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Hanson D, Gillespie S. 'Housing First' Increased Psychiatric Care Office Visits And Prescriptions While Reducing Emergency Visits. Health Aff (Millwood) 2024; 43:209-217. [PMID: 38266198 DOI: 10.1377/hlthaff.2023.01041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Housing First is an approach to ending homelessness that recognizes permanent housing as a platform for stability and engagement in health services. As part of a randomized controlled trial to test the effects of permanent supportive housing with the Housing First approach in Denver, Colorado, we analyzed the intervention's impact on health care use, Medicaid enrollment, and mortality among people experiencing chronic homelessness who had frequent arrests and jail stays. Two years after assignment to the Housing First intervention, participants had an average of eight more office-based visits for psychiatric diagnoses, three more prescription medications, and six fewer emergency department visits than the control group. Although enrollment in Medicaid increased over the course of the study for both the intervention group and the control group, the intervention group was 5 percentage points less likely to be enrolled in Medicaid. Supportive housing had no significant impact on mortality. When considering pathways to scale up supportive housing, policy makers should recognize the potential of Housing First to facilitate the use of office-based psychiatric care and medications in a population with many health care needs.
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Fleming MD, Evans JL, Graham-Squire D, Cawley C, Kanzaria HK, Kushel MB, Raven MC. Association of Shelter-in-Place Hotels With Health Services Use Among People Experiencing Homelessness During the COVID-19 Pandemic. JAMA Netw Open 2022; 5:e2223891. [PMID: 35895061 PMCID: PMC9331083 DOI: 10.1001/jamanetworkopen.2022.23891] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Some jurisdictions used hotels to provide emergency noncongregate shelter and support services to reduce the risk of COVID-19 infection among people experiencing homelessness (PEH). A subset of these shelter-in-place (SIP) hotel guests were high users of acute health services, and the association of hotel placement with their service use remains unknown. OBJECTIVE To evaluate the association of SIP hotel placements with health services use among a subset of PEH with prior high acute health service use. DESIGN, SETTING, AND PARTICIPANTS This study used a matched retrospective cohort design comparing health services use between PEH with prior high service use who did and did not receive a SIP hotel placement, from April 2020 to April 2021. The setting was 25 SIP hotels in San Francisco, California, with a daily capacity of 2500 people. Participants included PEH who were among the top 10% high users of acute medical, mental health, and substance use services and who had 3 or more emergency department (ED) visits in the 9 months before the implementation of the SIP hotel program. Data analysis for this study was performed from February 2021 to May 2022. EXPOSURES SIP hotel placement with on-site supportive services. MAIN OUTCOMES AND MEASURES The primary outcomes were ED visits, hospitalizations and bed days, psychiatric emergency visits, psychiatric hospitalizations, outpatient mental health and substance use visits, and outpatient medical visits. RESULTS Of 2524 SIP guests with a minimum of 90-day stays, 343 (13.6%) met criteria for high service use. Of 686 participants with high service use (343 SIP group; 343 control), the median (IQR) age was 54 (43-61) years, 485 (70.7%) were male, 283 (41.3%) were Black, and 337 (49.1%) were homeless for more than 10 years. The mean number of ED visits decreased significantly in the high-user SIP group (1.84 visits [95% CI, 1.52-2.17 visits] in the 90 days before SIP placement to 0.82 visits [95% CI, 0.66-0.99 visits] in the 90 days after SIP placement) compared with high-user controls (decrease from 1.33 visits [95% CI, 1.39-1.58 visits] to 1.00 visits [95% CI, 0.80-1.20 visits]) (incidence rate ratio [IRR], 0.60; 95% CI, 0.47-0.75; P < .001). The mean number of hospitalizations decreased significantly from 0.41 (95% CI, 0.30-0.51) to 0.14 (95% CI, 0.09-0.19) for SIP guests vs 0.27 (95% CI, 0.19-0.34) to 0.22 (95% CI, 0.15-0.29) for controls (IRR, 0.41; 95% CI, 0.27-063; P < .001). Inpatient hospital days decreased significantly from a mean of 4.00 (95% CI, 2.44-5.56) to 0.81 (95% CI, 0.40-1.23) for SIP guests vs 2.27 (95% CI, 1.27-3.27) to 1.85 (95% CI, 1.06-2.65) for controls (IRR, 0.25; 95% CI, 0.12-0.54; P < .001), as did psychiatric emergency visits, from a mean of 0.03 (95% CI, 0.01-0.05) to 0.01 (95% CI, 0.00-0.01) visits for SIP guests vs no change in the control group (IRR, 0.25; 95% CI, 0.11-0.51; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that in a population of PEH with high use of acute health services, SIP hotel placement was associated with significantly reduced acute care use compared with high users without a placement.
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Affiliation(s)
| | - Jennifer L. Evans
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco
| | - Dave Graham-Squire
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco
| | - Caroline Cawley
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Department of Emergency Medicine, University of California, San Francisco
| | - Hemal K. Kanzaria
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco
- Department of Emergency Medicine, University of California, San Francisco
- Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Margot B. Kushel
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco
| | - Maria C. Raven
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Department of Emergency Medicine, University of California, San Francisco
- Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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Chen J, Hao S, Wu Y. Housing and health in vulnerable social groups: an overview and bibliometric analysis. REVIEWS ON ENVIRONMENTAL HEALTH 2022; 37:267-279. [PMID: 34049423 DOI: 10.1515/reveh-2020-0167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/08/2021] [Indexed: 06/12/2023]
Abstract
Previous studies have confirmed that poor living conditions can lead to a wide range of health problems. However, in the context of the COVID-19 pandemic, vulnerable groups in unstable housing are more susceptible to disease. This study aims to systematically examine the housing and health problems of vulnerable groups using a bibliometric approach to explore how housing causes health problems, types of health illnesses, and coping strategies. It is found that the poor housing mechanism, persistent inequalities, and poor housing environments have a significant impact on the health of vulnerable groups. Therefore, the government must make concerted efforts across all sectors to ensure that the housing and health care needs of vulnerable groups are improved, and that housing security standards and related policies are improved; targeted safety plans are formulated with community as the carrier, taking into account the characteristics of vulnerable groups; and new information technology is widely used to provide medical convenience for vulnerable groups. It is hoped that the research in this paper can arouse social attention to the health of vulnerable groups and improve their health from the perspective of housing, so as to point out the direction for solving the housing health problems of vulnerable groups in the future.
