Accuracy of Self-Reported Health Care Use in a Population-Based Sample of Homeless Adults

COVID-19 vaccination uptake in people experiencing homelessness during the first three years of the global COVID-19 vaccination effort: A systematic review and meta-analysis

There are complex barriers to vaccination, including COVID-19 vaccination, in people experiencing homelessness. Consequently, it is likely COVID-19 vaccination uptake in this vulnerable population is lower than in general populations. This systematic review and meta-analysis reports COVID-19 vaccination uptake in people experiencing homelessness, including in comparison to general populations, in literature published during the first three years of the global COVID-19 vaccination effort. Searches were conducted on eight electronic databases. Peer-reviewed studies from high-income countries available in English and in full-text were considered for inclusion. Studies were considered up to 31 December 2023. In total 1884 studies were retrieved and, after removal of duplicates, 1167 were screened. Thirty-one studies were included in this review. For studies reporting uptake of either any, or first, COVID-19 vaccine a random effects meta-analysis was used to pool coverage estimates. It included 28 first vaccine dose coverage estimates from 18 studies including 104,139 vaccinated individuals in 308,253 participants. The pooled estimate for first dose vaccine coverage in people experiencing homelessness was 43 % (95 % CI: 35 %, 51 %). The 95 % prediction interval was (0, 88 %). Uptake of subsequent doses was heterogeneous and was reported narratively. Uptake of the second dose ranged upwards from 31.3 %, and uptake of the third dose was reported in one study as 7.2 %. COVID-19 vaccination uptake in people experiencing homelessness is lower than in general populations. Disparities in uptake persisted when comparing uptake at regional/state/national levels, at multiple timepoints, and in studies focused on different sub-populations including veterans. This is problematic, considering people experiencing homelessness are more likely to have poorer COVID-19-associated outcomes. It is important to recognise people experiencing homelessness are an at-risk, hard-to-reach group for vaccination, and vaccination strategies should be targeted to this population to improve uptake.

The EQ-5D and EQ-HWB fit the perceptions of quality of life from a Chinese perspective: a concept mapping study

BACKGROUND

The escalating globalization of health assessments underscores a pivotal challenge: Do Quality of Life (QoL) instruments, developed primarily in Western contexts, accurately reflect the perspectives of non-Western populations? This study evaluates the alignment of EQ-5D and EQ-HWB items with QoL dimensions identified in Chinese literature, and compares QoL perceptions between Chinese residents and those living abroad who may be influenced by Western values.

METHODS

This study employed three successive rounds of participant recruitment to refine the concept mapping process. Initially, 13 bilingual QoL experts in the Netherlands piloted the methodology, providing feedback on item translation and expression. Subsequently, 18 Chinese expatriates in the Netherlands, with partial education abroad, reviewed the revised materials to represent perspectives influenced by Western culture. Finally, 20 native Chinese residents, who were born and educated in China, formed the target group. Utilizing feedback from the pilot stage, a pool of 54 QoL items derived from Chinese literature, plus an additional eight from the EQ-HWB, were assembled. The Group Concept Mapping (GCM) method was used, with participants organizing the items to reflect their interrelationships. Data were analyzed via Groupwisdom™, an online tool supporting multidimensional scaling (MDS) and cluster analysis, culminating in visual cluster rating maps that highlighted the item associations and groupings.

RESULTS

In China, a five-cluster MDS map was identified: personal abilities, family and society, physical health, mental health, and self-cognition (stress value: 0.183), with physical health prioritized. Abroad, four clusters appeared: mental health, social connections, daily activities, and physical function (stress value: 0.185), prioritizing social connections. The EQ-5D missed the "family and society" cluster in China and "social connections" abroad. In contrast, the EQ-HWB covered all clusters in both groups.

CONCLUSIONS

The EQ-5D items align well with the somatic and partially with the mental clusters, while the EQ-HWB also covers the adaptation cluster and the remaining mental cluster aspects. Both instruments reflect the QoL perceptions of Chinese individuals, although EQ-5D focuses more on health than overall well-being. Cultural differences affect priorities: participants in China value physical health most, whereas those abroad emphasize social connections.

Participation in screening for breast and cervical cancer among women with current or previous drug use: a survey study

BACKGROUND

Women with current or previous drug use (WCPDU) have an increased risk of poor breast and cervical cancer outcomes. Screening is known to decrease the mortality of these common cancer forms, but screening participation has been sparsely investigated among women with drug dependency. The aim of this study was to assess participation in screening for breast and cervical cancer among WCPDU.

METHODS

We recruited WCPDU to a survey study, from six opioid substitution treatment (OST) clinics and one needle exchange program (NEP) in Malmö, Sweden, and through the Drug Users Union in Stockholm, Sweden. The survey was constructed according to results from focus group discussions about cancer screening in a sample of women in OST. Survey data were analyzed using descriptive statistics. We analyzed associations between non-compliance to screening and healthcare contact (OST, NEP or none) by logistic regression analysis; unadjusted and adjusted for age, native language, housing situation, educational attainment and main source of income.

RESULTS

A total of 298 women (median age 43 years) responded to the survey. The self-reported compliance with cancer screening recommendations was 29% for breast cancer screening and 41% for cervical cancer screening. Non-compliance with cervical cancer screening was associated with NEP participation in univariate but not multivariate analysis. We did not find an association between non-compliance with breast cancer screening and healthcare contact. Non-compliance with screening for cervical cancer was also associated with unstable housing in univariate and multivariate analyses, and inversely associated with increasing age in a univariate analysis. Non-compliance with breast cancer was associated with unstable housing in a univariate analysis, and inversely associated with not having Swedish as a native language in a multivariate analysis.

CONCLUSION

The self-reported compliance with the national cancer screening programs for breast cancer and cervical cancer of WCPDU is notably lower than in the Swedish general population. Women with unstable housing seem to be particularly vulnerable to non-compliance with cancer screening. Interventions to minimize barriers to cancer screening are crucial to decrease the increased cancer morbidity and mortality among WCPDU.

A systematic scoping review of primary health care service outreach for homeless populations

BACKGROUND

Homeless populations (HPs) have difficulties obtaining necessary medical care, and primary health care service outreach (PHSO) might be useful to bridge this gap.

OBJECTIVE

Using the Centre for Evidence-Based Management Critically Appraised Topics framework, to provide systematic evidence of the usefulness of PHSO interventions for HPs.

