Diabetes management interventions for homeless adults: a systematic review

Early Mortality and Medical Complexity Among Medicolegal Cardiovascular Disease Deaths: Comparing Housed and Unhoused Decedents

BACKGROUND

There are extreme psychosocial, environmental, and behavioral risks to the health and well-being of persons experiencing homelessness. Within this complex and hazardous environment, there is an opportunity to gain clearer perspective into the role of accelerating cardiovascular disease (CVD) progression alongside the aging cohort effect in this population.

METHOD

Utilizing 2021 and 2022 data from the Harris County Medical Examiner, investigators analyzed CVD-associated deaths for excess mortality and impact of age-related factors specific to persons experiencing homelessness. All medicolegal deaths involving CVD were examined to determine relative frequencies of secondary causes of death and the influence of age between housed individuals and individuals experiencing homelessness.

RESULTS

The examination of the CVD mortality cases among persons experiencing homelessness in 2021 (n = 52) and 2022 (n = 71) revealed important trends. The mean age for CVD deaths for persons experiencing homelessness was 58.6 and 60.6 years in 2021 and 2022, respectively. Despite this slight, recent increase, the average age for CVD death among persons experiencing homelessness is dramatically lower than the housed, medicolegal CVD deaths, and the general population. Top-associated conditions were hypertension and atherosclerosis, regardless of housing status. However, chronic obstructive pulmonary disease and congestive heart failure were more common in CVD deaths of people experiencing homelessness.

DISCUSSION

These findings reemphasize the uniqueness and complexity of the risks for premature mortality in people experiencing homelessness. This underscores the call for social services and healthcare systems to be more responsive to the challenges faced by persons experiencing homelessness, with more integrated and targeted health and aging care interventions to address the specific needs of these marginalized individuals.

Health impacts of cold exposure among people experiencing homelessness: A narrative systematic review on risks and risk-reduction approaches

OBJECTIVE

To systematically review evidence from high income countries on health risks from cold weather exposure among people experiencing homelessness (PEH) and assess evidence on risk-reduction interventions and their effectiveness.

STUDY DESIGN

Narrative systematic review.

METHODS

Keyword-structured searches were performed in CINAHL, Emcare, Medline, SocINDEX, Scopus, OpenGrey, Social Policy and Practice and Web of Science, and supplemented by grey literature searches in a selection of other databases, from 1973 to 2024. Articles were double-screened on title/abstract and full text. Extracted data included information on study setting and population, health risks from cold exposure, intervention characteristics and effect sizes where reported. Studies were critically appraised using Joanna Briggs Institute checklists.

RESULTS

24 studies were included, predominantly from the UK and US. People sleeping rough were found to be at greater risk than the general population of mortality due to hypothermia, and of hypothermic injury. Studies assessing health service utilisation indicated higher than population average admission rates due to cold exposure among PEH. Studies on interventions to reduce health risks from cold exposure in these populations all addressed multi-component programmes including shelter provision as a central component. Evidence of effectiveness was very limited.

CONCLUSION

PEH are at greater risk of death from hypothermia, and of hypothermic injury due to cold exposure than the general population. The use of overnight shelters and severe weather emergency plans are established approaches in high income settings for reducing risks from cold exposure among those sleeping rough, but further evidence on effectiveness is needed.

Group Versus Individual Diabetes Education for Persons With Experience of Homelessness in Canada

PURPOSE

The purpose of the study was to explore various forms of diabetes self-management education (DSME), including group and individual sessions, for persons with lived experiences of homelessness (PWLEH) in Canada.

METHODS

A qualitative descriptive study using open-ended interviews with health care and homeless sector service providers was utilized to serve those experiencing homelessness in 5 cities across Canada. NVivo qualitative data analysis software was used to facilitate thematic analysis, focusing on variations in DSME for PWLEH.

RESULTS

We conducted interviews with 96 unique health and social care providers. Four themes were identified through focused coding of interviews. First, the use of a harm reduction approach during diabetes education tailored to PWLEH considered patients' access to food, medications, and supplies and other comorbidities, including mental health and substance use disorders. The second theme related to the unsuitability of the curriculum in mainstream diabetes education in a group setting for PWLEH. Third, the role of group education in community building is to create supportive relationships among members. The final theme was the importance of trust and confidentiality in DSME, which were most easily maintained during individual education, compared to group formats.

CONCLUSIONS

Overall, PWLEH experience unique challenges in managing diabetes. DSME adapted to these individuals' unique needs may be more successful and could be delivered in both individual and group settings.

The status of patient portal use among Emergency Department patients experiencing houselessness: A large-scale single-center observational study

OBJECTIVE

Patient portal (PP) use has rapidly increased in recent years. However, the PP use status among houseless patients is largely unknown. We aim to determine 1) the PP use status among Emergency Department (ED) patients experiencing houselessness, and 2) whether PP use is linked to the increase in patient clinic visits.