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Affiliation(s)
- Junhua Chen
- Department of Urban and Real Estate Management, Central University of Finance and Economics, Beijing, Beijing, China
| | - Shuya Hao
- Department of Urban and Real Estate Management, Central University of Finance and Economics, Beijing, Beijing, China
| | - Ying Wu
- National Institute of Social Development, Central University of Finance and Economics, No. 5 Jiangguomennei Street, 100732, Beijing, Beijing, China
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Raven MC, Niedzwiecki MJ, Kushel M. A randomized trial of permanent supportive housing for chronically homeless persons with high use of publicly funded services. Health Serv Res 2021; 55 Suppl 2:797-806. [PMID: 32976633 PMCID: PMC7518819 DOI: 10.1111/1475-6773.13553] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To examine whether randomization to permanent supportive housing (PSH) versus usual care reduces the use of acute health care and other services among chronically homeless high users of county‐funded services. Data Sources Between 2015 and 2019, we assessed service use from Santa Clara County, CA, administrative claims data for all county‐funded health care, jail and shelter, and mortality. Study Design We conducted a randomized controlled trial among chronically homeless high users of multiple systems. We compared postrandomization outcomes from county‐funded systems using multivariate regression analysis. Data Collection We extracted encounter data from an integrated database capturing health care at county‐funded facilities, shelter and jails, county housing placement, and death certificates. Principal Findings We enrolled 423 participants (199 intervention; 224 control). Eighty‐six percent of those randomized to PSH received housing compared with 36 percent in usual care. On average, the 169 individuals housed by the PSH intervention have remained housed for 28.8 months (92.9 percent of the study follow‐up period). Intervention group members had lower rates of psychiatric ED visits IRR 0.62; 95% CI [0.43, 0.91] and shelter days IRR 0.30; 95% CI [0.17, 0.53], and higher rates of ambulatory mental health services use IRR 1.84; 95% CI [1.43, 2.37] compared to controls. We found no differences in total ED or inpatient use, or jail. Seventy (37 treatment; 33 control) participants died. Conclusions The intervention placed and retained frequent user, chronically homeless individuals in housing. It decreased psychiatric ED visits and shelter use, and increased outpatient mental health care, but not medical ED visits or hospitalizations. Limitations included more than one‐third of usual care participants received another form of subsidized housing, potentially biasing results to the null, and loss of power due to high death rates. PSH can house high‐risk individuals and reduce emergent psychiatric services and shelter use. Reductions in hospitalizations may be more difficult to realize.
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Affiliation(s)
- Maria C Raven
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.,Mathematica Policy Research, Oakland, CA, USA
| | - Matthew J Niedzwiecki
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, USA
| | - Margot Kushel
- Mathematica Policy Research, Oakland, CA, USA.,Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,UCSF Benioff Homelessness and Housing Initiative, San Francisco, CA, USA
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Permanent Supportive Housing With Housing First to Reduce Homelessness and Promote Health Among Homeless Populations With Disability: A Community Guide Systematic Review. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2020; 26:404-411. [PMID: 32732712 DOI: 10.1097/phh.0000000000001219] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Poor physical and mental health and substance use disorder can be causes and consequences of homelessness. Approximately 2.1 million persons per year in the United States experience homelessness. People experiencing homelessness have high rates of emergency department use, hospitalization, substance use treatment, social services use, arrest, and incarceration. OBJECTIVES A standard approach to treating homeless persons with a disability is called Treatment First, requiring clients be "housing ready"-that is, in psychiatric treatment and substance-free-before and while receiving permanent housing. A more recent approach, Housing First, provides permanent housing and health, mental health, and other supportive services without requiring clients to be housing ready. To determine the relative effectiveness of these approaches, this systematic review compared the effects of both approaches on housing stability, health outcomes, and health care utilization among persons with disabilities experiencing homelessness. DESIGN A systematic search (database inception to February 2018) was conducted using 8 databases with terms such as "housing first," "treatment first," and "supportive housing." Reference lists of included studies were also searched. Study design and threats to validity were assessed using Community Guide methods. Medians were calculated when appropriate. ELIGIBILITY CRITERIA Studies were included if they assessed Housing First programs in high-income nations, had concurrent comparison populations, assessed outcomes of interest, and were written in English and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES Housing stability, physical and mental health outcomes, and health care utilization. RESULTS Twenty-six studies in the United States and Canada met inclusion criteria. Compared with Treatment First, Housing First programs decreased homelessness by 88% and improved housing stability by 41%. For clients living with HIV infection, Housing First programs reduced homelessness by 37%, viral load by 22%, depression by 13%, emergency departments use by 41%, hospitalization by 36%, and mortality by 37%. CONCLUSIONS Housing First programs improved housing stability and reduced homelessness more effectively than Treatment First programs. In addition, Housing First programs showed health benefits and reduced health services use. Health care systems that serve homeless patients may promote their health and well-being by linking them with effective housing services.
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Comparing Unsheltered and Sheltered Homeless: Demographics, Health Services Use and Predictors of Health Services Use. Community Ment Health J 2020; 56:271-279. [PMID: 31552539 DOI: 10.1007/s10597-019-00470-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 09/18/2019] [Indexed: 10/26/2022]
Abstract
Secondary data obtained through the 2015 point-in-time homelessness count and an administrative health care utilization database was used to identify differences in demographic characteristics, health service use, and predictors of health service use among people experiencing unsheltered and sheltered homelessness. Compared to sheltered participants, unsheltered participants had higher proportions of males and Caucasians, were younger, were more likely to use any type of health service and ED services, and used significantly more of any health service and ED and outpatient services. Results also confirm that health services utilization is a complex phenomenon predicted by a variety of predisposing, enabling, and need-related factors, including mental health problems. Together, these findings demonstrate important differences between people living unsheltered and those residing in shelters and they inform local health policy and program initiatives tailored towards these homeless populations.
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Gupta R, Ghaly M, Todoroff C, Wali S. Creating value for communities: Los Angeles County's investment in Housing for Health. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2020; 8:100387. [PMID: 32001247 DOI: 10.1016/j.hjdsi.2019.100387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 09/17/2019] [Accepted: 10/05/2019] [Indexed: 10/25/2022]
Abstract
With U.S. healthcare expenditures leading and social service spending trailing other developed nations, patients, caregivers, and employers are insisting on improved value in health and healthcare for communities. Yet, health systems struggle to understand how to best invest existing funding or savings to reach these goals. We share the experience of Los Angeles County's health system that has invested in housing through their Housing for Health Program (HFH) to address the needs of high cost populations within communities. The approach rested on four key program strategies including having partnerships with various housing facilities, a whole person approach with broad community-based resources, a local footprint in community health services, and a robust jail and prison transitions program. HFH also relied on three key implementation strategies including having dynamic funding sources, stakeholder alignment, and continuous improvement. This case report describes these program and implementation strategies plus challenges and lessons learned navigating homeless individuals through the regulations of various funding contracts, maintaining service provider capacity, maintaining local culture in implementation, and persistent gaps in affordable housing availability. Future policies can incentivize similar efforts and infrastructure to transfer healthcare dollars into public services to improve housing and value for communities.
