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Rogers JH, Hawes SE, Wolf CR, Hughes JP, Englund JA, Starita LM, Chu HY. Care-seeking correlates of acute respiratory illness among sheltered adults experiencing homelessness in Seattle, WA, 2019: a community-based cross-sectional study. Front Public Health 2023; 11:1090148. [PMID: 37408748 PMCID: PMC10319010 DOI: 10.3389/fpubh.2023.1090148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 05/15/2023] [Indexed: 07/07/2023] Open
Abstract
Objective Multifarious barriers to accessing healthcare services among people experiencing homelessness (PEH) lead to delays in seeking care for acute infections, including those caused by respiratory viruses. PEH are at high risk of acute respiratory illness (ARI)-related complications, especially in shelter settings that may facilitate virus spread, yet data characterizing healthcare utilization for ARI episodes among sheltered PEH remained limited. Methods We conducted a cross-sectional study of viral respiratory infection among adult residents at two homeless shelters in Seattle, Washington between January and May 2019. We assessed factors associated with seeking medical care for ARI via self-report. We collected illness questionnaires and nasal swabs were tested for respiratory viruses by reverse transcription quantitative real-time PCR (RT-qPCR). Results We observed 825 encounters from 649 unique participants; 241 (29.2%) encounters reported seeking healthcare for their ARI episode. Seasonal influenza vaccine receipt (adjusted prevalence ratio [aPR] 1.39, 95% CI 1.02-1.88), having health insurance (aPR 2.77, 95% CI 1.27-6.02), chronic lung conditions (aPR 1.55, 95% CI 1.12-2.15), and experiencing influenza-like-illness symptoms (aPR 1.63, 95% CI 1.20 - 2.20) were associated with increased likelihood of seeking care. Smoking (aPR 0.65, 95% CI 0.45-0.92) was associated with decreased likelihood of seeking care. Discussion Findings suggest that care seeking for viral respiratory illness among PEH may be supported by prior engagement with primary healthcare services. Strategies to increase healthcare utilization may lead to earlier detection of respiratory viruses.
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Affiliation(s)
- Julia H. Rogers
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Stephen E. Hawes
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Caitlin R. Wolf
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, United States
| | - James P. Hughes
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Janet A. Englund
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Seattle Children’s Research Institute, University of Washington, Seattle, WA, United States
| | - Lea M. Starita
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
- Department of Genome Sciences, University of Washington, Seattle, WA, United States
| | - Helen Y. Chu
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, United States
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Abstract
Context In recent years, cities across the world have seen widespread growth in unsheltered homelessness, in which a person sleeps in a place not meant for human habitation such as cars, parks, sidewalks, and abandoned buildings. It is widely understood that people experiencing homelessness have poorer health outcomes than the general population. Less is known about the health of people who are unsheltered, yet they may be exposed to greater health risks than their sheltered counterparts. The purpose of this literature review is to evaluate and summarize the evidence on unsheltered homelessness and health. Evidence Acquisition A literature search was conducted using PubMed to identify publications on unsheltered homelessness and health. A total of 42 studies were included for review. Evidence Synthesis Unsheltered populations experience higher rates of chronic disease, serious mental illness, and substance abuse than sheltered populations. Unsheltered homelessness is strongly associated with chronic homelessness that exacerbates serious mental illness and substance use, which is often co-occurring. Despite having large unmet health needs, unsheltered populations have lower healthcare utilization and often lack health insurance. Conclusions Evaluating the impact of shelter status on health outcomes has important implications for the allocation of housing and health services. Longitudinal studies are needed to examine the relationship between the duration of sheltered and unsheltered homelessness and health outcomes and explore the mediating mechanisms that lead to poor health among unsheltered populations. Despite these limitations, our results also suggest an urgent need to address the unique and severe challenges facing unsheltered populations and the need for intervention approaches that are sensitive to these unique disease burdens.