METHODS

A systematic search was conducted in 4 electronic databases: PubMed, Web of Science, CINAHL, and Cochrane (publication dates between January 1980 and November 2020). In total, 2,872 articles were identified. Primary research about PHSO for HPs in high-income countries were included. Data were extracted from eligible studies, summarized, and collated into a narrative account.

RESULTS

Twenty-four studies that described and evaluated PHSO interventions for adults experiencing homelessness were selected in the final synthesis. Most studies had a nonrandomized design. PHSO was found to successfully address some barriers to health care access for HPs through flexible appointments in convenient locations, fostering an understanding relationship between doctor and patients, and provision of additional basic necessities and referrals. Outreach was provided for a range of health care concerns, and several solutions to engage more HPs in primary care, improve continuity of care and to decrease the running costs were identified. Outreach also helped to implement preventative measures and reduced emergency service admissions.

CONCLUSION

Our review adds to the evidence that PHSO likely improves health care access for HPs. Further studies over longer time periods, involving collaborations with experts with lived experience of homelessness, and utilizing randomized study designs are needed to test outreach efficacy.

Integrating data analytics, peer support, and whole health coaching to improve the health outcomes of homeless veterans: Study protocol for an effectiveness-implementation trial

BACKGROUND

Homelessness is a strong determinant of acute care service utilization (inpatient hospitalization, emergency department visits) among US adults. Data analytics, peer support, and patient-centered approaches can collectively offer high-quality care for homeless patients who frequently utilize acute care ("super utilizers"). However, few outpatient programs have integrated these components and tested their effectiveness for this patient population.

OBJECTIVE

To test the effectiveness and implementation potential of a novel intervention that integrates data analytics with peers trained in whole health coaching ("Peer Whole Health") to reduce use of acute care among homeless adults.

METHODS

Using a randomized controlled trial design at two US Veterans Health Administration Medical Centers, we plan to enroll 220 veterans in primary care on VHA's Homeless Registry who are flagged on a super-utilizer clinical dashboard. Participants will complete a baseline interview, be randomized to Enhanced Usual Care (EUC; primary care and data analytics) or EUC plus 18 sessions of Peer Whole Health over 6 months, and be re-interviewed at 3, 6, and 9 months. Qualitative interviews with primary care staff and patients will identify facilitators and barriers to more widespread implementation of the intervention.

DISCUSSION

The primary hypothesis is that those who receive the intervention will have fewer total days of all-cause hospitalization. If confirmed, the findings can provide healthcare systems that serve homeless super-utilizers with a high-value approach to care that can be integrated into primary care services and reduce overall costs for these patients.

CLINICAL TRIAL REGISTRATION

The study is registered with ClinicalTrials.gov (NCT05176977).

Women sleeping rough: The health, social and economic costs of homelessness

This study seeks to assess the health, social and economic outcomes associated with rough sleeping among women and compare those outcomes with those of (1) men sleeping rough, and (2) women experiencing other forms of homelessness (such as being housed in temporary supported accommodation due to family and domestic violence). The paper analyses survey data using the Vulnerability Index-Service Prioritization Decision Analysis Tool (VI-SPDAT) collected from 2735 women experiencing homelessness and 3124 men sleeping rough in Australian cities from 2010 to 2017. We find that women sleeping rough report poorer physical and mental health outcomes and greater problematic drug and or alcohol use relative to both men sleeping rough and women experiencing other types of homelessness (all p < 0.5). Women sleeping rough report significantly higher levels of crisis service utilisation (Β = 17.9, SE = 3.9, p < 0.001) and interactions with police in the previous 6 months (Β = 1.9, SE = 0.3, p < 0.001) than women experiencing homelessness not sleeping rough. Women sleeping rough also report greater healthcare utilisation, and, therefore, healthcare costs, than women experiencing homelessness not sleeping rough and men sleeping rough (all p < 0.05). From a policy perspective, the evidence presented in this paper supports a social determinants approach that moves from addressing symptoms of poor health outcomes associated with homelessness to preventing and ending homelessness with a particular focus on the life trajectories of women. Integrated services and homelessness strategies need to be developed through a gender lens, providing women sleeping rough with tailored permanent housing with wrap-around supportive housing to address poor health outcomes.

Housing First for homeless people with severe mental illness: extended 4-year follow-up and analysis of recovery and housing stability from the randomized Un Chez Soi d'Abord trial

AIMS

Housing First (HF), a recovery-oriented approach, was proven effective in stabilising housing situations of homeless individuals with severe mental disorders, yet had limited effectiveness on recovery outcomes on a short-term basis compared to standard treatment. The objective was to assess the effects of the HF model among homeless people with high support needs for mental and physical health services on recovery, housing stability, quality of life, health care use, mental symptoms and addiction issues on 4 years of data from the Un Chez Soi d'Abord trial.

METHODS

A multicentre randomised controlled trial was conducted from August 2011 to April 2018 with intent-to-treat analysis in four French cities: Lille, Marseille, Paris and Toulouse. Participants were homeless or precariously-housed patients with a DSM-IV-TR diagnosis of bipolar disorder or schizophrenia. Two groups were compared: the HF group (n = 353) had immediate access to independent housing and support from the assertive community treatment team; the Treatment-As-Usual (TAU) group (n = 350) had access to existing support and services. Main outcomes were personal recovery (Recovery Assessment Scale (RAS) scale), housing stability, quality of life (S-QoL), global physical and mental status (Medical Outcomes Study 36-item Short Form Health Survey (SF-36)), inpatient days, mental symptoms (Modified Colorado Symptom Index (MCSI)) and addictions (Mini International Neuropsychiatric Interview (MINI) and Alcohol Use Disorders Identification Test (AUDIT)). Mixed models using longitudinal and cluster designs were performed and adjusted to first age on the street, gender and mental disorder diagnosis. Models were tested for time × group and site × time interactions.

RESULTS

The 703 participants [123 (18%) female] had a mean age of 39 years (95% CI 38.0-39.5 years). Both groups improved RAS index from baseline to 48 months, with no statistically significant changes found between the HF and TAU groups over time. HF patients exhibited better autonomy (adjusted β = 2.6, 95% CI 1.2-4.1) and sentimental life (2.3, 95% CI 0.5-4.1), higher housing stability (28.6, 95% CI 25.1-32.1), lower inpatient days (-3.14, 95% CI -5.2 to -1.1) and improved SF-36 mental composite score (-0.8, 95% CI -1.6 to -0.1) over the 4-year follow-up. HF participants experienced higher alcohol consumption between baseline and 48 months. No significant differences were observed for self-reported mental symptoms or substance dependence.

