs are needed to test outreach efficacy.

The perceived impact of homelessness on health during pregnancy and the postpartum period: A qualitative study carried out in the metropolitan area of Nantes, France

The number of homeless people has been constantly increasing in Europe over recent years, as well as the proportion of women among the homeless population. Pregnancy can increase the risk of becoming homeless and, on the other hand, homelessness has been widely connected to adverse perinatal outcomes. The objective of this study was to describe the overall perceived impact of homelessness on health during pregnancy and the postpartum period, using a qualitative research approach to prioritize women's perspective. One-time semi structured interviews were conducted with 10 pregnant women and 10 women in the postpartum period experiencing homelessness in the metropolitan area of Nantes, as well as with six people from their social surroundings. A thematic analysis was performed to identify major themes and sub-themes. Homelessness was perceived as having an overall negative impact on all aspects of health (physical health, mental health, and social well-being) during pregnancy and the postpartum period. Stress and anxiety, food insecurity, social isolation, physical suffering, deterioration of chronic diseases, and pregnancy complications, were the main perceived consequences of homelessness on health. On the other hand, social support, and the "welcomeness" of healthcare professionals during pregnancy and the postpartum period were identified as capable of palliating those consequences. Finally, basic needs, such as having access to suitable housing, being independent, and being in good health, were identified by participants in the study as their main priorities. The results of this study, as well as those found by previous research, allowed us to identify possible axes in tackling homelessness and its complex consequences on health during pregnancy and the postpartum period. Housing and income assistance interventions, promoting social support and employment, outreach services enhancing collaborative networks among healthcare service providers, and integrating coordinated multidisciplinary approaches in primary care have shown to provide promising solutions to this issue.

Human Resource Management as an Area of Changes in a Healthcare Institution

Purpose

The underlying objective of the paper was to investigate the areas that require changes in human resource management in healthcare institutions. The practical objective of the study was to formulate recommendations targeted at the management staff of a healthcare institution, which allow to increase the adaptability and development capacity of medical personnel with the use of appropriate instruments and methods of human resource management.

Patients and Methods

The quantitative research was conducted among 652 patients using the services of primary health care clinics located in the Silesian province in Poland, in 2019. The share of women in the research sample was 61%, and men - 39%. 11% of the respondents were students, 27% - people of retirement age, and 62% were economically active. An anonymous survey questionnaire was used. Calculations were performed using Statistica software. Mann-Whitney U-test and correlation analysis using Gamma (Γ) coefficients were used.

Results

The results of the empirical research showed that the respondents positively assessed most of the examined elements (over 70% of positive opinions). Negative opinions did not exceed the error threshold and amounted up to 5%. The presented results allowed to conclude that the expectations and preferences of patients should be constantly monitored, have an impact on the management of medical personnel and imply introducing changes in the weakest areas.

Conclusion

The conducted research made it possible to identify the needs and expectations of patients and to develop possible solutions to improve human resource management in healthcare entities. In order to improve the operating conditions of the clinic, managers should constantly monitor patient satisfaction and, if necessary, introduce changes to raise service standards. This will allow early detection of shortcomings and the introduction of necessary changes in the clinic.

Characteristics and Effectiveness of Co-Designed Mental Health Interventions in Primary Care for People Experiencing Homelessness: A Systematic Review

People experiencing homelessness (PEH) face a disproportionately high prevalence of adverse mental health outcomes compared with the non-homeless population and are known to utilize primary healthcare services less frequently while seeking help in emergency care facilities. Given that primary health services are more efficient and cost-saving, services with a focus on mental health that are co-designed with the participation of users can tackle this problem. Hence, we aimed to synthesize the current evidence of such interventions to assess and summarize the characteristics and effectiveness of co-designed primary mental healthcare services geared towards adult PEH. Out of a total of 10,428 identified records, four articles were found to be eligible to be included in this review. Our findings show that co-designed interventions positively impacted PEH's mental health and housing situation or reduced hospital and emergency department admissions and increased primary care utilization. Therefore, co-designed mental health interventions appear a promising way of providing PEH with continued access to primary mental healthcare. However, as co-designed mental health interventions for PEH can improve overall mental health, quality of life, housing, and acute service utilization, more research is needed.

Quality of life and its correlated factors among patients with substance use disorders: a systematic review and meta-analysis

Background

Patients with substance use disorder (SUD) usually report lower quality of life (QoL) than other patients and as much as patients with other mental disorders. The present study investigated variables associated with QoL domains among patients with SUD.

