Medical respite post-hospitalization for adults experiencing homelessness

ABSTRACT

Nurses provide care in various settings and advocate for vulnerable populations. Recognizing the need for follow-up care after hospitalization and mobilizing necessary resources are part of caring for patients, including those experiencing homelessness. This article discusses how one community coalition assessed gaps in care that might be met by establishing medical respite in the community.

Use of health care utilization as a metric of intervention success may perpetuate racial disparities: An outcome evaluation of a homeless transitional care program

OBJECTIVE

This study explored race-based differences in disease burden, health care utilization, and mortality for Black and White persons experiencing homelessness (PEH) who were referred to a transitional care program, and health care utilization and program outcomes for program participants.

DESIGN

This was a quantitative program evaluation.

SAMPLE

Black and White PEH referred to a transitional care program (n = 450). We also analyzed data from the subgroup of program participants (N = 122). Of the 450 referrals, 122 participants enrolled in the program.

MEASURES

We included chronic disease burden, mental illness, substance use, health care utilization, and mortality rates for all PEH referred. For program participants, we added 6-month pre/post health care utilization and program outcomes. All results were dichotomized by race.

RESULTS

Black PEH who were referred to the program had higher rates of hypertension, diabetes, renal failure, and HIV and similar post-referral mortality rates compared to White PEH. Black and White PEH exhibited similar program outcomes; however, Black PEH revisited the emergency department (ED) less frequently than White PEH at 30 and 90 days after participating in the program.

CONCLUSIONS

Health care utilization may be a misleading indicator of medical complexity and morbidity among Black PEH. Interventions that rely on health care utilization as an outcome measure may unintentionally contribute to racial disparities.

Evaluation of Bundled Interventions for Patients With Opioid Use Disorder Experiencing Homelessness Receiving Extended Antibiotics for Severe Infection

Hospitalizations for serious infections in patients with opioid use disorder (OUD) experiencing homelessness are common. Patients receiving 4 interventions (infectious disease consultation, addiction consultation, case management, and medications for OUD [MOUD]) had higher odds of clinical cure (unadjusted odds ratio [OR], 3.15; P = .03; adjusted OR, 3.03; P = .049) and successful retention in addiction care at 30 days (unadjusted OR, 5.46; P = .01; adjusted OR, 6.36; P = .003).

Differences in Clinical Outcomes of Adults Referred to a Homeless Transitional Care Program Based on Multimorbid Health Profiles: A Latent Class Analysis

Background: People experiencing homelessness face significant medical and psychiatric illness, yet few studies have characterized the effects of multimorbidity within this population. This study aimed to (a) delineate unique groups of individuals based on medical, psychiatric, and substance use disorder profiles, and (b) compare clinical outcomes across groups. Methods: We extracted administrative data from a health system electronic health record for adults referred to the Durham Homeless Care Transitions program from July 2016 to June 2020. We used latent class analysis to estimate classes in this cohort based on clinically important medical, psychiatric and substance use disorder diagnoses and compared health care utilization, overdose, and mortality at 12 months after referral. Results: We included 497 patients in the study and found 5 distinct groups: "low morbidity" (referent), "high comorbidity," "high tri-morbidity," "high alcohol use," and "high medical illness." All groups had greater number of admissions, longer mean duration of admissions, and more ED visits in the 12 months after referral compared to the "low morbidity" group. The "high medical illness" group had greater mortality 12 months after referral compared to the "low morbidity" group (OR, 2.53, 1.03-6.16; 95% CI, 1.03-6.16; p = 0.04). The "high comorbidity" group (OR, 5.23; 95% CI, 1.57-17.39; p < 0.007) and "high tri-morbidity" group (OR, 4.20; 95% CI, 1.26-14.01; p < 0.02) had greater 12-month drug overdose risk after referral compared to the referent group. Conclusions: These data suggest that distinct groups of people experiencing homelessness are affected differently by comorbidities, thus health care programs for this population should address their risk factors accordingly.

