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Singh K, Timko C, Yu M, Taylor E, Blue-Howells J, Finlay AK. Scoping review of military veterans involved in the criminal legal system and their health and healthcare: 5-year update and map to the Veterans-Sequential Intercept Model. HEALTH & JUSTICE 2024; 12:18. [PMID: 38639813 PMCID: PMC11027330 DOI: 10.1186/s40352-024-00274-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND A previous scoping review of legal-involved veterans' health and healthcare (1947-2017) identified studies and their limitations. Given the influx of literature published recently, this study aimed to update the previous review and map articles to the Veterans-Sequential Intercept Model (V-SIM) - a conceptual model used by key partners, including Veterans Health Administration, veteran advocates, criminal justice practitioners, and local governments to identify intercept points in the criminal legal system where resources and programming can be provided. Developing an updated resource of literature is essential to inform current research, discover gaps, and highlight areas for future research. METHODS A systematic search of 5 databases identified articles related to legal-involved veterans' health and healthcare published between December 2017 through December 2022. The first and senior authors conducted abstract reviews, full-text reviews, and data extraction of study characteristics. Finally, each article was sorted by the various intercept points from the V-SIM. RESULTS Of 903 potentially relevant articles, 107 peer-reviewed publications were included in this review, most related to mental health (66/107, 62%) and used an observational quantitative study design (95/107, 89%). Although most articles did not explicitly use the V-SIM to guide data collection, analyses, or interpretation, all could be mapped to this conceptual model. Half of the articles (54/107, 50%) collected data from intercept 5 (Community Corrections and Support Intercept) of the V-SIM. No articles gathered data from intercepts 0 (Community and Emergency Services Intercept), 1 (Law Enforcement Intercept), or 2 (Initial Detention and Court Hearings Intercept). CONCLUSIONS There were 107 articles published in the last five years compared to 190 articles published in 70 years covered in the last review, illustrating the growing interest in legal-involved veterans. The V-SIM is widely used by front-line providers and clinical leadership, but not by researchers to guide their work. By clearly tying their research to the V-SIM, researchers could generate results to help guide policy and practice at specific intercept points. Despite the large number of publications, research on prevention and early intervention for legal-involved veterans is lacking, indicating areas of great need for future studies.
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Affiliation(s)
- Kreeti Singh
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.
| | - Christine Timko
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 291 Campus Drive, Li Ka Shing Building, Stanford, CA, 94305, USA
| | - Mengfei Yu
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
| | - Emmeline Taylor
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
- Department of Psychology, University of Colorado, Columbine Hall 4th Floor, 1420 Austin Bluffs Pkwy, Colorado Springs, CO, 80918, USA
| | - Jessica Blue-Howells
- Department of Veterans Affairs, Veterans Justice Programs, 810 Vermont Avenue, Washington DC, NW, 20420, USA
| | - Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
- Department of Veterans Affairs, National Center on Homelessness Among Veterans, 795 Willow Road, Menlo Park, CA, 94025, USA
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Kinney RL, Szymkowiak D, Tsai J. Growing Concern About Unsheltered Homelessness Among Veterans: Clinical Characteristics and Engagement in Health Care Services. Public Health Rep 2024:333549241227155. [PMID: 38323557 DOI: 10.1177/00333549241227155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
OBJECTIVES Veteran homelessness has declined in the past decade, but the proportion of unsheltered homeless veterans has increased. We identified characteristics of unsheltered homelessness in a large contemporary veteran cohort and examined outpatient and inpatient encounters before and after intake to US Department of Veterans Affairs (VA) homeless programs. METHODS National data from the Homeless Operations Management Evaluation System (HOMES) database and the Corporate Data Warehouse were analyzed on 191 204 veterans experiencing housing instability from January 2018 through December 2021. We used hierarchical multivariate logistic regressions to model associations between sheltered status and veteran correlates. Repeated-measures analysis of variance assessed changes in care utilization after intake in homeless programs. RESULTS Age <50 years (odds ratio [OR] = 1.3; 95% CI, 1.2-1.4), Hispanic ethnicity (OR = 1.2; 95% CI, 1.1-1.3), some college education (OR = 1.1; 95% CI, 1.0-1.1), and a bachelor's degree (OR = 1.2; 95% CI, 1.1-1.2) were associated with veteran unsheltered homelessness. Unsheltered veterans were more likely to have a VA service-connected disability (OR = 1.4; 95% CI, 1.4-1.5), military sexual trauma (OR = 1.1; 95% CI, 1.0-1.1), and/or combat exposure (OR = 1.1; 95% CI, 1.0-1.1). Unsheltered and sheltered homeless veterans had an increase in outpatient encounters and a decrease in inpatient care after intake to the VA homeless program. CONCLUSIONS Contemporary unsheltered homeless veterans are younger and Hispanic with some college education. Innovative public health approaches that better engage and reduce barriers to entry need to be tested for a diverse unsheltered homeless population.