Methods

Studies in English published before December 1^st 2021, were searched for on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on factors associated with QoL domains among patients with SUD. After reviewing for study duplicates, the full-texts of selected papers were assessed for eligibility using PECO (Participants, Exposures, Comparison and Outcome) criteria: (a) participants: patients with SUD; (b) exposures: sociodemographic factors, clinical, and service use variables; (c) comparison: patient groups without SUD; and (d) outcomes: four domains of QoL (physical, mental, social, and environmental domains). Three researchers recorded the data independently using predefined Excel spreadsheets. The Newcastle–Ottawa Scale (NOS) was used for assessing risk of bias and rated each study in terms of exposure, outcome, and comparability. Pooled odds ratios (ORs) and β coefficient were utilized at a 95% confidence level, and because sampling methods differed between studies’ pooled estimates, a random effects model was utilized.

Results

After the assessment of over 10,230 papers, a total of 17 studies met the eligibility criteria. Five studies (1260 participants) found that patients with SUD who were older were less likely to have a good physical Qol (OR = 0.86, 95% CI = 0.78, 0.95). Two studies (1171 participants) indicated that patients with SUD who were homeless were less likely to have a good environmental Qol (β = -0.47, p = 0.003). However, a better mental QoL was observed in four studies (1126 participants) among those receiving support from their family or friends (social networks) (OR = 1.05, 95% CI = 1.04, 1.07). Two studies (588 participants) showed that those using cocaine were less likely to have a good mental QoL (OR = 0.83, 95% CI = 0.75, 0.93). Two studies (22,534 participants) showed that those using alcohol were less likely to have a good physical QoL (β = -2.21, p = 0.001). Two studies (956 participants) showed that those having severe substance use disorders were less likely to have a good mental (β = -5.44, p = 0.002) and environmental (β = -0.59, p = 0.006) QoL respectively. Four studies (3515 participants) showed that those having mental disorders were less likely to have a good physical QoL (β = -1.05, p = 0.001), and another three studies (1211 participants) that those having mental disorders were less likely to have a good mental QoL (β = -0.33, p = 0.001). Finally, two studies (609 and 682 participants) showed that individuals who experienced trauma symptoms or mental disorders were less likely to have good social and environmental QoL, respectively (OR = 0.78, 95% CI = 0.61, 1.00) and (OR = 0.92, 95% CI = 0.9, 0.94).

Conclusions

The findings suggest the need for mental health services to improve the QOL among patients with SUD but further study is needed. Cocaine may cause behavioral changes which can increase the possibility of reckless and suicidal behaviors. Therefore, identifying cocaine user access, adherence, and satisfaction with treatment is recommended as an important component of adaptive functioning. Interventions that help patients with SUD get support from people within their social networks who support their recovery are also essential to their QoL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00940-0.

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

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

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Health status of recently arrived asylum seekers in their host country: results of a cross-sectional observational study

Background

The World Health Organization (WHO) considers that the heterogeneity of concepts and definitions of migrants is an obstacle to obtaining evidence to inform public health policies. There is no recent data on the health status of only asylum seekers who have recently arrived in their Western host country. The purpose of this study was to determine the health status of asylum seekers and search for explanatory factors for this health status.

Methods

This cross-sectional observational study screened the mental and somatic health of adult asylum seekers who had arrived in France within the past 21 days and went to the Marseille single center between March 1 and August 31, 2021. In order to study the explanatory factors of the asylum seekers' health status, a multivariate analysis was performed using a logistic regression model to predict the health status. Factors taken into account were those significantly associated with outcome (level < 0.05) in univariate analysis.

Results

In total, 419 asylum seekers were included and 96% CI95%[93;97.3] had at least one health disorder. Concerning mental health, 89% CI95% [85.1;91.4] had a mental disorder and in terms of somatic health exclusively, 66% CI95% [61.4;70.6] had at least one somatic disorder. Women were more likely to have a somatic disease OR = 1.80 [1.07; 3.05]. We found a statistically significant association between the presence of at least one disorder and sleeping in a public space OR = 3.4 [1.02;11.28] p = 0.046. This association is also found for mental disorders OR = 2.36 [1.16;4.84], p = 0.018.

Conclusions

Due to the high prevalence of health disorders our study found, asylum seekers are a population with many care needs when they arrive in their host country. The main factors linked to a poor health status seem to be related to a person’s sex, geographical origin and sleeping in a public space.