CONCLUSION

Data at 4 years were consistent with 2-year follow-up data: similar improvement in personal recovery outcomes but higher housing stability, autonomy and lower use of hospital services in the HF group compared to the TAU group, with the exception of an ongoing alcohol issue. These sustained benefits support HF as a valuable intervention for the homeless patients with severe mental illness.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01570712.

Views on health activation and support services among formerly homeless adults living in Permanent Supportive Housing in the United States

Individuals who have experienced chronic homelessness often have unmet physical and mental health needs and experiences of trauma and stigma. This study aimed to measure, for the first time, health activation (self-advocacy and empowerment) levels among formerly homeless adults living in Permanent Supportive Housing or PSH (referred to hereafter as residents). In addition, residents' experiences accessing health services, and their sense of health activation and efforts to manage their health within PSH settings, were explored. A mixed-methods study was conducted in Southern California (October 2018-June 2019) using a validated survey and interviews with a randomly selected group of residents (n = 61) from three PSH agencies. Activation levels were measured using the Patient Activation Measure. Descriptive and univariate survey analyses were conducted. Interview data was analysed using NVivo. Two coders coded all transcripts, and team meetings were held to reach consensus. Results showed most residents were female (64%), racial and ethnic minorities (66%), on average 54-year-olds, with 37 months of PSH residency, and 43% were taking some action to manage their health (intermediate activation level). Challenges accessing care were due to breakdowns in care, unpleasant experiences with providers, low health literacy and feeling overwhelmed by co-occurring chronic conditions. Health activation related to knowing when to take care of their health on their own and when to seek care. Unique challenges emerged related to PSH, such as lack of resident control within the housing setting and limited personnel responding to health emergencies. These challenges were magnified because residents live alone, per PSH requirements.

Cross-sectional Analysis of Food Insecurity and Frequent Emergency Department Use

INTRODUCTION

Emergency department (ED) patients have higher than average levels of food insecurity. We examined the association between multiple measures of food insecurity and frequent ED use in a random sample of ED patients.

METHODS

We completed survey questionnaires with randomly sampled adult patients from an urban public hospital ED (n = 2,312). We assessed food insecurity using four questions from the United States Department of Agriculture Household Food Security Survey. The primary independent variable was any food insecurity, defined as an affirmative response to any of the four items. Frequent ED use was defined as self-report of ≥4 ED visits in the past year. We examined the relationship between patient food insecurity and frequent ED use using bivariate and multivariable analyses and examined possible mediation by anxiety/depression and overall health status.

RESULTS

One-third (30.9%) of study participants reported frequent ED use, and half (50.8%) reported any food insecurity. Prevalence of food insecurity was higher among frequent vs. non-frequent ED users, 62.8% vs 45.4% (P <0.001). After controlling for potential confounders, food insecurity remained significantly associated with frequent ED use (adjusted odds ratio 1.48, 95% confidence interval, 1.20-1.83). This observed association was partially attenuated when anxiety/depression and overall health status were added to models.

CONCLUSION

The high observed prevalence of food insecurity suggests that efforts to improve care of ED patients should assess and address this need. Further research is needed to assess whether addressing food insecurity may play an important role in efforts to reduce frequent ED use for some patients.

Electronic cigarette use patterns and chronic health conditions among people experiencing homelessness in MN: a statewide survey

BACKGROUND

Adults experiencing homelessness have higher rates of disease and premature morbidity compared to the general population. Tobacco use is a primary contributing factor to these disparities; however, less is known regarding e-cigarette use patterns among adults experiencing homelessness and whether e-cigarettes are used in a manner that is narrowing or widening health disparities. This study aimed to describe the 1) prevalence and trends in e-cigarette use, 2) correlates of e-cigarettes use, and 3) rates of chronic health conditions by product use pattern in a community-based sample of adults experiencing homelessness.

METHODS

Adults experiencing homelessness in Minnesota were surveyed by self-report in 2015 (n = 3672) and 2018 (n = 4181) regarding e-cigarette and combustible cigarette use, potential correlates of e-cigarette use, and self-reported chronic health conditions (i.e., asthma, hypertension, diabetes, and cancer).

RESULTS

Frequency of use increased from 2015 to 2018 for combustible cigarettes (66.9% vs. 72.3%), e-cigarettes (11.4% vs. 14.5%), and dual combustible/e-cigarette use (10.2% vs. 12.9%). The strongest bivariate correlates of past 30-day e-cigarette use were younger age, non-binary gender identification, non-heterosexual orientation, identification as White/Caucasian, greater frequency of lifetime homelessness, substance use, lack of regular place for medical care, mental health diagnosis, criminal justice involvement, and combustible cigarette smoking. Dual users had significantly higher rates of asthma and cancer than both those using combustible cigarettes and those using neither combustible nor e-cigarettes.

CONCLUSIONS

During a time when cigarette smoking, e-cigarette use, and dual use were decreasing in the general population in Minnesota, rates increased in the homeless population. We observed that the rates of dual use were more than five times greater among homeless adults compared to the general population in 2018. Correlates of e-cigarette use were identified and should be used to identify subpopulations for intervention targeting. Mechanisms of the relationship between dual use and increased risks of health conditions deserve further study.

Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: a randomised controlled trial

AIMS

Many people who are homeless with severe mental illnesses are high users of healthcare services and social services, without reducing widen health inequalities in this vulnerable population. This study aimed to determine whether independent housing with mental health support teams with a recovery-oriented approach (Housing First (HF) program) for people who are homeless with severe mental disorders improves hospital and emergency department use.

METHODS

We did a randomised controlled trial in four French cities: Lille, Marseille, Paris and Toulouse. Participants were eligible if they were 18 years or older, being absolutely homeless or precariously housed, with a diagnosis of schizophrenia (SCZ) or bipolar disorder (BD) and were required to have a high level of needs (moderate-to-severe disability and past hospitalisations over the last 5 years or comorbid alcohol or substance use disorder). Participants were randomly assigned (1:1) to immediate access to independent housing and support from the Assertive Community Treatment team (social worker, nurse, doctor, psychiatrist and peer worker) (HF group) or treatment as usual (TAU group) namely pre-existing dedicated homeless-targeted programs and services. Participants and interviewers were unmasked to assignment. The primary outcomes were the number of emergency department (ED) visits, hospitalisation admissions and inpatient days at 24 months. Secondary outcomes were recovery (Recovery Assessment Scale), quality of life (SQOL and SF36), mental health symptoms, addiction issues, stably housed days and cost savings from a societal perspective. Intention-to-treat analysis was performed.

