Supportive Housing and Its Relationship With Diabetes Diagnosis and Management Among Homeless Persons in New York City

Changes in Medication Utilization and Adherence Associated with Homeless Adults' Entry into Permanent Supportive Housing

BACKGROUND

Permanent supportive housing (PSH) programs, which have grown over the last decade, have been associated with changes in health care utilization and spending. However, little is known about the impact of such programs on use of prescription drugs critical for managing chronic diseases prevalent among those with unstable housing.

OBJECTIVE

To evaluate the effects of PSH on medication utilization and adherence among Medicaid enrollees in Pennsylvania.

DESIGN

Difference-in-differences study comparing medication utilization and adherence between PSH participants and a matched comparison cohort from 7 to 18 months before PSH entry to 12 months post PSH entry.

SUBJECTS

Pennsylvania Medicaid enrollees (n = 1375) who entered PSH during 2011-2016, and a propensity-matched comparison cohort of 5405 enrollees experiencing housing instability who did not receive PSH but received other housing services indicative of episodic or chronic homelessness (e.g., emergency shelter stays).

MAIN MEASURES

Proportion with prescription fill, mean proportion of days covered (PDC), and percent adherent (PDC ≥ 80%) for antidepressants, antipsychotics, anti-asthmatics, and diabetes medications.

KEY RESULTS

The PSH cohort saw a 4.77% (95% CI 2.87% to 6.67%) relative increase in the proportion filling any prescription, compared to the comparison cohort. Percent adherent among antidepressant users in the PSH cohort rose 7.41% (95% CI 0.26% to 14.57%) compared to the comparison cohort. While utilization increased in the other medication classes among the PSH cohort, differences from the comparison cohort were not statistically significant.

CONCLUSIONS

PSH participation is associated with increases in filling prescription medications overall and improved adherence to antidepressant medications. These results can inform state and federal policy to increase PSH placement among Medicaid enrollees experiencing homelessness.

Evaluation of New York/New York III permanent supportive housing program

In 2005, the city and state of New York launched New York/New York III (NY/NY III), a permanent supportive housing program for individuals experiencing homelessness or at risk of homelessness with complex medical and behavioral health issues. This review paper summarizes a decade of findings (2007-2017) from the NY/NY III evaluation team, to analyze this program's impact on various housing and health outcomes. The evaluation team linked NY/NY III eligible persons with administrative data from two years pre- and two years post-eligibility and compared housing and health outcomes between placed and unplaced groups using propensity score analysis. Placement into NY/NY III housing was associated with improved physical and mental health outcomes, increased housing stability, and statistically significant cost savings per person after one year of placement. The evaluation team recommends that municipalities invest in supportive housing as a means for mitigating homelessness and improving health outcomes in this vulnerable population.

Development of a New Measure of Housing Security: The REDD-CAT Housing Security Measure

BACKGROUND

Housing security is a key social determinant of behavior related to health outcomes.

OBJECTIVE

The purpose of this study was to develop a new patient-reported outcome measure that evaluates aspects of housing security for use in the Re-Engineered Discharge for Diabetes-Computer Adaptive Test (REDD-CAT) measurement system.

DESIGN

Qualitative data, literature reviews, and cross-sectional survey study.

PARTICIPANTS

A total of 225 people with T2DM provided responses to the items in this item pool.

MAIN MEASURES

A new item pool that evaluates important aspects of housing security was developed using stakeholder data from focus groups of persons with T2DM.

KEY RESULTS

For the Housing Affordability scale, factor analysis (both exploratory and confirmatory) supported the retention of six items. Of these items, none exhibited sparse cells or problems with monotonicity; no items were deleted due to low item-adjusted total score correlations. For the six affordability items, a constrained graded response model indicated no items exhibited misfit; thus, all were retained. No items indicated differential item functioning (examined for age, sex, education, race, and socioeconomic status). Thus, the final Affordability item bank comprised six items. A Housing Safety index (three items) and a Home Features index (eight items) were also developed. Reliability (i.e., internal consistency and test-retest reliability) and validity (i.e., convergent, discriminant, and known-groups) of the new measures were also supported.