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Affiliation(s)
- Reshma Gupta
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA; UCLA-Olive View Medical Center, Los Angeles County Department of Health Services, Los Angeles, CA, USA.
| | - Mark Ghaly
- Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Cheri Todoroff
- Housing for Health, Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Soma Wali
- UCLA-Olive View Medical Center, Los Angeles County Department of Health Services, Los Angeles, CA, USA
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8
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Stenius-Ayoade A, Eriksson JG, Kautiainen H, Gissler M, Haaramo P. Duration of homelessness and its relationship to use of hospital and emergency department services in Helsinki, Finland. Scand J Public Health 2019; 48:259-266. [PMID: 31200627 DOI: 10.1177/1403494819854008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims: Homelessness is associated with poor health outcomes and increased use of hospital and emergency department (ED) services. Little is known about the duration of homelessness in relation to health care service use. The aim of this study was to examine the use of hospital and ED services among the homeless in Helsinki, Finland, and for the first time, to examine the relationship between service use and duration of homelessness. Methods: Six hundred and eighty-three persons staying at least one night in a shelter between September 2009 and September 2010 were followed until the end of 2014. Using negative binominal regression analysis we calculated the use of hospital and ED services and compared the use with that of a matched control group (N = 1361). We also analyzed service use in relation to the time spent homeless during follow-up. Results: The mean time spent homeless during the follow-up was 8.5 months, one third was temporarily homeless (less than 2% of the follow-up time), but recurrent episodes of homelessness were also common. The study group's incidence rate ratios for medical-surgical hospital days was 6.23 (95% CI: 4.73 to 8.21), for psychiatric hospital days 43.11 (95% CI: 23.02 to 80.74) and for ED visits 10.21 (95% CI: 8.77 to 11.90), compared with controls. The number of medical-surgical hospital days and ED visits/person-year increased as homelessness was prolonged, but the pattern was opposite for psychiatric hospital days. Conclusions: Homeless persons are heavy users of hospital and ED services, and there is also increased use among those temporarily homeless.
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Affiliation(s)
- Agnes Stenius-Ayoade
- Folkhälsan Research Center, Finland.,National Institute for Health and Welfare, Mental Health Unit, Finland.,City of Helsinki, Department of Social Services and Health Care, Finland
| | - Johan G Eriksson
- Folkhälsan Research Center, Finland.,National Institute for Health and Welfare, Public Health Promotion Unit, Finland.,Department of General Practice and Primary Health Care, Helsinki University Hospital, University of Helsinki, Finland
| | - Hannu Kautiainen
- Folkhälsan Research Center, Finland.,Department of General Practice and Primary Health Care, Helsinki University Hospital, University of Helsinki, Finland.,University of Eastern Finland, Finland
| | - Mika Gissler
- Information Services Department, National Institute for Health and Welfare, Finland.,Research Center for Child Psychiatry, University of Turku, Finland.,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Sweden
| | - Peija Haaramo
- National Institute for Health and Welfare, Public Health Promotion Unit, Finland
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Pakzad S, Bourque PÉ, Bourque J, Aubry T, Gallant L, LeBlanc SR, Tivendell J. A Comparison of the Use of Physical and Mental Health Services by Homeless People With Severe Mental Health Problems in the Moncton Area Through the At Home/Chez Soi Program. ACTA ACUST UNITED AC 2017. [DOI: 10.7870/cjcmh-2017-024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The At Home / Chez Soi demonstration project was conducted to investigate the effectiveness of the Housing First model in 5 Canadian cities. Using a randomized controlled trial design, this study evaluates the impact of this project on the use of health services by people with severe and persistent mental health problems and a history of homelessness in the greater Moncton area. The sample comprised 193 homeless persons, 95 in the control group and 98 in the treatment group. The results show a significant difference between the 2 groups only in the number of days of hospitalization, particularly in the psychiatric unit. Factors associated with the use of health services by people who are homeless and who have severe mental health problems need to be further investigated.
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The Effects of Housing Status, Stability and the Social Contexts of Housing on Drug and Sexual Risk Behaviors. AIDS Behav 2017; 21:2079-2092. [PMID: 28243936 DOI: 10.1007/s10461-017-1738-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Research on the relationship between housing instability and HIV risk has often focused on two different conceptions of stability. In one conceptualization, housing stability is defined according to physical location with homeless or unstably housed individuals defined as those who reside in places not meant for human habitation or in emergency shelters. The other conceptualization has defined housing stability as individuals' degree of transience, often operationalized as the number of moves or evictions a person has had within a specified amount of time. Less studied has been the social context of living situation, e.g. living with other drug users, conflict over living expenses, or having to have sex in order to stay. This paper uses data from 392 low-income residents in Hartford, CT to explore how people in different housing situations-including those who are housed and homeless-experience housing stability, feelings of security in their homes, and the social context of their housing. We then explore how these varied measures of housing context affect drug use frequency and sexual risk. Results show that participants who are homeless feel more overall housing instability in terms of number of moves and negative reasons for moving. Those who were doubled up with family or friends were more likely to experience conflict over household expenses and more likely to live with drug users. Among homeless and housed, hard drug use was associated with experiencing violence in the place where they lived, perceiving greater housing stability, having moved for a positive reason, doubling up, and longer periods of homelessness, while number of moves and longer prison sentence predicted sexual risk. Among the housed, living with other drug users was associated with more hard drug use, while contributing money toward household expenses was associated with less hard drug use. Two significant interactions were associated with sexual risk among the housed. Those with longer prison sentences who lived with drug users had more sexual partners, and those with longer prison sentences who doubled up had more sex partners. Results of this study indicate that measures of housing status not often considered in the literature such as the social context of housing have significant effects on HIV risk.
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Jaworsky D, Gadermann A, Duhoux A, Naismith TE, Norena M, To MJ, Hwang SW, Palepu A. Residential Stability Reduces Unmet Health Care Needs and Emergency Department Utilization among a Cohort of Homeless and Vulnerably Housed Persons in Canada. J Urban Health 2016; 93:666-81. [PMID: 27457795 PMCID: PMC4987593 DOI: 10.1007/s11524-016-0065-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This study examined the association of housing status over time with unmet physical health care needs and emergency department utilization among homeless and vulnerably housed persons in Canada. Homeless and vulnerably housed individuals completed interviewer-administered surveys on housing, unmet physical health care needs, health care utilization, sociodemographic characteristics, substance use, and health conditions at baseline and annually for 4 years. Generalized logistic mixed effects regression models examined the association of residential stability with unmet physical health care needs and emergency department utilization, adjusting for potential confounders. Participants were from Vancouver (n = 387), Toronto (n = 390), and Ottawa (n = 396). Residential stability was associated with lower odds of having unmet physical health needs (adjusted odds ratio (AOR), 0.82; 95 % confidence interval (CI), 0.67, 0.98) and emergency department utilization (AOR, 0.74; 95 % CI, 0.62, 0.88) over the 4-year follow-up period, after adjusting for potential confounders. Residential stability is associated with fewer unmet physical health care needs and lower emergency department utilization among homeless and vulnerably housed individuals. These findings highlight the need to address access to stable housing as a significant determinant of health disparities.