Homelessness at the San Diego Central Library: Assessing the Potential Role of Social Workers

Nationwide, public libraries are experiencing an increase in “on-premise” opioid overdoses and other issues (e.g., suicide attempts) affecting unstably housed library users. The public library presents a unique opportunity to access an otherwise hidden population. In partnership with the San Diego Central Library, researchers led focus groups, in-depth interviews, and surveys with 63 library patrons experiencing homelessness or housing instability (n = 49) and library staff (n = 14) (January–June 2019). Using a consensus organizing framework and mixed methods approach, the researchers conducted in-depth interviews exploring the library’s strengths and opportunities for patrons experiencing homelessness, the barriers to meeting their aspirations, and whether having a social worker at the library or other policy changes in government or the library could help. Specifically, participants answered inquiries about the opportunities for the library to address substance use and human trafficking. In brief surveys, library patrons and staff provided views on the patrons’ educational needs, library staff’s training needs, and changes needed in government or library policies. Results revealed the desire of the library patrons (69%) and staff (93%) to have a library social worker who could link patrons to housing services, substance use harm reduction or treatment, and address food-insecure youth/families and human trafficking/sexual exploitation. Participants also valued peer advocates with lived homelessness experiences. Over 70% of the unstably housed patrons said they would like library patrons to participate in peer leadership training. Other significant themes were the need for crisis prevention and intervention, connecting patrons to resources and each other, and creating consistent assistance. Libraries urgently need more on-premise support to address patrons’ pressing housing, health, and mental health needs.

Integration, population commissioning and prison health and well-being – an exploration of benefits and challenges through the study of telemedicine

Purpose

This paper seeks to understand relationships between prison healthcare and integrated care systems (ICS), including how these affect the delivery of new healthcare interventions. It also aims to understand how closer integration between prison and ICS could improve cross system working between community and prison healthcare teams, and highlights challenges that exist to integration between prison healthcare and ICS.

Design/methodology/approach

The study uses evidence from research on the implementation of a pilot study to establish telemedicine secondary care appointments between prisons and an acute trust in one English region (a cross-system intervention). Qualitative interview data were collected from prison (n = 12) and community (n = 8) healthcare staff related to the experience of implementing a cross-system telemedicine initiative. Thematic analysis was undertaken on interview data, guided by an implementation theory and framework.

Findings

The research found four main themes related to the closer integration between prison healthcare and ICS: (1) Recognition of prison health as a priority; (2) Finding a way to reconcile networks and finances between community and prison commissioning; (3) Awareness of prison service influence on NHS healthcare planning and delivery; and (4) Shared investment in prison health can lead to benefits.

Originality/value

This is the first article to provide research evidence to support or challenge the integration of specialist health and justice (H&J) commissioning into local population health.

Brief Report: Heterogeneous Preferences for Care Engagement Among People With HIV Experiencing Homelessness or Unstable Housing During the COVID-19 Pandemic

BACKGROUND/SETTING

In San Francisco, HIV viral suppression is 71% among housed individuals but only 20% among unhoused individuals. We conducted a discrete choice experiment at a San Francisco public HIV clinic to evaluate care preferences among people living with HIV (PLH) experiencing homelessness/unstable housing during the COVID-19 pandemic.

METHODS

From July to November 2020, we conducted a discrete choice experiment among PLH experiencing homelessness/unstable housing who accessed care through (1) an incentivized, drop-in program (POP-UP) or (2) traditional primary care. We investigated 5 program features: single provider vs team of providers; visit incentives ($0, $10, and $20); location (current site vs current + additional site); drop-in vs scheduled visits; in-person only vs optional telehealth visits; and navigator assistance. We estimated relative preferences using mixed-effects logistic regression and conducted latent class analysis to evaluate preference heterogeneity.

RESULTS

We enrolled 115 PLH experiencing homelessness/unstable housing, 40% of whom lived outdoors. The strongest preferences were for the same provider (β = 0.94, 95% CI: 0.48 to 1.41), visit incentives (β = 0.56 per $5; 95% CI: 0.47 to 0.66), and drop-in visits (β = 0.47, 95% CI: 0.12 to 0.82). Telehealth was not preferred. Latent class analysis revealed 2 distinct groups: 78 (68%) preferred a flexible care model, whereas 37 (32%) preferred a single provider.

CONCLUSIONS

We identified heterogeneous care preferences among PLH experiencing homelessness/unstable housing during the COVID-19 pandemic, with two-thirds preferring greater flexibility and one-third preferring provider continuity. Telehealth was not preferred, even with navigator facilitation. Including patient choice in service delivery design can improve care engagement, particularly for marginalized populations, and is an essential tool for ending the HIV epidemic.