CONCLUSIONS

The REDD-CAT Housing Security Measure provides a reliable and valid assessment of housing affordability, safety, and home features in people with type 2 diabetes mellitus. Future work is needed to establish the clinical utility of this measure in other clinical populations.

Relationship between food insecurity and housing instability on quality of care and quality of life in adults with diabetes

OBJECTIVE

Examine the relationship between food and housing insecurities, quality of care and quality of life in adults with diabetes using a nationally representative data source.

METHODS

Data from 39,604 adults with diabetes who indicated if they experienced food and/or housing insecurity in the Behavioral Risk Factor Surveillance System (2014, 2015, 2017) was analyzed. Outcomes included quality of care (HbA1c test, eye exam, diabetes education, foot check) and quality of life (general health status, poor physical and mental health days, poor overall health days). Logistic models were run for each quality of care measure and linear models were run for each quality of life measure adjusting for socio-demographics, insurance status, and comorbidity count.

RESULTS

35.6% of adults with diabetes reported housing insecurity, 31.8% reported food insecurity, and 23.4% reported both. After adjustment, food and housing insecurity was significantly associated with lower odds of having an eye exam (housing:0.73, 95%CI:0.63,0.85; food:0.78, 95%CI:0.67,0.92; both:0.69, 95%CI:0.59,0.82), worse general health status (housing:-0.06 95%CI:-0.11,-0.01; food:-0.16, 95%CI:-0.21,-0.10; both:-0.14, 95%CI:-0.20,-0.09), and an increased number of poor mental health days (housing:1.73, 95%CI:0.83,2.63; food:2.08, 95%CI:1.16,3.00; both:1.97, 95%CI:1.05,2.90). Food insecurity was also associated with lower odds of receiving diabetes education (0.86, 95%CI:0.74,0.99) and an increased number of poor physical health days (0.95, 95%CI:0.14,1.76).

CONCLUSION

Changes to our healthcare delivery system are critical to improving standards of care and quality of life in all populations and may require a shift towards consideration of overlapping social risk factors rather than the siloed approach currently used.

The Impact of Supportive Housing on Liver-Related Outcomes Among Persons With Hepatitis C Virus Infection

BACKGROUND

Hepatitis C virus (HCV) infection disproportionately impacts people experiencing homelessness. Hepatitis C virus can lead to negative health outcomes, including mortality. We evaluated the impact of a permanent supportive housing (PSH) program (ie, "treatment") on liver-related morbidity and mortality among persons with chronic homelessness and HCV infection.

METHODS

We matched records for persons eligible for a New York City PSH program (2007-2014) with Heath Department HCV and Vital Statistics registries and Medicaid claims. Among persons diagnosed with HCV before or 2 years posteligibility, we added stabilized inverse probability of treatment weights to negative binomial regression models to compare rates for liver disease-related emergency department visits and hospitalizations, and hazard ratios for mortality, by program placement 2 and 5 years posteligibility.

RESULTS

We identified 1158 of 8783 placed and 1952 of 19 019 unplaced persons with laboratory-confirmed HCV infection. Permanent supportive housing placement was associated with significantly reduced liver-related emergency department visits (adjusted rate ratio [aRR] = 0.76, 95% confidence interval [CI] = .61-.95), hospitalizations (aRR = 0.62, 95% CI = .54-.71), and all-cause (adjusted hazard ratio [aHR] = 0.65, 95% CI = .46-.92) and liver-related mortality (aHR = 0.72, 95% CI = .09-.83) within 2 years. The reduction remained significant for hospitalizations after 5 years.

CONCLUSIONS

Placement into PSH was associated with reduced liver-related morbidity and mortality among persons with HCV infection and chronic homelessness.