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Affiliation(s)
- Denise Jaworsky
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anne Gadermann
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, 588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | | | - Trudy E Naismith
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Monica Norena
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, 588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Matthew J To
- Centre for Research in Inner City Health, St. Michael's Hospital, Toronto, ON, Canada
| | - Stephen W Hwang
- Centre for Research in Inner City Health, St. Michael's Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Anita Palepu
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada. .,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, 588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Leibler JH, Zakhour CM, Gadhoke P, Gaeta JM. Zoonotic and Vector-Borne Infections Among Urban Homeless and Marginalized People in the United States and Europe, 1990-2014. Vector Borne Zoonotic Dis 2016; 16:435-44. [PMID: 27159039 DOI: 10.1089/vbz.2015.1863] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION In high-income countries, homeless individuals in urban areas often live in crowded conditions with limited sanitation and personal hygiene. The environment of homelessness in high-income countries may result in intensified exposure to ectoparasites and urban wildlife, which can transmit infections. To date, there have been no systematic evaluations of the published literature to assess vector-borne and zoonotic disease risk to these populations. OBJECTIVES The primary objectives of this study were to identify diversity, prevalence, and risk factors for vector-borne and zoonotic infections among people experiencing homelessness and extreme poverty in urban areas of high-income countries. METHODS We conducted a systematic review and narrative synthesis of published epidemiologic studies of zoonotic and vector-borne infections among urban homeless and very poor people in the United States and Europe from 1990 to 2014. RESULTS Thirty-one observational studies and 14 case studies were identified (n = 45). Seroprevalence to the human louse-borne pathogen Bartonella quintana (seroprevalence range: 0-37.5%) was identified most frequently, with clinical disease specifically observed among HIV-positive individuals. Seropositivity to Bartonella henselae (range: 0-10.3%) and Rickettsia akari (range: 0-16.2%) was noted in multiple studies. Serological evidence of exposure to Rickettsia typhi, Rickettsia prowazekii, Bartonella elizabethae, West Nile virus, Borellia recurrentis, lymphocytic choriomeningitis virus, Wohlfartiimonas chitiniclastica, Seoul hantavirus (SEOV), and Leptospira species was also identified in published studies, with SEOV associated with chronic renal disease later in life. HIV infection, injection drug use, and heavy drinking were noted across multiple studies as risk factors for infection with vector-borne and zoonotic pathogens. CONCLUSIONS B. quintana was the most frequently reported vector-borne infection identified in our article. Delousing efforts and active surveillance among HIV-positive individuals, who are at elevated risk of complication from B. quintana infection, are advised to reduce morbidity. Given documented exposure to rodent-borne zoonoses among urban homeless and marginalized people, reducing human contact with rodents remains an important public health priority.
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Affiliation(s)
- Jessica H Leibler
- 1 Department of Environmental Health, Boston University School of Public Health , Boston, Massachusetts
| | - Christine M Zakhour
- 2 Department of Epidemiology, Boston University School of Public Health , Boston, Massachusetts
| | - Preety Gadhoke
- 3 College of Pharmacy and Health Sciences, St. Johns University , Queens, New York
| | - Jessie M Gaeta
- 4 Boston Health Care for the Homeless Program, Boston, Massachusetts.,5 Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
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Predictors of Emergency Department Visits and Inpatient Admissions Among Homeless and Unstably Housed Adolescents and Young Adults. Med Care 2016; 53:1010-7. [PMID: 26492212 DOI: 10.1097/mlr.0000000000000436] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Individuals under age 25 years are estimated to comprise one third of the homeless population nationally. Understanding the reasons for utilization of hospitals by homeless youth is important for optimizing disposition planning. OBJECTIVES Objectives of the present study were to: (1) report prevalence of emergency department (ED) and inpatient admissions among homeless and unstably housed youth; (2) describe demographic characteristics of those youth who seek hospital care; (3) describe their patterns of injury, illness, psychiatric, and substance use conditions; and (4) identify demographic and diagnostic predictors of ED visit or hospital readmission. METHODS Retrospective cohort study of 15-25-year-olds (N=402) who were admitted to the ED or inpatient floors of 2 urban teaching hospitals in King County, WA between July 1, 2009 and June 30, 2012 and whose address was "homeless" or "none" or a homeless shelter or service agency (ie, homeless or unstably housed), during any recorded encounter between July 1, 2009 and June 30, 2012. RESULTS A total of 1151 ED visits and 227 inpatient admissions were documented. Fifty percent of patients had an ED visit or hospital readmission within 1 year, with 43.1% receiving care within 30 days of discharge. Cox regression showed that female individuals with an injury diagnosis (hazard ratio=1.74, 95% confidence interval=1.06, 2.85) and male individuals with an acute medical condition (hazard ratio=1.59, 95% confidence interval=1.09, 2.32) at index visit were more likely to have an ED visit or hospital readmission during the following year, as were patients who provided a private address at their index visit. CONCLUSIONS Homeless young people who seek hospital care demonstrate a high rate of ED visits and hospital readmissions, with unique predictors of utilization associated with sex and housing status. Additional research is necessary to determine how best to transition these young people from hospital-based to community-based care.