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Affiliation(s)
- Jessica Richards
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Randall Kuhn
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
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Tsai J, Havlik J, Howell BA, Johnson E, Rosenthal D. Primary Care for Veterans Experiencing Homelessness: a Narrative Review of the Homeless Patient Aligned Care Team (HPACT) Model. J Gen Intern Med 2023; 38:765-783. [PMID: 36443628 PMCID: PMC9971390 DOI: 10.1007/s11606-022-07970-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/16/2022] [Indexed: 11/29/2022]
Abstract
In 2011, the U.S. Department of Veterans Health (VA) implemented a homeless-tailored primary care medical home model called the Homeless Patient Aligned Care Teams (HPACTs). The impact of HPACTs on health and healthcare outcomes of veterans experiencing homelessness has not been adequately synthesized. This narrative review summarized peer-reviewed studies published in databases Ovid MEDLINE, Ovid EMBASE, and APA PsycInfo from 1946 to February 2022. Only original research studies that reported outcomes of the HPACT model were included in the review. Of 575 studies that were initially identified and screened, 26 studies met inclusion criteria and were included in this review. Included studies were categorized into studies that described the following: (1) early HPACT pilot implementation; (2) HPACT's association with service quality and utilization; and (3) specialized HPACT programs. Together, studies in this review suggest HPACT is associated with reductions in emergency department utilization and improvements in primary care utilization, engagement, and positive patient experiences; however, the methodological rigor of the included studies was low, and thus, these findings should only be considered preliminary. There is a need for randomized controlled trials assessing the impact of the PACT model on key outcomes of interest, as well as to determine whether the model is a viable way to manage healthcare for persons experiencing homelessness outside of the VA system.
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Affiliation(s)
- Jack Tsai
- Office of Homeless Programs, U.S. Department of Veterans Affairs, Washington D.C., USA.
- University of Texas Health Science Center at Houston, School of Public Health, 1200 Pressler St, Houston, TX, 77030, USA.
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
| | - John Havlik
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin A Howell
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Erin Johnson
- Office of Homeless Programs, U.S. Department of Veterans Affairs, Washington D.C., USA
| | - David Rosenthal
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- 4Catalyzer Inc., CT, Guilford, USA
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Subedi K, Acharya B, Ghimire S. Factors Associated With Hospital Readmission Among Patients Experiencing Homelessness. Am J Prev Med 2022; 63:362-370. [PMID: 35367105 PMCID: PMC9398926 DOI: 10.1016/j.amepre.2022.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Homelessness is associated with increased acute care utilization and poor healthcare outcomes. This study aims to compare hospital readmission rates among patients experiencing homelessness and patients who are not homeless and assess the impact of different clinical and demographic characteristics on acute care utilization among patients experiencing homelessness. METHODS This was a retrospective study of patients encountered in 2018 and 2019 at ChristianaCare Health Systems. The analysis was done in August 2021. The prevalence of major chronic conditions among patients experiencing homelessness (n=1,329) and those not experiencing it (n=143,360) was evaluated. Patients experiencing homelessness were matched with nonhomeless patients using 1:1 propensity score matching. Time-to-event analysis approaches were used to analyze time-to-readmission and 30-day readmission rates. RESULTS The 30-day readmission rates were 42.8% among patients experiencing homelessness and 19.9% among matched patients not experiencing homelessness. The hazard of 30-day readmission among patients experiencing homelessness was 2.6 (95% CI=1.93, 3.53) times higher than that among the matched nonhomeless cohort. In patients experiencing homelessness, drug use disorder, major depressive disorder, chronic kidney disease, obesity, arthritis, HIV/AIDS, and epilepsy were associated with shortened time to readmission. Moreover, Black racial identity was associated with shortened time to readmission. CONCLUSIONS Patients experiencing homelessness had higher acute care utilization than those not experiencing homelessness. Black racial identity and several comorbidities were associated with increased acute care utilization among patients experiencing homelessness. Efforts to address upstream social determinants of health, destigmatization, and healthcare management accounting for the whole spectrum of clinical comorbidities might be important in promoting the health of people experiencing homelessness.