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Affiliation(s)
- Rebecca L Kinney
- VA National Center on Homelessness Among Veterans, US Department of Veterans Affairs, Washington, DC, USA
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Dorota Szymkowiak
- VA National Center on Homelessness Among Veterans, US Department of Veterans Affairs, Washington, DC, USA
| | - Jack Tsai
- VA National Center on Homelessness Among Veterans, US Department of Veterans Affairs, Washington, DC, USA
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Hoisington AJ, Stearns-Yoder KA, Stamper CE, Holliday R, Brostow DP, Penzenik ME, Forster JE, Postolache TT, Lowry CA, Brenner LA. Association of homelessness and diet on the gut microbiome: a United States-Veteran Microbiome Project (US-VMP) study. mSystems 2024; 9:e0102123. [PMID: 38132705 PMCID: PMC10804991 DOI: 10.1128/msystems.01021-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/18/2023] [Indexed: 12/23/2023] Open
Abstract
Military veterans account for 8% of homeless individuals living in the United States. To highlight associations between history of homelessness and the gut microbiome, we compared the gut microbiome of veterans who reported having a previous experience of homelessness to those from individuals who reported never having experienced a period of homelessness. Moreover, we examined the impact of the cumulative exposure of prior and current homelessness to understand possible associations between these experiences and the gut microbiome. Microbiome samples underwent genomic sequencing and were analyzed based on alpha diversity, beta diversity, and taxonomic differences. Additionally, demographic information, dietary data, and mental health history were collected. A lifetime history of homelessness was found to be associated with alcohol use disorder, substance use disorder, and healthy eating index compared to those without such a history. In terms of differences in gut microbiota, beta diversity was significantly different between veterans who had experienced homelessness and veterans who had never been homeless (P = 0.047, weighted UniFrac), while alpha diversity was similar. The microbial community differences were, in part, driven by a lower relative abundance of Akkermansia in veterans who had experienced homelessness (mean; range [in percentages], 1.07; 0-33.9) compared to veterans who had never been homeless (2.02; 0-36.8) (P = 0.014, ancom-bc2). Additional research is required to facilitate understanding regarding the complex associations between homelessness, the gut microbiome, and mental and physical health conditions, with a focus on increasing understanding regarding the longitudinal impact of housing instability throughout the lifespan.IMPORTANCEAlthough there are known stressors related to homelessness as well as chronic health conditions experienced by those without stable housing, there has been limited work evaluating the associations between microbial community composition and homelessness. We analyzed, for the first time, bacterial gut microbiome associations among those with experiences of homelessness on alpha diversity, beta diversity, and taxonomic differences. Additionally, we characterized the influences of diet, demographic characteristics, military service history, and mental health conditions on the microbiome of veterans with and without any lifetime history of homelessness. Future longitudinal research to evaluate the complex relationships between homelessness, the gut microbiome, and mental health outcomes is recommended. Ultimately, differences in the gut microbiome of individuals experiencing and not experiencing homelessness could assist in identification of treatment targets to improve health outcomes.