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Cheung A, Somers JM, Moniruzzaman A, Patterson M, Frankish CJ, Krausz M, Palepu A. Emergency department use and hospitalizations among homeless adults with substance dependence and mental disorders. Addict Sci Clin Pract 2015; 10:17. [PMID: 26242968 PMCID: PMC4636835 DOI: 10.1186/s13722-015-0038-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 07/16/2015] [Indexed: 11/14/2022] Open
Abstract
Background Homelessness, substance use, and mental disorders each have been associated with higher rates of emergency department (ED) use and hospitalization. We sought to understand the correlation between ED use, hospital admission, and substance dependence among homeless individuals with concurrent mental illness who participated in a ‘Housing First’ (HF) intervention trial. Methods The Vancouver At Home study consisted of two randomized controlled trials addressing homeless individuals with mental disorders who have “high” or “moderate” levels of need. Substance dependence was determined at baseline prior to randomization, using the Mini International Neuropsychiatric Interview diagnostic tool, version 6.0. To assess health service use, we reviewed the number of ED visits and the number of hospital admissions based on administrative data for six urban hospitals. Negative binomial regression modeling was used to test the independent association between substance dependence and health service use (ED use and hospitalization), adjusting for HF intervention, age, gender, ethnicity, education, duration of lifetime homelessness, mental disorders, chronic health conditions, and other variables that were selected a priori to be potentially associated with use of ED services and hospital admission. Results Of the 497 homeless adults with mental disorders who were recruited, we included 381 participants in our analyses who had at least 1 year of follow-up and had a personal health number that could be linked to administrative health data. Of this group, 59% (n = 223) met criteria for substance dependence. We found no independent association between substance dependence and ED visits or hospital admissions [rate ratio (RR) = 0.85; 95% CI 0.62–1.17 and RR = 1.21; 95% CI 0.83–1.77, respectively]. The most responsible diagnoses (defined as the diagnosis that accounts for the length of stay) for hospital admissions were schizo-affective disorder, schizophrenia-related disorder, or bipolar affective disorder; collectively reported in 48% (n = 263) of admissions. Fifteen percent (n = 84) of hospital admissions listed substance dependence as the most responsible diagnosis. Conclusions Substance dependence was not independently associated with ED use or hospital admission among homeless adults with mental disorders participating in an HF trial. Hospital admissions among this cohort were primarily associated with severe mental disorders. Trial registration: ISRCTN57595077 and ISRCTN66721740
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Affiliation(s)
- Adrienne Cheung
- Department of Medicine, Centre for Health Evaluation and Outcome Sciences, University of British Columbia, 588B-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Julian M Somers
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada.
| | - Akm Moniruzzaman
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada.
| | | | | | - Michael Krausz
- School of Population and Public Health, Vancouver, Canada. .,Department of Psychiatry, University of British Columbia, Vancouver, Canada.
| | - Anita Palepu
- Department of Medicine, Centre for Health Evaluation and Outcome Sciences, University of British Columbia, 588B-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Su Z, Khoshnood K, Forster SH. Assessing Impact of Community Health Nurses on Improving Primary Care Use by Homeless/Marginally Housed Persons. J Community Health Nurs 2015. [PMID: 26212468 DOI: 10.1080/07370016.2015.1057082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This study invited a cross-sectional sample of 112 homeless/marginally housed adults in New Haven, CT to respond to a structured survey questionnaire. Seventy-six individuals responded. Among them, 39 (51%) had utilized primary care services during the preceding 2 years. Multivariate logistic regression analysis adjusting for age, sex, ethnicity, housing status, health insurance status, and self-reported health status found that having utilized primary care services was significantly associated with having regular contact with a community health nurse. This finding indicates that community health nurses may have a significant influence in increasing primary care service utilization by homeless and marginally housed individuals.
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Affiliation(s)
- Zhuo Su
- a Morse College, Yale University , New Haven , Connecticut
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Mautner DB, Pang H, Brenner JC, Shea JA, Gross KS, Frasso R, Cannuscio CC. Generating hypotheses about care needs of high utilizers: lessons from patient interviews. Popul Health Manag 2014; 16 Suppl 1:S26-33. [PMID: 24070247 DOI: 10.1089/pop.2013.0033] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Informed by a largely secondary and quantitative literature, efforts to improve care and outcomes for complex patients with high levels of emergency and hospital-based health care utilization have offered mixed results. This qualitative study identifies psychosocial factors and life experiences described by these patients that may be important to their care needs. Semi-structured interviews were conducted with 19 patients of the Camden Coalition of Healthcare Providers' Care Management Team. Investigators coded transcripts using a priori and inductively-derived codes, then identified 3 key themes: (1) Early-life instability and traumas, including parental loss, unstable or violent relationships, and transiency, informed many participants' health and health care experiences; (2) Many "high utilizers" described a history of difficult interactions with health care providers during adulthood; (3) Over half of the participants described the importance to their well-being of positive and "caring" relationships with primary health care providers and the outreach team. Additionally, the transient and vulnerable nature of this complex population posed challenges to follow-up, both for research and care delivery. These themes illuminate potentially important hypotheses to be explored in more generalizable samples using robust and longitudinal methods. Future work should explore the prevalence and impact of adverse childhood experiences among "high utilizers," and the different types of relationships they have with providers. Investigators should test new modes of care delivery that attend to patients' trauma histories. This qualitative study was well suited to provide insight into the life stories of these complex, vulnerable patients, informing research questions for further investigation.
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Affiliation(s)
- Dawn B Mautner
- 1 Department of Family Medicine and Community Health, University of Pennsylvania , Philadelphia, Pennsylvania
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Quinn K, Dickson-Gomez J, McAuliffe T, Owczarzak J. EXPLORING MULTIPLE LEVELS of ACCESS to RENTAL SUBSIDIES and SUPPORTIVE HOUSING. HOUSING POLICY DEBATE 2014; 24:467-484. [PMID: 31548783 PMCID: PMC6756751 DOI: 10.1080/10511482.2013.875052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Despite the well-documented benefits of stable housing, there are myriad barriers that preclude low-income and homeless individuals from accessing housing support. This paper examines which individual characteristics predict greater or more limited access to supportive housing and rental subsidy programs in Hartford, Connecticut. Although individuals with HIV/AIDS are most likely to access housing, limited options remain for other vulnerable populations, including those with substance use disorders and mental illness.
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Affiliation(s)
- Katherine Quinn
- Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Julia Dickson-Gomez
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Timothy McAuliffe
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jill Owczarzak
- Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
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Hwang SW, Chambers C, Chiu S, Katic M, Kiss A, Redelmeier DA, Levinson W. A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance. Am J Public Health 2013; 103 Suppl 2:S294-301. [PMID: 24148051 PMCID: PMC3969141 DOI: 10.2105/ajph.2013.301369] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2013] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We comprehensively assessed health care utilization in a population-based sample of homeless adults and matched controls under a universal health insurance system. METHODS We assessed health care utilization by 1165 homeless single men and women and adults in families and their age- and gender-matched low-income controls in Toronto, Ontario, from 2005 to 2009, using repeated-measures general linear models to calculate risk ratios and 95% confidence intervals (CIs). RESULTS Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum = 141.1), 2.0 emergency department (ED) encounters (maximum = 104.9), 0.2 medical-surgical hospitalizations (maximum = 14.9), and 0.1 psychiatric hospitalizations per person-year (maximum = 4.8). Rate ratios for homeless participants compared with matched controls were 1.76 (95% CI = 1.58, 1.96) for ambulatory care encounters, 8.48 (95% CI = 6.72, 10.70) for ED encounters, 4.22 (95% CI = 2.99, 5.94) for medical-surgical hospitalizations, and 9.27 (95% CI = 4.42, 19.43) for psychiatric hospitalizations. CONCLUSIONS In a universal health insurance system, homeless people had substantially higher rates of ED and hospital use than general population controls; these rates were largely driven by a subset of homeless persons with extremely high-intensity usage of health services.