Primary Care Engagement Among Individuals with Experiences of Homelessness and Serious Mental Illness: an Evidence Map

BACKGROUND

Experiences of homelessness and serious mental illness (SMI) negatively impact health and receipt of healthcare. Interventions that promote the use of primary care services for people with both SMI and homelessness may improve health outcomes, but this literature has not been evaluated systematically. This evidence map examines the breadth of literature to describe what intervention strategies have been studied for this population, elements of primary care integration with other services used, and the level of intervention complexity to highlight gaps for future intervention research and program development.

METHODS

We followed an a priori protocol developed in collaboration with clinical stakeholders. We systematically searched the published literature to identify interventions for adults with homelessness who also had SMI. We excluded case reports, editorials, letters, and conference abstracts. Data abstraction methods followed standard practice. Data were categorized into intervention strategies and primary care integration strategies. Then we applied the Complexity Assessment Tool for Systematic Reviews (iCAT_SR) to characterize intervention complexity.

RESULTS

Twenty-two articles met our inclusion criteria evaluating 15 unique interventions to promote engagement in primary care for adults with experiences of homelessness and SMI. Study designs varied widely from randomized controlled trials and cohort studies to single-site program evaluations. Intervention strategies varied across studies but primarily targeted patients directly (e.g., health education, evidence-based interactions such as motivational interviewing) with fewer strategies employed at the clinic (e.g., employee training, multidisciplinary teams) or system levels (e.g., data sharing). We identified elements of primary care integration, including referral strategies, co-location, and interdisciplinary care planning. Interventions displayed notable complexity around the number of intervention components, interaction between intervention components, and extent to which interventions were tailored to specific patient populations.

DISCUSSION

We identified and categorized elements used in various combinations to address the primary care needs of individuals with experiences of homeless and SMI.

Self-harm in people experiencing homelessness: investigation of incidence, characteristics and outcomes using data from the Multicentre Study of Self-Harm in England

BACKGROUND

People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population.

AIMS

To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm.

METHOD

Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender.

RESULTS

There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04-1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94-2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32-1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41-3.57, P < 0.001).

CONCLUSIONS

People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

The impact of an integrated safer use space and safer supply program on non-fatal overdose among emergency shelter residents during a COVID-19 outbreak: a case study

Background

Opioid-related harms, including fatal and non-fatal overdoses, rose dramatically during the COVID-19 pandemic and presented unique challenges during outbreaks in congregate settings such as shelters. People who are deprived of permanent housing have a high prevalence of substance use and substance use disorders, and need nimble, rapid, and portable harm reduction interventions to address the harms of criminalized substance use in an evidence-based manner.

Case study

In February 2021, a COVID-19 outbreak was declared at an emergency men’s shelter in Hamilton, Ontario, Canada. Building on pre-existing relationships, community and hospital-based addictions medicine providers and a local harm reduction group collaborated to establish a shelter-based opioid agonist treatment and safer supply program, and a volunteer run safer drug use space that also distributed harm reduction supplies. In the 4 weeks preceding the program, the rate of non-fatal overdoses was 0.93 per 100 nights of shelter bed occupancy. During the 26 days of program operation, there were no overdoses in the safer use space and the rate of non-fatal overdoses in the shelter was 0.17 per 100 nights of shelter bed occupancy. The odds ratio of non-fatal overdose pre-intervention to during intervention was 5.5 (95% CI 1.63–18.55, p = 0.0059). We were not able to evaluate the impact of providing harm reduction supplies and did not evaluate the impact of the program on facilitating adherence to public health isolation and quarantine orders. The program ended as the outbreak waned, as per the direction from the shelter operator.

Conclusions

There was a significant reduction in the non-fatal overdose rate after the safer drug use and safer supply harm reduction program was introduced. Pre-existing relationships between shelter providers, harm reduction groups, and healthcare providers were critical to implementing the program. This is a promising approach to reducing harms from the criminalization of substance use in congregate settings, particularly in populations with a higher prevalence of substance use and substance use disorders.

Lonely, harassed and abandoned in society: the lived experiences of Iranian homeless youth

Introduction

Homelessness is increasing among young adults in large cities. According to the United Nations, there are more than one billion absolute or relative homeless people in the world. This study was conducted to explain the lived experiences of homeless youth in southeastern Iran.