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Affiliation(s)
- Andrew J. Hoisington
- Department of Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, Colorado, USA
- Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, Colorado, USA
- Department of Systems Engineering and Management, Air Force Institute of Technology, Wright-Patterson Air Force Base, Ohio, USA
| | - Kelly A. Stearns-Yoder
- Department of Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, Colorado, USA
- Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher E. Stamper
- Department of Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, Colorado, USA
- Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ryan Holliday
- Department of Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, Colorado, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Diana P. Brostow
- Department of Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, Colorado, USA
- Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Molly E. Penzenik
- Department of Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jeri E. Forster
- Department of Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Teodor T. Postolache
- Department of Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, Colorado, USA
- Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, Colorado, USA
- Mood and Anxiety Program, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Veterans Affairs, Veterans Integrated Service Networks (VISN) 5 MIRECC, Baltimore, Maryland, USA
| | - Christopher A. Lowry
- Department of Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, Colorado, USA
- Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, USA
- Center for Neuroscience, University of Colorado Boulder, Boulder, Colorado, USA
- Center for Microbial Exploration, University of Colorado Boulder, Boulder, Colorado, USA
| | - Lisa A. Brenner
- Department of Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, Colorado, USA
- Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, Colorado, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Jones AL, Chu K, Rose DE, Gelberg L, Kertesz SG, Gordon AJ, Wells KB, Leung L. Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness. J Gen Intern Med 2023; 38:2436-2444. [PMID: 36810631 PMCID: PMC10465405 DOI: 10.1007/s11606-023-08077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/30/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Persons who experience homelessness (PEH) have high rates of depression and incur challenges accessing high-quality health care. Some Veterans Affairs (VA) facilities offer homeless-tailored primary care clinics, although such tailoring is not required, within or outside VA. Whether services tailoring enhances care for depression is unstudied. OBJECTIVE To determine whether PEH in homeless-tailored primary care settings receive higher quality of depression care, compared to PEH in usual VA primary care. DESIGN Retrospective cohort study of depression treatment among a regional cohort of VA primary care patients (2016-2019). PARTICIPANTS PEH diagnosed or treated for a depressive disorder. MAIN MEASURES The quality measures were timely follow-up care (3 + completed visits with a primary care or mental health specialist provider, or 3 + psychotherapy sessions) within 84 days of a positive PHQ-2 screen result, timely follow-up care within 180 days, and minimally appropriate treatment (4 + mental health visits, 3 + psychotherapy visits, 60 + days antidepressant) within 365 days. We applied multivariable mixed-effect logistic regressions to model differences in care quality for PEH in homeless-tailored versus usual primary care settings. KEY RESULTS Thirteen percent of PEH with depressive disorders received homeless-tailored primary care (n = 374), compared to usual VA primary care (n = 2469). Tailored clinics served more PEH who were Black, who were non-married, and who had low income, serious mental illness, and substance use disorders. Among all PEH, 48% received timely follow-up care within 84 days of depression screening, 67% within 180 days, and 83% received minimally appropriate treatment. Quality metric attainment was higher for PEH in homeless-tailored clinics, compared to PEH in usual VA primary care: follow-up within 84 days (63% versus 46%; adjusted odds ratio [AOR] = 1.61, p = .001), follow-up within 180 days (78% versus 66%; AOR = 1.51, p = .003), and minimally appropriate treatment (89% versus 82%; AOR = 1.58, p = .004). CONCLUSIONS Homeless-tailored primary care approaches may improve depression care for PEH.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center and Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, UT, 84148, USA.