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Affiliation(s)
- Stephen W Hwang
- Stephen W. Hwang, Catharine Chambers, and Shirley Chiu are with the Centre for Research on Inner City Health, part of the Keenan Research Centre in the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario. Marko Katic and Alex Kiss are with the Department of Research Design and Biostatistics, Sunnybrook Health Sciences Centre, Toronto. Donald A. Redelmeier is with the Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto. Wendy Levinson is with the Department of Medicine, University of Toronto
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McCormack RP, Hoffman LF, Wall SP, Goldfrank LR. Resource-limited, collaborative pilot intervention for chronically homeless, alcohol-dependent frequent emergency department users. Am J Public Health 2013; 103 Suppl 2:S221-4. [PMID: 24148034 DOI: 10.2105/ajph.2013.301373] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We introduced case management and homeless outreach to chronically homeless, alcohol-dependent, frequent emergency department (ED) visitors using existing resources. We assessed the difference in differences of ED visits 6 months pre- and postintervention using a prospective, nonequivalent control group trial. Secondary outcomes included changes in hospitalizations and housing. The differences in differences between intervention and prospective patients and retrospective controls were -12.1 (95% CI = -22.1, -2.0) and -12.8 (95% CI = -26.1, 0.6) for ED visits and -8.5 (95% CI = -22.8, 5.8) and -19.0 (95% CI = -34.3, -3.6) for inpatient days, respectively. Eighteen participants accepted shelter; no controls were housed. Through intervention, ED use decreased and housing was achieved.
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Affiliation(s)
- Ryan P McCormack
- Ryan P. McCormack, Lily F. Hoffman, Stephen P. Wall, and Lewis R. Goldfrank are with the Department of Emergency Medicine, New York University School of Medicine, New York, NY
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Desilva MB, Manworren J, Targonski P. Impact of a housing first program on health utilization outcomes among chronically homeless persons. J Prim Care Community Health 2013; 2:16-20. [PMID: 23804657 DOI: 10.1177/2150131910385248] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The authors examined the impact of a Housing First program on the use of specific health services, detoxification services, and criminal activity of long-term homeless individuals. The study sample consisted of eligible members of the inception cohort (18 enrollees) in the Single Adults Residential Assistance program (SARA) in Minneapolis, Minnesota. Analyses examined participant housing stability after enrollment in SARA and compared the use of a county medical center, detoxification programs, and criminal activity in the 2 years before and after enrollment in SARA. Only 1 of the 18 enrollees studied experienced homelessness during the 2-year follow-up after enrollment in SARA. There was a significant reduction in the amount of criminal activity in the 2-year period after SARA enrollment. The direction of association observed for other service uses remained consistent with expectations in existing literature, but were not statistically significant. Supportive housing for chronically homeless individuals may be successful at decreasing homelessness among this fragile population and may help reduce criminal activity.
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Food insecurity is associated with greater acute care utilization among HIV-infected homeless and marginally housed individuals in San Francisco. J Gen Intern Med 2013; 28:91-8. [PMID: 22903407 PMCID: PMC3539018 DOI: 10.1007/s11606-012-2176-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 06/22/2012] [Accepted: 06/28/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Food insecurity, or the uncertain availability of nutritionally adequate, safe foods, has been associated with poor HIV outcomes. There are few data on the extent to which food insecurity impacts patterns of health-care utilization among HIV-infected individuals. OBJECTIVE We examined whether food insecurity was associated with hospitalizations, Emergency Department (ED) visits, and non-ED outpatient visits. METHODS HIV-infected, homeless and marginally housed individuals participating in the San Francisco Research on Access to Care in the Homeless (REACH) cohort underwent quarterly structured interviews and blood draws. We measured food insecurity with the validated Household Food Insecurity Access Scale, and categorized participants as food secure, mild/moderately food insecure, and severely food insecure. Primary outcomes were: (1) any hospitalizations, (2) any ED visits, and (3) any non-ED outpatient visits. Generalized estimating equations were used to estimate model parameters, adjusting for socio-demographic (age, sex, ethnicity, education, income, housing status, health insurance) and clinical variables (CD4 nadir, time on antiretroviral therapy, depression, and illicit drug use). RESULTS Beginning in November 2007, 347 persons were followed for a median of 2 years. Fifty-six percent of participants were food insecure at enrollment. Compared with food-secure persons, those with severe food insecurity had increased odds of hospitalizations [adjusted odds ratio (AOR) = 2.16, 95 % confidence interval (CI) = 1.50-3.09] and ED visits (AOR = 1.71, 95 % CI = 1.06-2.30). While the odds of an outpatient visit were 41 % higher for severely food insecure individuals, the effect was not statistically significant (AOR = 1.41, 95 % CI = 0.99-2.01). Mild/moderate food insecurity was also associated with increased hospitalizations (AOR = 1.56, 95 % CI = 1.06-2.30), ED visits (AOR = 1.57, 95 % CI = 1.22-2.03), and outpatient visits (AOR = 1.68, 95 % CI = 1.20-2.17). CONCLUSIONS Food insecurity is associated with increased health services utilization among homeless and marginally housed HIV-infected individuals in San Francisco. Increased ED visits and hospitalizations are not related to fewer ambulatory care visits among food-insecure individuals. Addressing food insecurity should be a critical component of HIV treatment programs and may reduce reliance on acute care utilization.
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Chwastiak L, Tsai J, Rosenheck R. Impact of health insurance status and a diagnosis of serious mental illness on whether chronically homeless individuals engage in primary care. Am J Public Health 2012; 102:e83-9. [PMID: 23078477 DOI: 10.2105/ajph.2012.301025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated the impact of a diagnosis of serious mental illness on use of a primary care provider (vs the emergency department [ED]) as a source of care by people who were chronically homeless. METHODS We used data from 750 chronically homeless adults enrolled in the 11-site Collaborative Initiative to Help End Chronic Homelessness and identified demographic and clinical characteristics independently associated with using a primary care provider rather than an ED. RESULTS The factor most strongly associated with using the ED as a regular source of medical care was previous-year lack of health insurance. Despite high rates of serious mental illness, neither a diagnosis of serious mental illness nor increased severity of psychiatric symptoms was associated with such use. CONCLUSIONS Findings suggest that people who are chronically homeless and have chronic medical illness would be more likely to access care if they had health insurance. Individual states' deciding not to expand Medicaid coverage will likely have a tremendous impact on the health outcomes and health care costs associated with this and other vulnerable populations.