RESULTS

Eligible patients were randomly assigned to the HF group (n = 353) or TAU group (n = 350). No differences were found in the number of hospital admissions (relative risk (95% CI), 0.96 (0.76-1.21)) or ED visits (0.89 (0.66-1.21)). Significantly less inpatient days were found for HF v. TAU (0.62 (0.48-0.80)). The HF group exhibited higher housing stability (difference in slope, 116 (103-128)) and higher scores for sub-dimensions of S-QOL scale (psychological well-being and autonomy). No differences were found for physical composite score SF36, mental health symptoms and rates of alcohol or substance dependence. Mean difference in costs was €-217 per patient over 24 months in favour of the HF group. HF was associated with cost savings in healthcare costs (RR 0.62(0.48-0.78)) and residential costs (0.07 (0.05-0.11)).

CONCLUSION

An immediate access to independent housing and support from a mental health team resulted in decreased inpatient days, higher housing stability and cost savings in homeless persons with SCZ or BP disorders.

Heterogeneous Influences of Social Support on Physical and Mental Health: Evidence from China

Employing a national representative survey (the China Labor-force Dynamics Survey 2016, CLDS2016) data (N = 14246), this paper examines the heterogeneous influences of social support on individual physical and mental health in China. Social support is characterized by four dimensions: emotional support, tangible or instrumental support, interaction or exchange support, and community support. Physical health is measured by self-rated health and body mass index (BMI), while mental health is measured by depression, hopelessness, failure, fear, loneliness, and meaninglessness. The results indicate that different dimensions of social support have heterogeneous effects on individual physical and mental health. Specifically, the correlation between emotional support and individual physical health is not significant, but emotional support is significantly related to some mental health variables. Tangible or instrumental support is significantly related to individual self-rated physical health but not to BMI or mental health. Interaction or exchange support is significantly correlated with individual self-rated health and some mental health variables. In general, there are significant correlations between community support, and individual physical and mental health. The results also suggest that the influences of social support on physical and mental health of individuals at different ages (<60 years and ≥60 years) are heterogeneous. The results of this study provide direction for the dimension selection of social support to promote individual health.

Engagement in primary health care among marginalized people who use drugs in Ottawa, Canada

BACKGROUND

There may be less primary health care engagement among people who use drugs (PWUD) than among the general population, even though the former have greater comorbidity and more frequent use of emergency department care. We investigated factors associated with primary care engagement among PWUD.

METHODS

The Participatory Research in Ottawa: Understanding Drugs (PROUD) cohort study meaningfully engaged and trained people with lived experience to recruit and survey marginalized PWUD between March-December 2013. We linked this survey data to provincial-level administrative databases held at ICES. We categorized engagement in primary care over the 2 years prior to survey completion as: not engaged (< 3 outpatient visits to the same family physician) versus engaged in care (3+ visits to the same family physician). We used multivariable logistic regression to determine factors associated with engagement in primary care.

RESULTS

Characteristics of 663 participants included a median age of 43 years, 76% men, and 67% living in the two lowest income quintile neighborhoods. Despite high comorbidity and a median of 4 (interquartile range 0-10) primary care visits in the year prior to survey completion, only 372 (56.1%) were engaged in primary care. Engagement was most strongly associated with the following factors: receiving provincial benefits, including disability payments (adjusted odds ratio [AOR] 4.14 (95% confidence interval [CI] 2.30 to 7.43)) or income assistance (AOR 3.69 (95% CI 2.00 to 6.81)), having ever taken methadone (AOR 3.82 (95% CI 2.28 to 6.41)), mental health comorbidity (AOR 3.43 (95% CI 2.19 to 5.38)), and having stable housing (AOR 2.09 (95% CI 1.29 to 3.38)).

CONCLUSIONS

Despite high comorbidity, engagement in primary care among PWUD was low. Our findings suggest that social care (housing, disability, and income support) and mental health care are associated with improved primary care continuity; integration of these care systems with primary care and opioid substitution therapy may lessen the significant morbidity and acute care use among PWUD.

Exploring the Association of Community Integration in Mental Health among Formerly Homeless Individuals Living in Permanent Supportive Housing

Supportive housing has been widely used among persons experiencing chronic homelessness and/or mental health conditions. While it has been demonstrated to be effective in addressing homelessness among populations with complex needs, community integration remains a challenge. Community integration is the extent to which individuals live, participate, and socialize in their community and consists of three aspects: physical, social, and psychological. The study utilized data from the Transitions to Housing project that followed formerly homeless individuals (N = 383) throughout their first year of residence in permanent supportive housing (PSH). The study set out to examine which aspects of community integration are associated with mental health symptoms in this population. Five nested multivariate linear regression models were conducted and then compared. The model that accounted for demographics, substance use, neighborhood quality, and all three aspects of community integration simultaneously was the best fit and explained the most variance in mental health symptoms (24%). The complete model suggested higher levels of psychological integration were significantly associated with decreased mental health symptoms in this sample. This finding suggests fostering a sense of belonging among PSH residents could improve mental health outcomes. Implications for practice and future research are discussed.

Cardiovascular disease in homeless versus housed individuals: a systematic review of observational and interventional studies

OBJECTIVES

To identify: (i) risk of cardiovascular disease (CVD) in homeless versus housed individuals and (ii) interventions for CVD in homeless populations.

METHODS

We conducted a systematic literature review in EMBASE until December 2018 using a search strategy for observational and interventional studies without restriction regarding languages or countries. Meta-analyses were conducted, where appropriate and possible. Outcome measures were all-cause and CVD mortality, and morbidity.

RESULTS

Our search identified 17 articles (6 case-control, 11 cohort) concerning risk of CVD and none regarding specific interventions. Nine were included to perform a meta-analysis. The majority (13/17, 76.4%) were high quality and all were based in Europe or North America, including 765 459 individuals, of whom 32 721 were homeless. 12/17 studies were pre-2011. Homeless individuals were more likely to have CVD than non-homeless individuals (pooled OR 2.96; 95% CI 2.80 to 3.13; p<0.0001; heterogeneity p<0.0001; I²=99.1%) and had increased CVD mortality (age-standardised mortality ratio range: 2.6-6.4). Compared with non-homeless individuals, hypertension was more likely in homeless people (pooled OR 1.38-1.75, p=0.0070; heterogeneity p=0.935; I²=0.0%).