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Karen Chu
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
| | - Danielle E Rose
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
| | - Lillian Gelberg
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California-Los Angeles (UCLA), Los Angeles, CA, USA
- UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Stefan G Kertesz
- Birmingham VA Health Care System, Birmingham, AL, USA
- Heersink University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center and Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, UT, 84148, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kenneth B Wells
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California-Los Angeles (UCLA), Los Angeles, CA, USA
- UCLA Fielding School of Public Health, Los Angeles, CA, USA
- UCLA Center for Health Services and Society, Los Angeles, CA, USA
| | - Lucinda Leung
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California-Los Angeles (UCLA), Los Angeles, CA, USA
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Lo E, Tsai J, Stefanovics EA, Rosenheck R. Does Street Outreach Engage Its Intended Target Population? Clinical Experience in the Veteran's Health Administration Homeless Service Programs. Psychiatr Q 2022; 93:1003-1016. [PMID: 36331755 DOI: 10.1007/s11126-022-10004-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clinical street outreach programs serve people experiencing unsheltered homelessness, who have been shown to have greater medical and psychiatric comorbidities, and increased social and financial challenges. However, outreach programs may struggle in practice to engage the most vulnerable of these individuals. METHODS Data from the Veterans Health Administration's (VHA's) Homeless Operations Management System (HOMES) from 2018 to 2019 (N = 101,998) were used to compare sociodemographic, clinical, and financial characteristics of literally homeless veterans contacted through street outreach to those who were self-referred or clinic-referred. RESULTS Veterans engaged through street outreach reported substantially more days of unsheltered homelessness in the past month (mean (M) = 11.18 days, s.d.=13.8) than the clinic-referred group (M = 6.75 days, s.d.=11.1), and were more likely to have spent the past 30 days unsheltered (RR = 2.23). There were notably few other differences between the groups. CONCLUSION Despite epidemiologic evidence in the literature showing higher medical, psychiatric, and social and financial vulnerabilities among unsheltered homeless individuals, our street outreach group was not found to be any worse off on such variables than the clinic-referred or self-referred groups, other than increased time unsheltered. Outreach workers seem to engage more unsheltered individuals, but do not necessarily engage those with such severe vulnerabilities. Dedicated outreach program funding, training, and support are needed to support street outreach to those with the most severe problems.
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Affiliation(s)
- Emma Lo
- Yale Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
- Connecticut Mental Health Center, Department of Mental Health and Addiction Services, New Haven, CT, USA.
| | - Jack Tsai
- Yale Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- US Department of Veterans Affairs, VA National Center on Homelessness Among Veterans, Tampa, FL, US
- School of Public Health, University of Texas at Houston, San Antonio, TX, US
| | - Elina A Stefanovics
- Yale Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- US Department of Veterans Affairs, VA National Center on Homelessness Among Veterans, Tampa, FL, US
- VA New England Mental Illness, Research and Clinical Center, West Haven, CT, USA
| | - Robert Rosenheck
- Yale Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- US Department of Veterans Affairs, VA National Center on Homelessness Among Veterans, Tampa, FL, US
- VA New England Mental Illness, Research and Clinical Center, West Haven, CT, USA
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Koh KA, Roncarati JS, Racine MW, O'Connell JJ, Gaeta JM. Unsheltered vs. Sheltered Adults Experiencing Homelessness: Health Care Spending and Utilization. J Gen Intern Med 2022; 37:2100-2102. [PMID: 34643873 PMCID: PMC9198173 DOI: 10.1007/s11606-021-07153-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 09/10/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Katherine A Koh
- Boston Health Care for the Homeless Program, Boston, MA, USA. .,Department of Psychiatry, Massachusetts General Hospital, 15 Parkman Street, WAC 8, Boston, MA, 02114, USA.
| | - Jill S Roncarati
- Center for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs, MA, Bedford, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - James J O'Connell
- Boston Health Care for the Homeless Program, Boston, MA, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jessie M Gaeta
- Boston Health Care for the Homeless Program, Boston, MA, USA.,Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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