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Affiliation(s)
- Lydia Chwastiak
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
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Hermanstyne KA, Bangsberg DR, Hennessey K, Weinbaum C, Hahn JA. The association between use of non-injection drug implements and hepatitis C virus antibody status in homeless and marginally housed persons in San Francisco. J Public Health (Oxf) 2012; 34:330-9. [PMID: 22451327 DOI: 10.1093/pubmed/fds018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Up to 17,000 persons in the USA became infected with hepatitis C virus (HCV) in 2007, and many cases have unknown transmission routes. To date research on transmission of HCV via shared implements used to snort or smoke non-injection drugs has been inconclusive. METHODS We tested stored sera for HCV antibodies (anti-HCV) in a large population-based study of homeless and marginally housed persons in San Francisco. We examined the association between sharing implements used for snorting and smoking drugs and anti-HCV while controlling for sociodemographic variables in those who denied ever injecting drugs (n = 430). We also examined the association of anti-HCV status with history of incarceration, tattoo and piercing history, sexual history and alcohol consumption. RESULTS Seventeen percent of our sample was anti-HCV positive. We found no statistically significant associations with sharing implements used to smoke or snort drugs with anti-HCV status in our various multivariate models. There was a statistically significant negative association between ever snorting cocaine and anti-HCV status (adjusted odds ratio: 0.39; 95% confidence interval: 0.21-0.73). There were no other statistically significant associations with any other measured covariates in multivariate analyses. CONCLUSIONS Our findings suggest that sharing implements to snort or smoke drugs is not a significant risk factor for anti-HCV-positive status.
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Affiliation(s)
- Keith A Hermanstyne
- Department of Psychiatry, University of California-San Francisco, 401 Parnassus Ave., Box 0984, San Francisco, CA 94143-0984, USA.
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Abstract
In this study, cognitive interviewing methods were used to test targeted questionnaire items from a battery of quantitative instruments selected for a large multisite trial of supported housing interventions for homeless individuals with mental disorders. Most of the instruments had no published psychometrics in this population. Participants were 30 homeless adults with mental disorders (including substance use disorders) recruited from service agencies in Vancouver, Winnipeg, and Toronto, Canada. Six interviewers, trained in cognitive interviewing methods and using standard interview schedules, conducted the interviews. Questions and, in some cases, instructions, for testing were selected from existing instruments according to a priori criteria. Items on physical and mental health status, housing quality and living situation, substance use, health and justice system service use, and community integration were tested. The focus of testing was on relevance, comprehension, and recall, and on sensitivity/acceptability for this population. Findings were collated across items by site and conclusions validated by interviewers. There was both variation and similarity of responses for identified topics of interest. With respect to relevance, many items on the questionnaires were not applicable to homeless people. Comprehension varied considerably; thus, both checks on understanding and methods to assist comprehension and recall are recommended, particularly for participants with acute symptoms of mental illness and those with cognitive impairment. The acceptability of items ranged widely across the sample, but findings were consistent with previous literature, which indicates that "how you ask" is as important as "what you ask." Cognitive interviewing methods worked well and elicited information crucial to effective measurement in this unique population. Pretesting study instruments, including standard instruments, for use in special populations such as homeless individuals with mental disorders is important for training interviewers and improving measurement, as well as interpreting findings.
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Hwang SW, Gogosis E, Chambers C, Dunn JR, Hoch JS, Aubry T. Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program. J Urban Health 2011; 88:1076-90. [PMID: 21638115 PMCID: PMC3232412 DOI: 10.1007/s11524-011-9592-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Supportive housing, defined as subsidized housing in conjunction with site-based social services, may help improve the health and residential stability of highly disadvantaged individuals. This study examined changes in health status, quality of life, substance use, health care utilization, and residential stability among 112 homeless and vulnerably housed individuals who applied to a supportive housing program in Toronto, Canada, from December 2005 to June 2007. Follow-up interviews were conducted every 6 months for 18 months. Comparisons were made between individuals who were accepted into the program (intervention) and those who were wait-listed (usual care) using repeated-measures analyses. Individuals who were accepted into the housing program experienced significantly greater improvements in satisfaction with living situation compared with individuals in the usual care group (time, F(3,3,261) = 47.68, p < 0.01; group × time, F(3,3,261) = 14.60, p < 0.01). There were no significant differences in other quality of life measures, health status, health care utilization, or substance use between the two groups over time. Significant improvement in residential stability occurred over time, independent of assigned housing group (time, F(3,3,261) = 9.96, p < 0.01; group × time, F(3,3,261) = 1.74, p = 0.17). The ability to examine the effects of supportive housing on homeless individuals was limited by the small number of participants who were literally homeless at baseline and by the large number of participants who gained stable housing during the study period regardless of their assigned housing status. Nonetheless, this study shows that highly disadvantaged individuals with a high prevalence of poor physical and mental health and substance use can achieve stable housing.
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Affiliation(s)
- Stephen W Hwang
- Centre for Research on Inner City Health, Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
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Fitzpatrick-Lewis D, Ganann R, Krishnaratne S, Ciliska D, Kouyoumdjian F, Hwang SW. Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review. BMC Public Health 2011; 11:638. [PMID: 21831318 PMCID: PMC3171371 DOI: 10.1186/1471-2458-11-638] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 08/10/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research on interventions to positively impact health and housing status of people who are homeless has received substantially increased attention over the past 5 years. This rapid review examines recent evidence regarding interventions that have been shown to improve the health of homeless people, with particular focus on the effect of these interventions on housing status. METHODS A total of 1,546 articles were identified by a structured search of five electronic databases, a hand search of grey literature and relevant journals, and contact with experts. Two reviewers independently screened the first 10% of titles and abstracts for relevance. Inter-rater reliability was high and as a result only one reviewer screened the remaining titles and abstracts. Articles were included if they were published between January 2004 and December 2009 and examined the effectiveness of an intervention to improve the health or healthcare utilization of people who were homeless, marginally housed, or at risk of homelessness. Two reviewers independently scored all relevant articles for quality. RESULTS Eighty-four relevant studies were identified; none were of strong quality while ten were rated of moderate quality. For homeless people with mental illness, provision of housing upon hospital discharge was effective in improving sustained housing. For homeless people with substance abuse issues or concurrent disorders, provision of housing was associated with decreased substance use, relapses from periods of substance abstinence, and health services utilization, and increased housing tenure. Abstinent dependent housing was more effective in supporting housing status, substance abstinence, and improved psychiatric outcomes than non-abstinence dependent housing or no housing. Provision of housing also improved health outcomes among homeless populations with HIV. Health promotion programs can decrease risk behaviours among homeless populations. CONCLUSIONS These studies provide important new evidence regarding interventions to improve health, housing status, and access to healthcare for homeless populations. The additional studies included in this current review provide further support for earlier evidence which found that coordinated treatment programs for homeless persons with concurrent mental illness and substance misuse issues usually result in better health and access to healthcare than usual care. This review also provides a synthesis of existing evidence regarding interventions that specifically support homeless populations with HIV.