CONCLUSIONS

Homeless people have an approximately three times greater risk of CVD and an increased CVD mortality. However, there are no studies of specific pathways/interventions for CVD in this population. Future research should consider design and evaluation of tailored interventions or integrating CVD into existing interventions.

Leveraging health information exchange for clinical research: Extreme underreporting of hospital service utilization among patients with substance use disorders

BACKGROUND

Substance use disorders are associated with inefficient and fragmented use of healthcare services. The Chesapeake Regional Information System for Our Patients, Inc. (CRISP) is a Health Information Exchange (HIE) linking disparate systems of care in the mid-Atlantic region.

METHODS

This article describes applications of HIE for tracking hospital service utilization in substance use disorder clinical and services research, drawing upon data from one of the first studies approved to access the CRISP HIE. Participants were 200 medical/surgical inpatients with comorbid opioid, cocaine, and/or alcohol use disorder (45.5 % female; 56.5 % black; 77.5 % opioid use disorder; 42.0 % homeless). This study compared HIE-identified hospital service utilization with conventional methods of participant self-report during in-person research follow-ups (3-, 6-, and 12-months post-discharge) and electronic health record (EHR) review from the hospital system of the index admission.

RESULTS

This sample exhibited high levels of hospital utilization, which would have been underestimated using conventional methods. Relying exclusively on self-report in the 12-month observation period would have identified only 33.8 % of 429 inpatient hospitalizations and 9.0 % of 1,287 ED visits, due to both loss-to-follow-up and failure to report events. Even combining self-report with single-system EHR review identified only 66.2 % of inpatient hospitalizations and 59.8 % of ED visits.

CONCLUSIONS

CRISP HIE data were superior to conventional methods for ascertaining hospital service utilization in this sample of patients exhibiting high-volume and fragmented care. The use of HIE holds implications for improving rigor, safety, and efficiency in research studies.

Predictors of Overnight and Emergency Treatment among Homeless Adults

High usage of emergency treatment and hospitalization has been reported among homeless individuals. Hence, this study aimed to identify the sociodemographic predictors associated with overnight and emergency hospital treatment among a sample of homeless adults. Participants were recruited from a shelter in Dallas, Texas (N = 354; Mage = 43.7 ± 11.7) and were predominantly uninsured, low-income men from various racial groups. The outcome variables were: (a) stayed overnight for treatment in a hospital; and (b) treated in a hospital emergency room. In logistic regression models, sex emerged as the only predictor of overnight treatment in a hospital (OR = 2.68, 95% CI = 1.61-4.47), and treatment in an emergency room (OR = 2.21, 95% CI = 1.34-3.65), such that women were more likely than men to be treated overnight and use emergency care. Targeted interventions and policies are needed to address homeless women's primary care needs and reduce costlier treatment.

Mental health change in the transition to permanent supportive housing: The role of housing and social networks

AIMS

Permanent Supportive Housing (PSH) may improve homeless adults' mental health via housing stabilization and/or improved relational factors, however, the role of housing and social networks on PSH residents' mental health change is minimally understood.

METHODS

Interviews were conducted with a baseline sample of adults experiencing homelessness ( N = 421), across their initial year in PSH (3-months, 6-months, and 12-months). Generalized linear mixed models assessed changes in positive past-month psychiatric disability screenings (Modified-Colorado Symptom Index [MCSI]) and probable posttraumatic stress disorder (PC-PTSD) in controlled models, and between and within-subject effects of time-varying social network correlates on mental health changes.

RESULTS

Compared with baseline, positive MCSI screens continuously decreased over time (56%, 54%, and 50%) while PC-PTSD screens declined initially (40%) with marginal decreases at remaining follow-ups (39% and 38%). These differences remained significant in controlled models. Gaining a romantic partner was associated with a longitudinal increase in a positive MCSI screening. Between subjects, emotional health counselors and conflicting network members were associated with an increased likelihood in positive screenings, while doctors and case managers were protective.

CONCLUSION

Housing may facilitate positive changes in PSH residents' mental health, yet positive screenings remain high. Social network interventions that increase residents' positive interpersonal exchanges and prosocial relationships are warranted.

Cold Weather Conditions and Risk of Hypothermia Among People Experiencing Homelessness: Implications for Prevention Strategies

Hypothermia is a preventable condition that disproportionately affects individuals who experience homelessness, yet limited data exist to inform the response to cold weather. To fill this gap, we examined the association between meteorological conditions and the risk of hypothermia among homeless individuals. Hypothermic events were identified from emergency department charts and coroner's records between 2004 and 2015 in Toronto, Canada. A time-stratified case-crossover design with conditional logistic regression was used to assess the relationship between the meteorological conditions (minimum temperature and precipitation) and the risk of hypothermia. There were 97 hypothermic events identified: 79 injuries and 18 deaths. The odds of experiencing a hypothermic event increased 1.64-fold (95% CI: 1.30-2.07) with every 5 °C decrease in the minimum daily temperature and 1.10-fold (95% CI: 1.03-1.17) with every 1 mm increase in precipitation. The risk of hypothermia among individuals experiencing homelessness increased with declining temperature; however, most cases occurred during periods of low and moderate cold stress. 72% occurred when the minimum daily temperatures were warmer than -15 °C. These findings highlight the importance of providing a seasonal cold weather response to prevent hypothermia, complemented by an alert-based response on extremely cold days.