METHODS

This is a single-center retrospective observational study. From March 1, 2019, to February 28, 2021, houseless patients who presented at ED were included. Their PP use status, including passive PP use (log-on only PP) and effective PP use (use PP of functions) was compared between houseless and non-houseless patients. The number of clinic visits was also compared between these two groups. Lastly, a multivariate logistic regression was analyzed to determine the association between houseless status and PP use.

RESULTS

We included a total of 236,684 patients, 13% of whom (30,956) were houseless at time of their encounter. Fewer houseless patients had effective PP use in comparison to non-houseless patients (7.3% versus 11.6%, p < 0.001). In addition, a higher number of clinic visits were found among houseless patients who had effective PP use than those without (18 versus 3, p < 0.001). The adjusted odds ratio of houseless status associated with PP use was 0.48 (95% CI 0.46-0.49, p < 0.001).

CONCLUSIONS

Houselessness is a potential risk factor preventing patient portal use. In addition, using patient portals could potentially increase clinic visits among the houseless patient population.

Hospital-based preventative interventions for people experiencing homelessness in high-income countries: A systematic review

BACKGROUND

People experiencing homelessness have significant unmet needs and high rates of unplanned care. We aimed to describe preventative interventions, defined in their broadest sense, for people experiencing homelessness in a hospital context. Secondary aims included mapping outcomes and assessing intervention effectiveness.

METHODS

We searched online databases (MEDLINE, Embase, PsycINFO, HMIC, CINAHL, Web of Science, Cochrane Library) from 1999-2019 and conducted backward and forward citation searches to 31 December 2020 (PROSPERO CRD42019154036). We included quantitative studies in emergency and inpatient settings measuring health or social outcomes for adults experiencing homelessness in high income countries. We assessed rigour using the "Quality Assessment Tool for Quantitative Studies" and summarised findings using descriptive quantitative methods, a binomial test, a Harvest Plot, and narrative synthesis. We used PRISMA and SWiM reporting guidelines.

FINDINGS

Twenty-eight studies identified eight intervention types: care coordination (n=18); advocacy, support, and outreach (n=13); social welfare assistance (n=13); discharge planning (n=12); homelessness identification (n=6); psychological therapy and treatment (n=6); infectious disease prevention (n=5); and screening, treatment, and referrals (n=5). The evidence strength was weak (n=16) to moderate (n=10), with two high quality randomised controlled trials. We identified six outcome categories with potential benefits observed for psychosocial outcomes, including housing (11/13 studies, 95%CI=54.6-98.1%, p=0.023), healthcare use (14/17, 56.6-96.2%, p=0.013), and healthcare costs (8/8, 63.1-100%, p=0.008). Benefits were less likely for health outcomes (4/5, 28.3-99.5%, p=0.375), integration with onward care (2/4, 6.8-93.2%, p=1.000), and feasibility/acceptability (5/6, 35.9-99.6%, p=0.219), but confidence intervals were very wide. We observed no harms. Most studies showing potential benefits were multi-component interventions.

INTERPRETATION

Hospital-based preventative interventions for people experiencing homelessness are potentially beneficial, but more rigorous research is needed. In the context of high needs and extreme inequities, policymakers and healthcare providers may consider implementing multi-component preventative interventions.

FUNDING

SL is supported by an NIHR Clinical Doctoral Research Fellowship (ICA-CDRF-2016-02-042). JD is supported by an NIHR School of Public Health Research Pre-doctoral Fellowship (NU-004252). RWA is supported by a Wellcome Clinical Research Career Development Fellowship (206602).

Developing and evaluating a SAFER model to screen for diabetes complications among people experiencing homelessness: a pilot study protocol

Background

Diabetes management combined with housing instability intersects, forcing individuals to triage competing needs and critical stressors, such as safety and shelter, with fundamental diabetes self-management tasks like attending healthcare appointments to screen for the complications of diabetes, leaving individuals overwhelmed and overburdened. We aim to address this disjuncture found within our current healthcare delivery system by providing point-of-care screening opportunities in a more patient-centered approach.

Method

We describe a pilot study of a novel clinical intervention which provides timely, comprehensive, and accessible screening for diabetes complications to people experiencing homelessness. We will assess the reach, effectiveness, adoption, implementation, and maintenance, as per the RE-AIM framework, of a SAFER model of care (i.e., screening for A1C, feet, eyes, and renal function). A trained nurse will provide this screening within a homeless shelter. During these encounters, eligible participants will be screened for microvascular complications (neuropathy, nephropathy, retinopathy) and have their A1C measured, all at the point of care, using bedside tools and novel technology. Effectiveness, our primary objective, will be evaluated using a pre-post design, by comparing the rate of completion of full microvascular screening during the study period with individuals’ own historical screening in the 2-year period prior to enrollment. The other domains of the RE-AIM framework will be assessed using process data, chart reviews, patient surveys, and qualitative semi-structured interviews with service providers and participants. This study will be conducted in a large inner-city homeless shelter within a major urban Canadian city (Calgary, Canada).