Materials and methods

In this qualitative study, we recruited 13 participants in a big city, southeast Iran, in 2020. The participant was young homeless adults aged 18–29 years who were using homeless shelters provided by the municipality, sleeping in parks or on streets. Data were collected through in-depth and semi-structured interviews and three focus group discussions. Data were analyzed by conventional qualitative content analysis.

Results

The main category of “lonely, annoyed, and abandoned in society” and three subcategories of avoidance of/by society, comprehensive harassment, and lack of comprehensive support were extracted. The experiences of young homeless adults showed that they escaped from the community due to addiction, feeling like a burden to others, and social isolation, and not only have they been left without support in society, but they have also suffered from all kinds of physical and psychological harassments.

Conclusion

The lived experiences of homeless people show that in addition to appropriate facilities and living conditions, they require respect, reduced social stigma, discrimination, and favorable conditions for a return to life. Therefore, authorities should identify and settle their problems and needs.

Implementing the Street Psychiatry Model in New Haven, CT: Community-Based Care for People Experiencing Unsheltered Homelessness

"Street psychiatry" is an innovative model that serves people experiencing unsheltered homelessness, a vulnerable population with increased rates of mental illness and substance use disorders. Through community-based delivery of mental health and addiction treatment, street psychiatry helps the street-dwelling population overcome barriers to accessing care through traditional routes. Throughout the United States, street psychiatry programs have arisen in multiple cities, often in partnership with street medicine programs. We discuss the philosophy of street psychiatry, document operational highlights involved in the development of a street psychiatry program in New Haven, CT, suggest key ingredients to implementing a street psychiatry program, and explore challenges and future frontiers. Street psychiatry is an effective person-centered model of service delivery with the potential to be applied in a variety of urban settings to serve people experiencing street homelessness.

Barriers and facilitators to accessing health and social care services for people living in homeless hostels: a qualitative study of the experiences of hostel staff and residents in UK hostels

INTRODUCTION

The number of people living in homeless hostels in the UK has steadily increased over the past decade. Despite people experiencing homelessness often having considerable health problems and a range of complex needs frequently in association with addictions, the experiences of hostel staff and residents especially in relation to accessing health and social care support have seldom been explored. The aim of this paper is to identify the barriers and facilitators to accessing health and social care services for people living in homeless hostels.

DESIGN

Exploratory qualitative baseline data were collected as part of an intervention to facilitate palliative care in-reach into hostels.

SETTING/PARTICIPANTS

Interviews were conducted with 33 participants; 18 homeless hostel managers/support staff and 15 people experiencing homelessness, from six homeless hostels in London and Kent.

RESULTS

Three themes were identified (1) internal and external service barriers to health and social care access due to stigma, lack of communication and information sharing from services and assumptions around capacity and the role of the hostel, (2) the impact of lack of health and social care support on hostel staff leading to burnout, staff going beyond their job role and continuous support given to residents, (3) potential facilitators to health and social care access such in-reach and support from those who understand this population and hostel staff training.

DISCUSSION

Residents have multiple complex needs yet both hostel staff and residents face stigma and barriers accessing support from external services. Positive relationships were described between hostel residents and staff, which can be an essential step in engaging with other services. People experiencing homelessness urgently need better access to person-centred, trauma-informed support ideally via in-reach from people who understand the needs of the population.

Shelter-Based Integrated Model Is Effective in Scaling Up Hepatitis C Testing and Treatment in Persons Experiencing Homelessness

Hepatitis C virus (HCV) prevalence is high among people experiencing homelessness, but barriers to scaling up HCV testing and treatment persist. We aimed to implement onsite HCV testing and education and evaluate the effectiveness of low‐barrier linkage to HCV therapy among individuals accessing homeless shelters. HCV rapid testing was performed at four large shelters in San Francisco (SF) and Minneapolis (MN). Sociodemographic status, HCV risk, barriers to testing, and interest in therapy were captured. Participants received information about HCV. Those testing positive underwent formal HCV education and onsite therapy. Multivariable modeling assessed predictors of receipt of HCV therapy and sustained virologic response (SVR). A total of 766 clients were tested. Median age was 53.7 years, 68.2% were male participants, 46.3% were Black, 27.5% were White, 13.2% were Hispanic, and 57.7% had high school education or less; 162 (21.1%) were HCV antibody positive, 107 (66.0%) had detectable HCV RNA (82.1% with active drug use, 53.8% history of psychiatric illness), 66 (61.7%) received HCV therapy, and 81.8% achieved SVR. On multivariate analysis, shelter location (MN vs. SF, odds ratio [OR], 0.3; P = 0.01) and having a health care provider (OR, 4.1; P = 0.02) were associated with receipt of therapy. On intention to treat analysis, the only predictor of SVR when adjusted for age, sex, and race was HCV medication adherence (OR, 14.5; P = 0.01). Conclusion: Leveraging existing homeless shelter infrastructure was successful in enhancing HCV testing and treatment uptake. Despite high rates of active substance use, psychiatric illness, and suboptimal adherence, over 80% achieved HCV cure. This highlights the critical importance of integrated models in HCV elimination efforts in people experiencing homelessness that can be applied to other shelter settings.