Diabetes care and its predictors among persons experiencing homelessness compared with domiciled adults with diabetes in New York City; An observational study

BACKGROUND

There is a dearth of data regarding diabetes control among patients experiencing homelessness.

METHODS

We retrospectively collected type 2 diabetes-related measurements, sociodemographic, and clinical indicators from medical records of all incoming adults with diabetes (n = 418; homeless: 356 and domiciled: 58) seen in shelter-clinics in New York City in 2019. The outcomes were the rates of inadequately managed diabetes and associated factors.

FINDINGS

Bivariate analysis showed that patients experiencing homelessness (63% Black; 32% Hispanic) 134/304 (43⋅9%) were more likely than domiciled patients 13/57 (22·8%) to have inadequately managed diabetes (OR 2⋅67, CI 1·38-5·16, p = 0⋅003). The average HbA1c among homeless (8·4%, SD± 2·6) was higher than that of domiciled persons (7·3%, SD± 1·8, p = 0·002). In logistic regression, domiciled status (OR 0⋅ 42, CI 0·21 - 0·84, p = 0·013), older age (OR 0·97, CI 0·95 - 0·99, p = 0·004), and non-Hispanic/Latino ethnicity were associated with well-managed diabetes. Among persons experiencing homelessness, non-Hispanic/Latino (OR 0·61, CI 0·37-0·99, p = 0·047) and older age (0·96, CI 0·94-0·99, p = 0·003) were associated with well-managed diabetes. In linear regression, mental illness (-0·11, p = 0·048) and older age (-0·15, p = 0·010) were associated with lower HbA1c, suggesting better support in respective shelters. There was no statistically significant association between inadequately managed diabetes with several traditional risk factors including substance or alcohol use disorder, health insurance, or other chronic diseases.

INTERPRETATION

Interventions at shelters or shelter-clinics should target subgroups in addition to addressing traditional risk factors to improve diabetes control. mHealth strategies could be considered to improve engagement, care delivery, and medication taking. Ultimately, homelessness itself needs to be addressed.

FUNDING

There are no funding sources to declare.

Relationship between housing insecurity, diabetes processes of care, and self-care behaviors

Background

The aim of this analysis was to examine the influence of housing insecurity on diabetes processes of care and self-care behaviors and determine if that relationship varied by employment status or race/ethnicity.

Methods

Using nationally representative data from the Behavioral Risk Factor Surveillance System (2014-2015), 16,091 individuals were analyzed for the cross-sectional study. Housing insecurity was defined as how often respondents reported being worried or stressed about having enough money to pay rent/mortgage. Following unadjusted logistic models testing interactions between housing insecurity and either employment or race/ethnicity on diabetes processes of care and self-care behaviors, stratified models were adjusted for demographics, socioeconomic status, health insurance status, and comorbidity count.

Results

38.1% of adults with diabetes reported housing insecurity. Those reporting housing insecurity who were employed were less likely to have a physicians visit (0.58, 95%CI 0.37,0.92), A1c check (0.45, 95%CI 0.26,0.78), and eye exam (0.61, 95%CI 0.44,0.83), while unemployed individuals were less likely to have a flu vaccine (0.84, 95%CI 0.70,0.99). Housing insecure White adults were less likely to receive an eye exam (0.67, 95%CI 0.54,0.83), flu vaccine (0.84, 95%CI 0.71,0.99) or engage in physical activity (0.82, 95%CI 0.69,0.96), while housing insecure Non-Hispanic Black adults were less likely to have a physicians visit (0.56, 95%CI 0.32,0.99).

Conclusions

Housing insecurity had an influence on diabetes processes of care and self-care behaviors, and this relationship varied by employment status and race/ethnicity. Diabetes interventions should incorporate discussion surrounding housing insecurity and consider differences in the impact by demographic factors on diabetes care.