Self-reported health, healthcare service use and health-related needs: A comparison of older and younger homeless people

The number of older homeless people with a limited life expectancy is increasing. European studies on their health-related characteristics are lacking. This study compared self-reported health, healthcare service use and health-related needs of older and younger homeless people in the Netherlands. It is part of a cohort study that followed 513 homeless people in the four major Dutch cities for a period of 2.5 years, starting from the moment they registered at the social relief system in 2011. Using cross-sectional data from 378 participants who completed 2.5-year follow-up, we analysed differences in self-reported health, healthcare service use, and health-related needs between homeless adults aged ≥50 years (N = 97) and <50 years (N = 281) by means of logistic regression. Results show that statistically significantly more older than younger homeless people reported cardiovascular diseases (23.7% versus 10.3%), visual problems (26.8% versus 14.6%), limited social support from family (33.0% versus 19.6%) and friends or acquaintances (27.8% versus 14.6%), and medical hospital care use in the past year (50.5% versus 34.5%). Older homeless people statistically significantly less often reported cannabis (12.4% versus 45.2%) and excessive alcohol (16.5% versus 27.0%) use in the past month and dental (20.6% versus 46.6%) and mental (16.5% versus 25.6%) healthcare use in the past year. In both age groups, few people reported unmet health-related needs. In conclusion, compared to younger homeless adults, older homeless adults report fewer substance use problems, but a similar number of dental and mental problems, and more physical and social problems. The multiple health problems experienced by both age groups are not always expressed as needs or addressed by healthcare services. Older homeless people seem to use more medical hospital care and less non-acute, preventive healthcare than younger homeless people. This vulnerable group might benefit from shelter-based or community outreach programmes that proactively provide multidisciplinary healthcare services.

The Role of Mental Health and Substance Use in Homeless Adults' Tobacco Use and Cessation Attempts

Objective: Although tobacco use is prevalent among adults experiencing homelessness, research deficits exist regarding the mental health, substance use, and demographic correlates of tobacco use behaviors in this population. This study examined whether correlates of tobacco use among housed adults identified by the Center for Disease Control (CDC) were significant correlates of tobacco use and cessation attempts among a sample of homeless adults. Methods: Participants (N = 421) were adults experiencing homelessness entering permanent supportive housing programs in Los Angeles. Multivariate logistic regression determined associations of lifetime mental health diagnoses, recent substance use, demographic characteristics, and lifetime literal homelessness with daily tobacco use and cessation attempts. Results: Lifetime diagnoses of schizophrenia, posttraumatic stress disorder, depression, bipolar disorder, and illicit substance use were associated with increased odds of daily tobacco use. A lifetime diagnosis of depression was associated with an increased likelihood of a past 3-month tobacco cessation attempt, while illicit substance use was associated with a lower likelihood of a cessation attempt. Conclusions: Findings suggest that demographic and clinical characteristics associated with tobacco use differ among this sample of homeless adults and those identified by the CDC among housed adults. Mental health conditions and substance use appear to be the primary correlates of tobacco use among adults experiencing homelessness and may be critical in efforts aimed at improving cessation.

Residential moves and its association with substance use, healthcare needs, and acute care use among homeless and vulnerably housed persons in Canada

OBJECTIVES

To determine the relationship between housing instability, as measured by the number of residential moves, with problematic substance use, unmet healthcare needs, and acute care utilization.

METHODS

A cohort of homeless or vulnerably housed persons from Vancouver (n = 387), Toronto (n = 390), and Ottawa (n = 396) completed interviewer-administered surveys at baseline and annually for 4 years from 2009 to 2013. Generalized mixed effects logistic regression models were used to examine the association between the number of residential moves and each of the three outcome variables, adjusting for potential confounders.

RESULTS

The number of residential moves was significantly associated with higher acute care utilization [adjusted odds ratio (AOR) 1.25; 95% confidence interval (CI) CI: 1.17-1.33], unmet healthcare needs (AOR 1.14; 95% CI: 1.07-1.22), and problematic substance use (AOR 1.26; 95% CI: 1.16-1.36). Having chronic physical or mental conditions and recent incarceration were also found to be associated with the outcomes.

CONCLUSIONS

Housing instability increased the odds of all three poor health metrics, highlighting the importance of stable housing as a critical social determinant of health.

Cognition and Incarceration: Cognitive Impairment and Its Associated Outcomes in Older Adults in Jail

OBJECTIVES

To determine prevalence of, and outcomes associated with, a positive screen for cognitive impairment in older adults in jail.

DESIGN

Combined data from cross-sectional (n=185 participants) and longitudinal (n=125 participants) studies.

SETTING

Urban county jail.

PARTICIPANTS

Individuals in jail aged 55 and older (N = 310; mean age 59, range 55-80). Inclusion of individuals aged 55 and older is justified because the criminal justice system defines "geriatric prisoners" as those aged 55 and older.

MEASUREMENTS

Baseline and follow-up assessments of health, psychosocial factors, and cognitive status (using the Montreal Cognitive Assessment (MoCA)); 6-month acute care use and repeat arrest assessed in those followed longitudinally.

RESULTS

Participants were of low socioeconomic status (85% annual income < $15,000) and predominantly nonwhite (75%). Many (70%) scored less than 25 on the MoCA; those with a low MoCA score were more likely to be nonwhite (81% vs 62%, p<.001) and report fair or poor health (54% vs 41%, p=.04). Over 6 months, a MoCA score of less than 25 was associated with multiple emergency department visits (32% vs 13%, p=.02), hospitalization (35% vs 16%, p=.03), and repeat arrests (45% vs 21%, p=.01).

CONCLUSIONS

Cognitive impairment is prevalent in older adults in jail and is associated with adverse health and criminal justice outcomes. A geriatric approach to jail-based and transitional health care should be developed to assess and address cognitive impairment. Additional research is needed to better assess cognitive impairment and its consequences in this population. J Am Geriatr Soc 66:2065-2071, 2018.

Six-Month Emergency Department Use among Older Adults Following Jail Incarceration

Although the number of older adults who are arrested and subject to incarceration in jail is rising dramatically, little is known about their emergency department (ED) use or the factors associated with that use. This lack of knowledge impairs the ability to design evidence-based approaches to care that would meet the needs of this population. This 6-month longitudinal study aimed to determine the frequency of 6-month ED use among 101 adults aged 55 or older enrolled while in jail and to identify factors associated with that use. The primary outcome was self-reported emergency department use within 6 months from baseline. Additional measures included baseline socio-demographics, physical and mental health conditions, geriatric factors (e.g., recent falls, incontinence, functional impairment, concern about post-release safety), symptoms (pain and other symptoms), and behavioral and social health risk factors (e.g., substance use disorders, recent homelessness). Chi-square tests were used to identify baseline factors associated with ED use over 6 months. Participants (average age 60) reported high rates of multimorbidity (61%), functional impairment (57%), pain (52%), serious mental illness (44%), recent homelessness (54%), and/or substance use disorders (69%). At 6 months, 46% had visited the ED at least once; 21% visited multiple times. Factors associated with ED use included multimorbidity (p = 0.01), functional impairment (p = 0.02), hepatitis C infection (p = 0.01), a recent fall (p = 0.03), pain (p < 0.001), loneliness (p = 0.04), and safety concerns (p = 0.01). In this population of older adults in a county jail, geriatric conditions and distressing symptoms were common and associated with 6-month community ED use. Jail is an important setting to develop geriatric care paradigms aimed at addressing comorbid medical, functional, and behavioral health needs and symptomatology in an effort to improve care and decrease ED use in the growing population of criminal justice-involved older adults.