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.

Homeless Patients Associate Clinician Bias With Suboptimal Care for Mental Illness, Addictions, and Chronic Pain

Objective: To determine how accessible health care services are for people who are experiencing homelessness and to understand from their perspectives what impact clinician bias has on the treatment they receive. Methods: Narrative interviews were conducted with 53 homeless/vulnerably housed individuals in Ontario, Canada. Visit history records were subsequently reviewed at 2 local hospitals, for 52 of the interview participants. Results: Of the 53 participants only 28% had a primary care provider in town, an additional 40% had a provider in another town, and 32% had no access to a primary care provider at all. A subset of the individuals were frequent emergency department users, with 15% accounting for 75% of the identified hospital visits, primarily seeking treatment for mental illness, pain, and addictions. When seeking primary care for these 3 issues participants felt medication was overprescribed. Conversely, in emergency care settings participants felt prejudged by clinicians as being drug-seekers. Participants believed they received poor quality care or were denied care for mental illness, chronic pain, and addictions when clinicians were aware of their housing status. Conclusion: Mental illness, chronic pain, and addictions issues were believed by participants to be poorly treated due to clinician bias at the primary, emergency, and acute care levels. Increased access to primary care in the community could better serve this marginalized population and decrease emergency department visits but must be implemented in a way that respects the rights and dignity of this patient population.

Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings

BACKGROUND

More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited.

OBJECTIVE

The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients.

RESEARCH DESIGN

National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations.

PARTICIPANTS

A total of 5766 homeless-experienced veterans.

MEASURES

Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer (≤1) and more (≥2) vulnerabilities.

RESULTS

H-PACTs outscored mainstream PACTs on all scales (all P<0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI=6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with ≥2 vulnerabilities versus ≤1 (interaction P<0.0001).

CONCLUSIONS

Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.

Improving access to epilepsy care for homeless patients in the Dublin Inner City: a collaborative quality improvement project joining hospital and community care

Homelessness is associated with significant psychosocial and health disparities. The rate of epilepsy among this cohort is eight times greater than that in the settled population, and the associated morbidity is higher due to lack of integrated care, difficulties with treatment adherence, substance abuse and poor social circumstances. There is a high rate of seizure-related death in homeless patients. Seizures are one of the most common neurological cause for emergency department presentation among this population. The aim of this quality improvement project was to use a multistakeholder co-production approach to design a new pathway of care for homeless patients with epilepsy to improve access to specialist epilepsy care and to strengthen the links between hospital and community teams who manage this population. After several years of observation, stakeholder engagement and numerous tests of change, we have created a new care pathway and developed bespoke tools for primary care providers and for physicians working in the emergency department to enable them to assess and manage patients as they present, as well as provide access to remote epilepsy specialist support.

Met and unmet needs of homeless individuals at different stages of housing reintegration: A mixed-method investigation

This study aimed to identify and compare major areas of met and unmet needs reported by 455 homeless or recently housed individuals recruited from emergency shelters, temporary housing, and permanent housing in Quebec (Canada). Mixed methods, guided by the Maslow framework, were used. Basic needs were the strongest needs category identified, followed by health and social services (an emergent category), and safety; very few participants expressed needs in the higher-order categories of love and belonging, self-esteem, and self-actualization. The only significant differences between the three housing groups occurred in basic needs met, which favored permanent housing residents. Safety was the only category where individuals reported more unmet than met needs. The study results suggested that increased overall access to and continuity of care with family physicians, MD or SUD clinicians and community organizations for social integration should be provided to help better these individuals. Case management, stigma prevention, supported employment programs, peer support and day centers should particularly be more widely implemented as interventions that may promote a higher incidence of met needs in specific needs categories.