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Affiliation(s)
- Donna Fitzpatrick-Lewis
- The Effective Public Health Practice Project, School of Nursing, McMaster University, Hamilton, Canada
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Chin CN, Sullivan K, Wilson SF. A 'snap shot' of the health of homeless people in inner Sydney: St Vincent's Hospital. AUST HEALTH REV 2011; 35:52-6. [DOI: 10.1071/ah09824] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Accepted: 05/18/2010] [Indexed: 11/23/2022]
Abstract
Objectives. The poor health profile of people who are homeless results in a disproportionate use of health resources by these people. An in-hospital count of demographic and health data of homeless patients was conducted on two occasions at St Vincent’s Hospital in Sydney as an indicator of health resource utilisation for the Sydney region. Methods. Two in-hospital counts were conducted of homeless patients within the boundaries of St Vincent’s Hospital to coincide with the inaugural City of Sydney homeless street counts in winter 2008 and summer 2009. Data collected included level of homelessness, principal diagnosis, triage category, bed occupancy and linkages to services post hospital discharge. Results. Homeless patients at St Vincent’s utilised over four times the number of acute ward beds when compared with the state average. This corresponds to a high burden of mental health, substance use and physical health comorbidities in homeless people. There was high utilisation of mental health and drug and alcohol services by homeless people, and high levels of linkages with these services post-discharge. There were relatively low rates of linkage with general practitioner and ambulatory care services. Conclusion. Increasing knowledge of the health needs of the homeless community will assist in future planning and allocation of health services. What is known about the topic? The poor health status of people who are homeless has been previously noted in the USA, Canada and Scotland. What does this paper add? Homeless people living in Sydney also have a poor health profile and a disproportionate use of health resources when compared to people in the general population. What are the implications for practitioners? Health services for homeless people should be equipped to deal with mental health, substance use and physical health comorbidities.
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Ku BS, Scott KC, Kertesz SG, Pitts SR. Factors associated with use of urban emergency departments by the U.S. homeless population. Public Health Rep 2010; 125:398-405. [PMID: 20433034 DOI: 10.1177/003335491012500308] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Homeless individuals frequently use emergency departments (EDs), but previous studies have investigated local rather than national ED utilization rates. This study sought to characterize homeless people who visited urban EDs across the U.S. METHODS We analyzed the ED subset of the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED), a nationally representative probability survey of ED visits, using methods appropriate for complex survey samples to compare demographic and clinical characteristics of visits by homeless vs. non-homeless people for survey years 2005 and 2006. RESULTS Homeless individuals from all age groups made 550,000 ED visits annually (95% confidence interval [CI] 419,000, 682,000), or 72 visits per 100 homeless people in the U.S. per year. Homeless people were older than others who used EDs (mean age of homeless people = 44 years compared with 36 years for others). ED visits by homeless people were independently associated with male gender, Medicaid coverage and lack of insurance, and Western geographic region. Additionally, homeless ED visitors were more likely to have arrived by ambulance, to be seen by a resident or intern, and to be diagnosed with either a psychiatric or substance abuse problem. Compared with others, ED visits by homeless people were four times more likely to occur within three days of a prior ED evaluation, and more than twice as likely to occur within a week of hospitalization. CONCLUSIONS Homeless people who seek care in urban EDs come by ambulance, lack medical insurance, and have psychiatric and substance abuse diagnoses more often than non-homeless people. The high incidence of repeat ED visits and frequent hospital use identifies a pressing need for policy remedies.
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Affiliation(s)
- Bon S Ku
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Kertesz SG, Crouch K, Milby JB, Cusimano RE, Schumacher JE. Housing first for homeless persons with active addiction: are we overreaching? Milbank Q 2009; 87:495-534. [PMID: 19523126 PMCID: PMC2881444 DOI: 10.1111/j.1468-0009.2009.00565.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
CONTEXT More than 350 communities in the United States have committed to ending chronic homelessness. One nationally prominent approach, Housing First, offers early access to permanent housing without requiring completion of treatment or, for clients with addiction, proof of sobriety. METHODS This article reviews studies of Housing First and more traditional rehabilitative (e.g., "linear") recovery interventions, focusing on the outcomes obtained by both approaches for homeless individuals with addictive disorders. FINDINGS According to reviews of comparative trials and case series reports, Housing First reports document excellent housing retention, despite the limited amount of data pertaining to homeless clients with active and severe addiction. Several linear programs cite reductions in addiction severity but have shortcomings in long-term housing success and retention. CONCLUSIONS This article suggests that the current research data are not sufficient to identify an optimal housing and rehabilitation approach for an important homeless subgroup. The research regarding Housing First and linear approaches can be strengthened in several ways, and policymakers should be cautious about generalizing the results of available Housing First studies to persons with active addiction when they enter housing programs.
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Affiliation(s)
- Stefan G Kertesz
- Center for Surgical, Medical Acute Care Research and Transitions at the Birmingham Veterans Affairs Medical Center, University of Alabama, Birmingham, AL 35294, USA.
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Buchanan D, Kee R, Sadowski LS, Garcia D. The health impact of supportive housing for HIV-positive homeless patients: a randomized controlled trial. Am J Public Health 2009; 99 Suppl 3:S675-80. [PMID: 19372524 DOI: 10.2105/ajph.2008.137810] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the health impact of a housing and case management program, the Chicago Housing for Health Partnership, for homeless people with HIV. METHODS HIV-positive homeless inpatients at a public hospital (n = 105) were randomized to usual care or permanent housing with intensive case management. The primary outcome was survival with intact immunity, defined as CD4 count > or = 200 and viral load < 100,000. Secondary outcomes were viral loads, undetectable viral loads, and CD4 counts. RESULTS Outcomes were available for 94 of 105 enrollees (90%). Of 54 intervention participants, 35 (65%) reached permanent housing in program housing agencies. After 1 year, 55% of the intervention and 34% of the usual care groups were alive and had intact immunity (P = .04). Seventeen intervention (36%) and 9 usual care (19%) participants had undetectable viral loads (P = .051). Median viral loads were 0.89 log lower in the intervention group (P = .03). There were no statistical differences in CD4 counts. CONCLUSIONS Homelessness is a strong predictor of poor health outcomes and complicates the medical management of HIV. This housing intervention improved the health of HIV-positive homeless people.
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Affiliation(s)
- David Buchanan
- John Stroger Hospital of Cook County (formerly Cook County Hospital), Chicago, IL, and Rush University, Chicago, USA.
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Affiliation(s)
- Jeffrey L. Jackson
- General Medicine Division, Medicine-EDP, 4301 Jones Bridge Rd, Bethesda, MD 20814 USA
| | - Laura Sessums
- Division of General Internal Medicine, Walter Reed Army Medical Center, Washington, DC 20005 USA
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