Discussion

Currently, screening for diabetes complications is often inaccessible for individuals experiencing homelessness, which places heavy burdens on individuals and, ultimately, on already strained emergency and acute care services when complications go undetected at earlier stages. The SAFER intervention will modify the current standard of care for this population in a way that is less fragmented, more person-focused, and timely, with the goal of ultimately improving the rate of screening in an acceptable fashion to identify those requiring specialist referral at earlier stages.

Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials

BACKGROUND

Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population.

METHODS

Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted.

RESULTS

Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant.

CONCLUSION

While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.

Cutaneous Manifestation of Diabetes Mellitus in an Unsheltered Male Leading to Emergent Hospitalization

Diabetes mellitus (DM) is one of the most common chronic diseases in the United States. It is characterized by increased patient morbidity and mortality due to the many complications that can arise. Certain dermatological findings can be indicative of poorly controlled DM and can be a useful clue to further management. Persons experiencing homelessness (PEH) with DM often have higher rates of diabetic complications than the general diabetic population. Medical providers caring for PEH in the setting of limited resources should carefully evaluate cutaneous disease as a potential indicator of underlying illness. This physical manifestation of illness can serve to guide the next appropriate steps in management. A 41-year-old unsheltered male with an extensive medical history of hypertension, seizures, chronic diarrhea, and cocaine use was seen at a “foot-washing” medical outreach event. He presented with fevers, chills, and multiple painless right lower extremity ulcerated lesions of unspecified origin. A finger-stick glucose measurement was found to be 650 mg/dL. After immediate administration of 10 units of insulin, he was transported immediately to the emergency department and admitted. His month-long hospital course was complicated and involved the amputation of multiple toes. Preemptive outreach and management could have prevented the marked deterioration of his disease and represents the importance of outreach and regular follow-up with the PEH community.

The Determinants of Length of Homeless Shelter Stays: Evidence-Based Regression Analyses

Objective: To identify determinants that contribute to the length of homeless shelter stay. Methods: We utilized a unique dataset from the Homeless Management Information Systems from Boston, Massachusetts, United States, which contains 44,197 shelter stays for 17,070 adults between Jan. 2014 and May 2018. Results: Our statistical analyses and regression model analyses show that factors that contribute to the length of a homeless shelter stay include being female, senior, disability, being Hispanic, or being Asian or Black African. A significant fraction of homeless shelter stays (76%) are experienced by individuals with at least one of three disabilities: physical disability, mental health issues, or substance use disorder. Recidivism also contributes to longer homeless shelter stays. Conclusion: The results suggest possible program and policy implications. Several factors that contribute to longer homeless shelter stay, such as gender, age, disability, race, and ethnicity, may have funding implications. Age may point to the need for early interventions. Disability is developmental and may benefit from treatment and intervention. Finally, we find that length of stay and recidivism are not independent, and may form a vicious cycle that requires additional investigation.

Health status of women affected by homelessness: A cluster of in concreto human rights violations and a time for action

Health problems of women experiencing homelessness are driven either from the usual background characteristics of this population, or from the homeless lifestyle. Apart from poverty and unemployment, transition to homelessness is often associated with substance abuse, history of victimization, stress, poor mental health and human immunodeficiency virus (HIV). Water insecurity can undermine bodily hygiene and dental health, posing a greater risk of dehydration and opportunistic infections. Exposure to extreme environmental conditions like heat waves and natural disasters increases morbidity, accelerates aging, and reduces life expectancy. Nutrition-wise, a high prevalence of food insecurity, obesity, and micronutrient deficiencies are apparent due to low diet quality and food waste. Poor hygiene, violence, and overcrowding increase the susceptibility of these women to communicable diseases, including sexually transmitted ones and COVID-19. Furthermore, established cardiovascular disease and diabetes mellitus are often either undertreated or neglected, and their complications are more widespread than in the general population. In addition, lack of medical screening and contraception non-use induce a variety of reproductive health issues. All these health conditions are tightly related to violations of human rights in this population, including the rights to housing, water, food, reproduction, health, work, and no discrimination. Thus, the care provided to women experiencing homelessness should be optimized at a multidimensional level, spanning beyond the provision of a warm bed, to include access to clean water and sanitation, psychological support and stress-coping strategies, disease management and acute health care, food of adequate quality, opportunities for employment and support for any minor dependants.