Supporting Older Homeless Persons' Positive Relocations to Long-Term Care: Service Provider Views

BACKGROUND AND OBJECTIVES

This study sought to explore the challenges and opportunities associated with supporting older homeless persons' relocations to long-term care (LTC) from the perspective of service providers. It aims to inform how to improve relocation processes for this vulnerable and growing subpopulation of older persons.

RESEARCH DESIGN AND METHODS

This cross-sectional qualitative study employed semistructured face-to-face interviews with service providers from two Health and Social Service Centres in Montreal, Quebec. All interviews were audio-recorded, transcribed verbatim, and thematically analyzed in five stages.

RESULTS

A total of eight service providers reported on their experiences supporting over 40 relocations of older homeless persons (50+) in the last year. According to participants, older homeless persons' trajectories into LTC typically included a series of neglected medical issues followed by hospitalization and eventual relocation to LTC. Systemic barriers such as limited-time for proper planning, insufficient housing options for persons with minor functional limitations, disregard for preferred geographic location, multiple moves, and staff prejudices worked together to expedite premature relocation and challenge relocation processes.

DISCUSSION AND IMPLICATIONS

Older homeless persons appear to be at heightened risk of premature and challenging relocation processes. Expanding housing stock for persons with functional limitations, strengthening intersectoral collaborations, providing education and training to staff, and ensuring flexibility around rules and regulations in receiving LTC homes would both improve access to aging in place for this marginalized group of older persons and ensure conditions are in place to support positive relocations to LTC for those who require it.

Supporting Primary Care Access and Use among Homeless Persons

With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.

Novel health systems service design checklist to improve healthcare access for marginalised, underserved communities in Europe

BACKGROUND

Marginalised communities such as homeless people, people who use drugs (PWUD), lesbian, gay, bisexual, transgender and intersex people (LGBTI), prisoners, sex workers and undocumented migrants are at high risk of poor health and yet face substantial barriers in accessing health and support services. The Nobody Left Outside (NLO) Service Design Checklist aims to promote a collaborative, evidence-based approach to service design and monitoring based on equity, non-discrimination and community engagement.

METHODS

The Checklist was a collaborative project involving nine community advocacy organisations, with a focus on homeless people, PWUD, LGBTI people, prisoners, sex workers, and undocumented migrants. The Checklist was devised via a literature review; two NLO platform meetings; a multistakeholder policy workshop and an associated published concept paper; two conference presentations; and stakeholder consultation via a European Commission-led Thematic Network (including webinar).

RESULTS

The NLO Checklist has six sections in line with the WHO Health Systems Framework. These are: (1) service delivery, comprising design stage (6 items), services provided (2 items), accessibility and adaptation (16 items), peer support (2 items); (2) health workforce (12 items); (3) health information systems (7 items); (4) medical products and technologies (1 item); (5) financing (3 items); and (6) leadership and governance (7 items). It promotes the implementation of integrated (colocated or linked) healthcare services that are community based and people centred. These should provide a continuum of needs-based health promotion, disease prevention, diagnosis, treatment and management, together with housing, legal and social support services, in alignment with the goals of universal health coverage and the WHO frameworks on integrated, people-centred healthcare.

CONCLUSIONS

The Checklist is offered as a practical tool to help overcome inequalities in access to health and support services. Policymakers, public health bodies, healthcare authorities, practitioner bodies, peer support workers and non-governmental organisations can use it when developing, updating or monitoring services for target groups. It may also assist civil society in wider advocacy efforts to improve access for underserved communities.

The Association of Residential Instability and Hospitalizations among Homeless and Vulnerably Housed Individuals: Results from a Prospective Cohort Study

The present study examined the association of residential instability with hospitalizations among homeless and vulnerably housed individuals over a 4-year time period. Survey data were linked to administrative records on hospitalizations. Specifically, we used data from the Health and Housing in Transition study, a prospective cohort study that tracked the health and housing status of homeless and vulnerably housed individuals in Canada. Responses from Vancouver-based participants (n = 378) from baseline and 3 follow-ups were linked to their administrative health records on hospitalizations (Discharge Abstract Database - Hospital Separation Files; 2008-2012). A generalized estimating equations model was used to examine associations between the number of residential moves and any hospitalizations during each year (none versus ≥ 1 hospitalizations). Analyses included demographic and health variables. Survey data were collected via structured interviews. Hospitalizations were derived from provincial administrative health records. A higher number of residential moves were associated with hospitalization over the study period (adjusted odds ratio: 1.14; 95% confidence interval: 1.01, 1.28). Transgender, female gender, perceived social support, better self-reported mental health, and having ≥ 3 chronic health conditions also predicted having been hospitalized over the study period, whereas high school/higher education was negatively associated with hospitalizations. Our results indicate that residential instability is associated with increased risk of hospitalization, illustrating the importance of addressing housing as a social determinant of health.