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Affiliation(s)
- Keshab Subedi
- Institute for Research on Equity and Community Health, ChristianaCare Health Systems, Wilmington, Delaware.
| | - Binod Acharya
- Urban Health Collaborative, Drexel University, Philadelphia, Pennsylvania
| | - Shweta Ghimire
- Center for Bioinformatics & Computational Biology, University of Delaware, Newark, Delaware
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Addorisio S, Kamel MM, Westenberg JN, Heyd A, Maragha T, Abusamak M, Wild TC, Jang KL, Krausz RM. Unmet service needs and barriers to care of individuals experiencing absolute homelessness in Edmonton, Canada: a cross-sectional survey. Soc Psychiatry Psychiatr Epidemiol 2022; 57:387-395. [PMID: 33891161 DOI: 10.1007/s00127-021-02080-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Individuals experiencing absolute homelessness have complex needs but limited access to services, contributing to high rates of morbidity and mortality. The aim of this article is to describe the perceived unmet service needs of individuals experiencing absolute homelessness, identify their barriers to care, and examine factors associated with specific unmet service needs. METHODS Using a cross-sectional survey, 150 individuals experiencing absolute homelessness were recruited from Edmonton's inner city and adjoining areas. The majority of participants were male (71.3%) and self-identified as Indigenous (74.0%). An adapted version of the Perceived Need for Care Questionnaire was used to measure past-year unmet needs for 4 types of services: hospital care, counselling, skills training, and harm reduction. Descriptive statistics and bivariate analyses were used; odds ratio and confidence intervals were calculated for statistically significant outcomes. RESULTS Overall, 89.3% of participants perceived a need for care for one or more general health and social services during the past year regarding their substance use and/or mental health problems; participants reported the highest levels of unmet need for counselling (42.9%) and skills training (39.2%). Though 73.3% of participants reported receiving any service, only 8.0% of participants reported having their perceived needs fully met. CONCLUSION In this study, individuals reported a high percentage of unmet needs. By interacting and engaging with these hard-to-reach individuals, healthcare systems will be more equipped to service them and address their barriers to care. Better patient-centred care, housing and supports for this neglected and underserved population is needed.
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Affiliation(s)
- Sindi Addorisio
- Department of Psychiatry, University of British Columbia, David Strangway Building, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada.,School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Mostafa Mamdouh Kamel
- Department of Psychiatry, University of British Columbia, David Strangway Building, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada.,Department of Psychiatry, Tanta University, Tanta, Egypt
| | - Jean Nicolas Westenberg
- Department of Psychiatry, University of British Columbia, David Strangway Building, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada.
| | - Amber Heyd
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Tala Maragha
- Department of Psychiatry, University of British Columbia, David Strangway Building, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | | | - T Cameron Wild
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Kerry L Jang
- Department of Psychiatry, University of British Columbia, David Strangway Building, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - R Michael Krausz
- Department of Psychiatry, University of British Columbia, David Strangway Building, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
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Crone B, Metraux S, Sbrocco T. Health Service Access Among Homeless Veterans: Health Access Challenges Faced by Homeless African American Veterans. J Racial Ethn Health Disparities 2021; 9:1828-1844. [PMID: 34402040 PMCID: PMC8367031 DOI: 10.1007/s40615-021-01119-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/28/2022]
Abstract
Veteran homelessness is a public health crisis, especially among the disproportionate number of minority veterans in the homeless veteran population. African American homeless veterans in particular face unique challenges accessing appropriate health care services to meet their medical needs. Their needs are often underrepresented in the literature on veteran homelessness. Drawing together over 80 studies and government reports from the last two decades, this review provides a timely synopsis of homeless veterans' health care access, with a particular focus on the barriers faced by African American veterans. This review employs Penchansky and Thomas' Access Model to frame health access barriers faced by homeless veterans, dialing in on what is known about the experience of African American veterans, within the five dimensions of access: Availability, Accessibility, Accommodation, Affordability, and Acceptability. Actionable guidance and targeted interventions to address health access barriers for all veterans are delineated with a focus on the need to gather further data for African American homeless veterans and to consider tailoring interventions for this important and underserved group.