Documentary analysis as an assessment tool

BACKGROUND

Documentary analysis of existing information, such as newspaper articles, is an identified method for use in an assessment to provide a descriptive explanation of existing problems or assets. The intention of this case study is to explore the effectiveness of documentary analysis of newspaper articles as a tool to inform an assessment of factors influencing the implementation of a medical respite for the homeless. Two questions framed the assessment; (a) What was occurring or might occur that will affect the development of a medical respite; and (b) What opportunities or threats are generated as a result?

METHODS

Articles from two local newspapers identified themes related to the three external forces of change that impact medical respites; (a) funding; (b) community resistance; and (c) the health care system.

RESULTS

Three themes emerged: a) uncertain funding; b) neighborhood resistance, and c) improved access to healthcare would result from the Affordable Care Act.

CONCLUSION

Use of documentary analysis of newspaper articles provided applicable content for the assessment. Themes from the assessment informed strategic planning, such as addressing potential neighborhood resistance.

Improving hospital discharge arrangements for people who are homeless: A realist synthesis of the intermediate care literature

This review presents a realist synthesis of "what works and why" in intermediate care for people who are homeless. The overall aim was to update an earlier synthesis of intermediate care by capturing new evidence from a recent UK government funding initiative (the "Homeless Hospital Discharge Fund"). The initiative made resources available to the charitable sector to enable partnership working with the National Health Service (NHS) in order to improve hospital discharge arrangements for people who are homeless. The synthesis adopted the RAMESES guidelines and reporting standards. Electronic searches were carried out for peer-reviewed articles published in English from 2000 to 2016. Local evaluations and the grey literature were also included. The inclusion criteria was that articles and reports should describe "interventions" that encompassed most of the key characteristics of intermediate care as previously defined in the academic literature. Searches yielded 47 articles and reports. Most of these originated in the UK or the USA and fell within the realist quality rating of "thick description". The synthesis involved using this new evidence to interrogate the utility of earlier programme theories. Overall, the results confirmed the importance of (i) collaborative care planning, (ii) reablement and (iii) integrated working as key to effective intermediate care delivery. However, the additional evidence drawn from the field of homelessness highlighted the potential for some theory refinements. First, that "psychologically informed" approaches to relationship building may be necessary to ensure that service users are meaningfully engaged in collaborative care planning and second, that integrated working could be managed differently so that people are not "handed over" at the point at which the intermediate care episode ends. This was theorised as key to ensuring that ongoing care arrangements do not break down and that gains are not lost to the person or the system vis-à-vis the prevention of readmission to hospital.

Outcomes of specialist discharge coordination and intermediate care schemes for patients who are homeless: analysis protocol for a population-based historical cohort

INTRODUCTION

People who are homeless often experience poor hospital discharge arrangements, reflecting ongoing care and housing needs. Specialist integrated homeless health and care provision (SIHHC) schemes have been developed and implemented to facilitate the safe and timely discharge of homeless patients from hospital. Our study aims to investigate the health outcomes of patients who were homeless and seen by a selection of SIHHC services.

METHODS AND ANALYSIS

Our study will employ a historical population-based cohort in England. We will examine health outcomes among three groups of adults: (1) homeless patients seen by specialist discharge schemes during their hospital admission; (2) homeless patients not seen by a specialist scheme and (3) admitted patients who live in deprived neighbourhoods and were not recorded as being homeless. Primary outcomes will be: time from discharge to next hospital inpatient admission; time from discharge to next accident and emergency attendance and 28-day emergency readmission. Outcome data will be generated through linkage to hospital admissions data (Hospital Episode Statistics) and mortality data for November 2013 to November 2016. Multivariable regression will be used to model the relationship between the study comparison groups and each of the outcomes.

ETHICS AND DISSEMINATION

Approval has been obtained from the National Health Service (NHS) Confidentiality Advisory Group (reference 16/CAG/0021) to undertake this work using unconsented identifiable data. Health Research Authority Research Ethics approval (REC 16/EE/0018) has been obtained in addition to local research and development approvals for data collection at NHS sites. We will feedback the results of our study to our advisory group of people who have lived experience of homelessness and seek their suggestions on ways to improve or take this work further for their benefit. We will disseminate our findings to SIHHC schemes through a series of regional workshops.