Older adults in jail: high rates and early onset of geriatric conditions

BACKGROUND

The number of older adults in the criminal justice system is rapidly increasing. While this population is thought to experience an early onset of aging-related health conditions ("accelerated aging"), studies have not directly compared rates of geriatric conditions in this population to those found in the general population. The aims of this study were to compare the burden of geriatric conditions among older adults in jail to rates found in an age-matched nationally representative sample of community dwelling older adults.

METHODS

This cross sectional study compared 238 older jail inmates age 55 or older to 6871 older adults in the national Health and Retirement Study (HRS). We used an age-adjusted analysis, accounting for the difference in age distributions between the two groups, to compare sociodemographics, chronic conditions, and geriatric conditions (functional, sensory, and mobility impairment). A second age-adjusted analysis compared those in jail to HRS participants in the lowest quintile of wealth.

RESULTS

All geriatric conditions were significantly more common in jail-based participants than in HRS participants overall and HRS participants in the lowest quintile of net worth. Jail-based participants (average age of 59) experienced four out of six geriatric conditions at rates similar to those found in HRS participants age 75 or older.

CONCLUSIONS

Geriatric conditions are prevalent in older adults in jail at significantly younger ages than non-incarcerated older adults suggesting that geriatric assessment and geriatric-focused care are needed for older adults cycling through jail in their 50s and that correctional clinicians require knowledge about geriatric assessment and care.

Concurrent Disorders and Health Care Utilization Among Homeless and Vulnerably Housed Persons in Canada

OBJECTIVE

Individuals who are homeless or vulnerably housed have a higher prevalence of concurrent disorders, defined as having a mental health diagnosis and problematic substance use, compared to the general housed population. The study objective was to investigate the effect of having concurrent disorders on health care utilization among homeless or vulnerably housed individuals, using longitudinal data from the Health and Housing in Transition Study.

METHODS

In 2009, 1190 homeless or vulnerably housed adults were recruited in Ottawa, Toronto, and Vancouver, Canada. Participants completed baseline interviews and four annual follow-up interviews, providing data on sociodemographics, housing history, mental health diagnoses, problematic drug use with the Drug Abuse Screening Test (DAST-10), problematic alcohol use with the Alcohol Use Disorders Identification Test (AUDIT), chronic health conditions, and utilization of the following health care services: emergency department (ED), hospitalization, and primary care. Concurrent disorders were defined as the participant having ever received a mental health diagnosis at baseline and having problematic substance use (i.e., DAST-10 ≥ 6 and/or AUDIT ≥ 20) at any time during the study period. Three generalized mixed effects logistic regression models were used to examine the independent association of having concurrent disorders and reporting ED use, hospitalization, or primary care visits in the past 12 months.

RESULTS

Among our sample of adults who were homeless or vulnerably housed, 22.6% (n = 261) reported having concurrent disorders at baseline. Individuals with concurrent disorders had significantly higher odds of ED use (adjusted odds ratio [AOR] = 1.71; 95% confidence interval [CI], 1.4-2.11), hospitalization (AOR = 1.45; 95% CI, 1.16-1.81), and primary care visits (AOR = 1.34; 95% CI, 1.05-1.71) in the past 12 months over the four-year follow-up period, after adjusting for potential confounders.

CONCLUSIONS

Concurrent disorders were associated with higher rates of health care utilization when compared to those without concurrent disorders among homeless and vulnerably housed individuals. Comprehensive programs that integrate mental health and addiction services with primary care as well as community-based outreach may better address the unmet health care needs of individuals living with concurrent disorders who are vulnerable to poor health outcomes.

Racial and Ethnic Differences in Trajectories of Hospitalization in US Men and Women With Heart Failure

BACKGROUND

Prior studies have documented racial and ethnic disparities in hospitalization among patients with heart failure (HF). However, racial/ethnic differences in trajectories of hospitalization following the diagnosis of HF have not been well characterized. This study examined racial/ethnic differences in individual-level trajectories of hospitalization in older adults with diagnosed HF.

METHODS AND RESULTS

Data from a nationally representative prospective cohort of US men and women aged 45 years and older were used to examine the number of hospitalizations reported every 24 months. Participants who were non-Hispanic white, non-Hispanic black, and Hispanic with a reported diagnosis of HF (n=3011) were followed from 1998 to 2014. Results showed a quadratic change in the number of reported hospitalizations following HF diagnosis, with an average of 2.36 (95% confidence interval [CI], 2.19-2.53; P<0.001) hospitalizations within 24 months that decreased by 0.35 (95% CI, -0.45 to -0.25; P<0.001) every 24 months and subsequently increased by 0.03 (95% CI, 0.02-0.05; P<0.001) thereafter. In men, there were no racial/ethnic differences in hospitalizations reported at the time of diagnosis; however, Hispanic men had significant declines in hospitalizations after diagnosis (Hispanic×time=-0.52; 95% CI, -0.99 to -0.05 [P=0.031]) followed by a sizeable increase in hospitalizations at later stages of disease (Hispanic×time2=0.06; 95% CI, 0.00-0.12 [P=0.047]). In women, hospitalizations were consistently high following their diagnosis and black women had significantly more hospitalizations throughout follow-up than white women (black=0.28; 95% CI, 0.00-0.55 [P=0.048]). Racial/ethnic disparities varied by geography and the differences remained significant after adjusting for multiple sociodemographic, psychosocial, behavioral, and physiological factors.

CONCLUSIONS

There were significant racial/ethnic differences in trajectories of hospitalization following the diagnosis of HF in US men and women. Racial/ethnic disparities varied by place of residence and the differences persisted after adjustment for multiple risk factors. The findings have important implications that may be crucial to planning the immediate and long-term delivery of care in patients with HF to reduce potentially preventable hospitalizations.

Unmet healthcare needs in homeless women with children in the Greater Paris area in France

BACKGROUND

Despite their poor health status, homeless women encounter many barriers to care. The objectives of our study were to estimate the prevalence of unmet healthcare needs in homeless women and to analyse associated relationships with the following factors: financial and spatial access to care, housing history, migration status, healthcare utilisation, victimization history, caring for children, social network and self-perceived health status.