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Affiliation(s)
- Baylee Crone
- Uniformed Service University of the Health Sciences, Bethesda, MD, USA.
| | | | - Tracy Sbrocco
- Uniformed Service University of the Health Sciences, Bethesda, MD, USA
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Lin LP, Wang LY, Wang TW, Chen YC, Lin JD. Factors Associated with Free Hospital Outpatient Service Use among Middle-Aged and Older Urban Homeless Adults in Taipei. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105330. [PMID: 34067784 PMCID: PMC8156856 DOI: 10.3390/ijerph18105330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/07/2021] [Accepted: 05/13/2021] [Indexed: 11/16/2022]
Abstract
Homeless individuals have many negative experiences with inequality regarding access to and the use of primary healthcare services, so policies to eliminate the disparities in and barriers to primary care access for these people are needed. The aim of this study was to explore the use and determinants of free hospital outpatient services for homeless people, in order to describe the provision of free healthcare policies for this vulnerable population in Taipei. One cross-sectional survey was conducted to recruit homeless people aged 45 years old and over in Taipei in 2018. A structured questionnaire was used, and face-to-face interviews were conducted by three social workers to collect the data. Finally, 129 participants were recruited in the study. The results show that 81.4% of the homeless people had made free hospital outpatient care visits (mean = 5.9 visits) in the last three months. An unadjusted logistic regression analysis showed that those homeless people who reported having usual healthcare providers, with higher depressive symptom scores, who used medication and had been hospitalized within one year, and had more chronic diseases, were significantly more likely to make free hospital outpatient visits. The adjusted logistic regression model indicates that homeless people with severe depressive symptoms (odds ratio (OR) = 9.32, 95% CI = 1.15–56.07), who had received medication (OR = 3.93; 95% CI = 1.06–14.52), and who had more than five chronic diseases (OR = 1.06, 95% CI = 1.35–13.27), were significantly more likely to make free hospital outpatient visits than their counterparts. The findings highlight that homeless people have higher healthcare requirements than the general population, and the healthcare system should pay more attention to factors associated with higher outpatient service use, such as homelessness, severe depressive symptoms, the receipt of medication and chronic diseases.
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Affiliation(s)
- Lan-Ping Lin
- Department of Senior Citizen Care and Welfare, Ching Kuo Institute of Management and Health, Keelung 203, Taiwan;
| | - Li-Yun Wang
- Department of Family Studies and Child Development, Shih Chien University, Taipei 104, Taiwan;
| | - Tai-Wen Wang
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
| | - Yun-Cheng Chen
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
| | - Jin-Ding Lin
- Department of Family Studies and Child Development, Shih Chien University, Taipei 104, Taiwan;
- School of Public Health, National Defense Medical Center, Taipei 114, Taiwan; (T.-W.W.); (Y.-C.C.)
- Institute of Long-Term Care, Mackay Medical College, New Taipei City 252, Taiwan
- Correspondence:
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Rogers JH, Link AC, McCulloch D, Brandstetter E, Newman KL, Jackson ML, Hughes JP, Englund JA, Boeckh M, Sugg N, Ilcisin M, Sibley TR, Fay K, Lee J, Han P, Truong M, Richardson M, Nickerson DA, Starita LM, Bedford T, Chu HY. Characteristics of COVID-19 in Homeless Shelters : A Community-Based Surveillance Study. Ann Intern Med 2021; 174:42-49. [PMID: 32931328 PMCID: PMC7517131 DOI: 10.7326/m20-3799] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Homeless shelters are a high-risk setting for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission because of crowding and shared hygiene facilities. OBJECTIVE To investigate SARS-CoV-2 case counts across several adult and family homeless shelters in a major metropolitan area. DESIGN Cross-sectional, community-based surveillance study. (ClinicalTrials.gov: NCT04141917). SETTING 14 homeless shelters in King County, Washington. PARTICIPANTS A total of 1434 study encounters were done in shelter residents and staff, regardless of symptoms. INTERVENTION 2 strategies were used for SARS-CoV-2 testing: routine surveillance and contact tracing ("surge testing") events. MEASUREMENTS The primary outcome measure was test positivity rate of SARS-CoV-2 infection at shelters, determined by dividing the number of positive cases by the total number of participant encounters, regardless of symptoms. Sociodemographic, clinical, and virologic variables were assessed as correlates of viral positivity. RESULTS Among 1434 encounters, 29 (2% [95% CI, 1.4% to 2.9%]) cases of SARS-CoV-2 infection were detected across 5 shelters. Most (n = 21 [72.4%]) were detected during surge testing events rather than routine surveillance, and most (n = 21 [72.4% {CI, 52.8% to 87.3%}]) were asymptomatic at the time of sample collection. Persons who were positive for SARS-CoV-2 were more frequently aged 60 years or older than those without SARS-CoV-2 (44.8% vs. 15.9%). Eighty-six percent of persons with positive test results slept in a communal space rather than in a private or shared room. LIMITATION Selection bias due to voluntary participation and a relatively small case count. CONCLUSION Active surveillance and surge testing were used to detect multiple cases of asymptomatic and symptomatic SARS-CoV-2 infection in homeless shelters. The findings suggest an unmet need for routine viral testing outside of clinical settings for homeless populations. PRIMARY FUNDING SOURCE Gates Ventures.