Satisfaction with health and community services among homeless and formerly homeless individuals in Quebec, Canada

User satisfaction is a crucial quality indicator in health service provision. Few studies have measured user satisfaction among homeless and formerly homeless individuals, despite the high prevalence of mental health disorders (MHD) in this population. The purpose of this study was to assess overall satisfaction among 455 homeless and formerly homeless individuals who were receiving health and community services, and to identify factors associated with user satisfaction. Data collection occurred between January and September 2017. Study participants were 18 years old or over, with experience of homelessness in the current or recent past. They completed a questionnaire eliciting socio-demographic information, and data on residential history, service use and satisfaction and health profiles. Multivariate linear analysis was performed on overall satisfaction with health and community services in the previous 12 months. Independent variables were organised as predisposing, enabling and needs factors based on the Gelberg-Andersen Behavioral Model. The mean satisfaction score was 4.11 (minimum: 1; maximum: 5). Variables associated with greater user satisfaction included: older age, residence in permanent housing, common MHD (e.g., depression, anxiety), having a family physician, having a case manager, strong social network, good quality of life and, marginally, male sex and having substance use disorders (SUD). By contrast, frequent users of public ambulatory health services were the most dissatisfied. User satisfaction was more strongly associated with enabling factors. Strategies for improving satisfaction include: promoting more tailored primary care programmes (including family physician) adapted to the needs of this population, better integrating primary care with specialised services including SUD integrated treatment and enhancing continuity of care through the reinforcement of case management services. Further efforts aimed at increasing access to permanent housing with supports, and eliciting more active involvement by relatives and friends may also improve user satisfaction with services, and reduce unnecessary service use.

"Now that you've got that coverage": Promoting use of a regular source of primary care among homeless persons

BACKGROUND

The growing number of homeless persons in the United States demonstrates greater morbidity and mortality than the population as a whole. Homeless persons are often without a regular source of primary care. Homeless persons use emergency departments and are hospitalized at higher rates than nonhomeless persons. In 2010, the enactment of the Affordable Care Act expanded access to primary care services. Nurse practitioners were at the forefront of its subsequent implementation.

PURPOSE

The purpose of this qualitative study was to explore the factors that influence establishing and maintaining a regular source of primary care among homeless persons.

METHODOLOGICAL ORIENTATION

In 2017, semistructured interviews were conducted in a federally qualified health center that serves predominately homeless persons.

SAMPLE

A purposive convenience sample included adult health center users (N = 20). The majority of participants were insured (90%), African American (70%), and male (65%).

CONCLUSIONS

Thematic analysis revealed five facilitators: sense of community, mutual patient-provider respect, financial assurance, integrated health services, and patient care teams. To establish and maintain use of a regular primary care source, homeless persons desire to experience a sense of community, feel respected by their provider/staff, and have certainty that costs will not exceed their capacity to pay. Integrated care models that leverage a multidisciplinary team approach support the use of a regular primary care source.

IMPLICATIONS FOR PRACTICE

Actualizing achievable strategies that promote the consistent use of a regular primary care source can reduce use of avoidable emergency and hospital-based services, thereby improving health outcomes among homeless persons.

HIV Risk and Sociodemographic Factors Associated with Physician-Advised HIV Testing: What Factors Are Overlooked in African American Populations?

HIV is diagnosed at eight times the rate in African Americans (AAs) compared to whites. One-third of AAs have never been tested for HIV. Studies indicate low rates of HIV testing in healthcare settings, so understanding missed opportunities for HIV testing can inform prevention efforts in these settings. Our study examined predictors of self-reported physician-advised HIV testing using baseline survey data (N = 1500) from Taking It to the Pews (TIPS), a church-basedHIV/STD testing and education intervention. One-third (33%) of participants reported that their physician ever suggested an HIV test. Results indicated that participants who identified as homosexual/bisexual, received Medicaid or were uninsured, and/or had previously diagnosed STDs were more likely to report physician-advised HIV testing. AA churches provide a unique opportunity to increase the reach of HIV testing and may be well-positioned to equip their church and community members with information on HIV risk and strategies to advocate for physician-advised routine HIV testing in medical settings.