METHODS

We used data from 656 homeless women interviewed during the ENFAMS representative survey of sheltered homeless families, conducted in the Paris region in 2013. Structural equation models (SEM) were used to estimate the impact of various factors on homeless women's unmet healthcare needs.

RESULTS

Among those interviewed, 25.1% (95%CI[21.3-29.0]) had at least one unmet healthcare need over the previous year. Most had given up on visiting general practitioners and medical specialists. No association with factors related to financial access or to health insurance status was found. However, food insecurity, poor spatial health access and poor self-perceived health were associated with unmet healthcare needs. Self-perceived health appeared to be affected by victimization and depression.

DISCUSSION

The lower prevalence of unmet healthcare needs in homeless women compared with women in stable housing situations suggests that homeless women have lower needs perceptions and/or lower expectations of the healthcare system. This hypothesis is supported by the results from SEM. Strategies to provide better access to care for this population should not only focus on financial interventions but also more broadly on spatial healthcare access, cultural norms, and perceptions of health. Reducing their unmet needs and improving their access to healthcare and prevention must include an improvement in their living, financial and housing conditions.

The Hotel Study-Clinical and Health Service Effectiveness in a Cohort of Homeless or Marginally Housed Persons

OBJECTIVE

The Hotel Study was initiated in Vancouver's Downtown East Side (DTES) neighborhood to investigate multimorbidity in homeless or marginally housed people. We evaluated the clinical effectiveness of existing, illness-specific treatment strategies and assessed the effectiveness of health care delivery for multimorbid illnesses.

METHOD

For context, we mapped the housing locations of patients presenting for 552,062 visits to the catchment hospital emergency department (2005-2013). Aggregate data on 22,519 apprehensions of mentally ill people were provided by the Vancouver Police Department (2009-2015). The primary strategy was a longitudinal cohort study of 375 people living in the DTES (2008-2015). We analysed mortality and evaluated the clinical and health service delivery effectiveness for infection with human immunodeficiency virus or hepatitis C virus, opioid dependence, and psychosis.

RESULTS

Mapping confirmed the association between poverty and greater number of emergency visits related to substance use and mental illness. The annual change in police apprehensions did not differ between the DTES and other policing districts. During 1581 person-years of cohort observation, the standardized mortality ratio was 8.43 (95% confidence interval, 6.19 to 11.50). Physician visits were common (84.3% of participants over 6 months). Clinical treatment effectiveness was highest for HIV/AIDS, intermediate for opioid dependence, and lowest for psychosis. Health service delivery mechanisms provided examples of poor access, poor treatment adherence, and little effect on multimorbid illnesses.

CONCLUSIONS

Clinical effectiveness was variable, and illness-specific service delivery appeared to have little effect on multimorbidity. New models of care may need to be implemented.

Risk behavior and access to HIV/AIDS prevention services in a community sample of homeless persons entering permanent supportive housing

Homeless persons suffer disproportionately high rates of HIV infection, and moving into permanent supportive housing (PSH) can provide a stable base from which to access needed prevention services. However, little is known about HIV risk or prevention behavior during this critical time of transition. The current study investigated STI and HIV risk and prevention behavior and recent use of prevention and treatment services (i.e., education, testing, medication) among homeless persons preparing to move into PSH. Data come from interviews with 421 homeless adults before they moved into PSH. Thirty-seven percent of the respondents were sexually active; of those, 75.7% reported unprotected sex. Nearly two-thirds (64%) reported past year HIV testing and 40% reported testing for another STI. Fewer than one-third (31%) of respondents reported receiving posttest counseling at their last HIV test. HIV seropositivity was self-reported by 10%. Among those persons who were HIV-positive, 57.1% reported less than 100% antiretroviral (ARV) adherence. Among HIV-negative respondents, less than 1% had been prescribed preexposure prophylaxis (PrEP). Less than half (46.4%) of the sample reported any HIV prevention education in the past year. This population of homeless adults about to move into PSH report high rates of HIV risk behavior, but low rates of HIV prevention education and very little PrEP utilization. Further, low rates of ARV adherence among HIV-positive respondents indicate significant risk for HIV transmission and acquisition. Entering PSH is a period of transition for homeless persons when integrated care is critically important to ensure positive health outcomes, but these data suggest that PrEP and other HIV prevention services are poorly accessed among this population. As such, multipronged services that integrate PrEP and other HIV prevention services are needed to prevent transmission and acquisition of HIV in this high-risk, vulnerable population and ensure the health and wellbeing of PSH residents.

Differences in Health and Social Support between Homeless Men and Women Entering Permanent Supportive Housing

BACKGROUND

Permanent supportive housing (PSH) is the leading intervention to end chronic homelessness. Little is known, however, about gender differences, including potential disparities in physical and mental health and social support, that might inform services available through PSH.

METHODS

This study included 421 homeless adults, at least 39 years old, English- or Spanish-speaking, who were moving into PSH through 26 different agencies in the Los Angeles area.

RESULTS

Compared with men entering PSH, homeless women (28% of the sample) were younger (p < .01), less likely to have achieved at least a high school education (p < .05), and had lower incomes (p < .01). Women had more chronic physical health conditions (p < .01), were more likely to have any chronic mental health condition (odds ratio, 2.5; p < .01), and had more chronic mental health conditions than men (p < .01). Women had more relatives in their social networks (Coefficient, 0.79, p < .01) and more relatives who provided support (coefficient, 0.38; p < .05), but also more relatives with whom they had conflict (coefficient, 0.19; p < .01). Additionally, women were less likely to have caseworkers (coefficient, -0.59; p < .001) or physical and mental health care providers in their networks (coefficient, -0.23 [p < .01]; coefficient, -0.37 [p < .001], respectively). However, after correcting for multiple testing, three outcomes lost significance: number of chronic physical health conditions, number of relatives who provided any support, and number of relatives with whom there was conflict.

CONCLUSIONS

There is evidence of gender differences in mental health and social support among homeless adults moving into PSH. PSH cannot be a one-size-fits-all approach. Supportive services within housing should be tailored based on gender and other individual needs.

Residential Stability Reduces Unmet Health Care Needs and Emergency Department Utilization among a Cohort of Homeless and Vulnerably Housed Persons in Canada

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.