A national pilot program for chronic diseases and health inequalities in South Korea

BACKGROUND

To achieve the health equity, it is important to reduce socioeconomic inequalities when managing chronic diseases. In South Korea, a pilot program for chronic diseases was implemented at the national level. This study aimed to examine its effect on socioeconomic inequalities in chronic disease management at the individual and regional levels.

METHODS

Korean National Health Insurance data from September 2016 to October 2017 were used. Study subjects in the national pilot program for chronic diseases included 31,765 participants and 5,741,922 non-participants. The dependent variable was continuity of prescription medication. Socioeconomic position indicators were health insurance contribution level and the area deprivation index. Covariates were gender, age, and the Charlson Comorbidity Index (CCI). A multilevel logistic regression model was used to address the effects at both the individual and regional levels. This is a cross-sectional study.

RESULTS

Unlike the group of non-participants, the participants showed no inequality in prescription medication continuity according to individual-level socioeconomic position. However, continuity of prescription medication was higher among those in less deprived areas compared to those in more deprived areas in both the participation and non-participation groups.

CONCLUSIONS

This study found that the pilot program for chronic diseases at the least did not contribute to the worsening of health inequalities at the individual level in South Korea. However, there was a trend showing health inequalities based on the socioeconomic level of the area. These findings suggest that additional policy measures are needed to attain equality in the management of chronic diseases regardless of the regional socioeconomic position.

Housing stability and diabetes among people living in New York city public housing

Public housing provides affordable housing and, potentially, housing stability for low-income families. Housing stability may be associated with lower incidence or prevalence and better management of a range of health conditions through many mechanisms. We aimed to test the hypotheses that public housing residency is associated with both housing stability and reduced risk of diabetes incidence, and the relationship between public housing and diabetes risk varies by levels of housing stability. Using 2004-16 World Trade Center Health Registry data, we compared outcomes (housing stability measured by sequence analysis of addresses, self-reported diabetes diagnoses) between 730 New York City public housing residents without prevalent diabetes at baseline and 730 propensity score-matched non-public housing residents. Sequence analysis found 3 mobility patterns among all 1460 enrollees, including stable housing (65%), limited mobility (27%), and unstable housing patterns (8%). Public housing residency was associated with stable housing over 12 years. Diabetes risk was not associated with public housing residency; however, among those experiencing housing instability, a higher risk of diabetes was found among public housing versus non-public housing residents. Of those stably housed, the association remained insignificant. These findings provide important evidence for a health benefit of public housing via housing stability among people living in public housing.

Residential mobility and chronic disease among World Trade Center Health Registry enrollees, 2004-2016

Residential mobility is hypothesized to impact health through changes to the built environment and disruptions in social networks, and may vary by neighborhood deprivation exposure. However, there are few longitudinal investigations of residential mobility in relation to health outcomes. This study examined enrollees from the World Trade Center Health Registry, a longitudinal cohort of first responders and community members in lower Manhattan on September 11, 2001. Enrollees who completed ≥2 health surveys between 2004 and 2016 and did not have diabetes (N = 44,089) or hypertension (N = 35,065) at baseline (i.e., 2004) were included. Using geocoded annual home addresses, residential mobility was examined using two indicators: moving frequency and displacement. Moving frequency was defined as the number of times someone was recorded as living in a different neighborhood; displacement as any moving to a more disadvantaged neighborhood. We fit adjusted Cox proportional hazards models with time-dependent exposures (moving frequency and displacement) and covariates to evaluate associations with incident diabetes and hypertension. From 2004 to 2016, the majority of enrollees never moved (54.5%); 6.5% moved ≥3 times. Those who moved ≥3 times had a similar hazard of diabetes (hazard ratio (HR) = 0.78; 95% Confidence Interval (CI): 0.40, 1.53) and hypertension (HR = 0.99; 95% CI: 0.68, 1.43) compared with those who never moved. Similarly, displacement was not associated with diabetes or hypertension. Residential mobility was not associated with diabetes or hypertension among a cohort of primarily urban-dwelling adults.