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Affiliation(s)
- Julia H Rogers
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Amy C Link
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Denise McCulloch
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Elisabeth Brandstetter
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Kira L Newman
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington (M.L.J.)
| | - James P Hughes
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Janet A Englund
- Seattle Children's Research Institute, University of Washington, Seattle, Washington (J.A.E.)
| | - Michael Boeckh
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Nancy Sugg
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Misja Ilcisin
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Thomas R Sibley
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Kairsten Fay
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Jover Lee
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Peter Han
- University of Washington and Brotman Baty Institute for Precision Medicine, Seattle, Washington (P.H., M.T., L.M.S.)
| | - Melissa Truong
- University of Washington and Brotman Baty Institute for Precision Medicine, Seattle, Washington (P.H., M.T., L.M.S.)
| | - Matthew Richardson
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Deborah A Nickerson
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
| | - Lea M Starita
- University of Washington and Brotman Baty Institute for Precision Medicine, Seattle, Washington (P.H., M.T., L.M.S.)
| | - Trevor Bedford
- Fred Hutchinson Cancer Research Center, Seattle, Washington (M.B., M.I., T.R.S., K.F., J.L., T.B.)
| | - Helen Y Chu
- University of Washington, Seattle, Washington (J.H.R., A.C.L., D.M., E.B., K.L.N., J.P.H., N.S., M.R., D.A.N., H.Y.C.)
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Schaffer KB, Wang J, Nasrallah FS, Bayat D, Dandan T, Ferkich A, Biffl WL. Disparities in triage and management of the homeless and the elderly trauma patient. Inj Epidemiol 2020; 7:39. [PMID: 32654664 PMCID: PMC7358191 DOI: 10.1186/s40621-020-00262-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Trauma systems are designed to provide specialized treatment for the most severely injured. As populations change, it is imperative for trauma centers to remain dynamic to provide the best care to all members of the community. Methods A retrospective review of all trauma patients treated at one Level II trauma center in Southern CA over 5 years. Three cohorts of patients were studied: geriatric (> 65 years), the homeless, and all other trauma patients. Triage, hospitalization, and outcomes were collected and analyzed. Results Of 8431 patients treated, 30% were geriatric, 3% homeless and 67% comprised all other patients. Trauma activation criteria was met for 84% of all other trauma patients, yet only 61% of homeless and geriatric patients combined. Injury mechanism for homeless included falls (38%), pedestrian/bicycle related (27%) and assaults (24%), often while under the influence of alcohol and drugs. Average length of hospital stay (LOS) was greater for homeless and geriatric patients and frequently attributed to discharge planning challenges. Both the homeless and geriatric groups demonstrated increased complications, comorbidities, and death rates. Conclusions Homeless trauma patients reflect similar challenges in care as with the elderly, requiring additional resources and more complex case management. It is prudent to identify and understand the issues surrounding patients transported to our trauma center requiring a higher level of care yet are under-triaged upon arrival to the Emergency Department. Although a monthly review is done for all under-triaged patients, and geriatric patients are acknowledged to be a cohort continually having delays, the homeless cohort continues to be under-triaged. The admitted homeless trauma patient has similar complex case management issues as the elderly related to pre-existing health issues and challenges with discharge planning, both which can add to longer lengths of hospital stay as compared to other trauma patients. Given the lack of social support that is endemic to both populations, these cohorts represent a unique challenge to trauma centers. Further research into specialized care is required to determine best practices to address disparities evident in the homeless and elderly, and to promote health equity in marginalized populations.
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Affiliation(s)
- Kathryn B Schaffer
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA.
| | - Jiayan Wang
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Fady S Nasrallah
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Dunya Bayat
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Tala Dandan
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Anthony Ferkich
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
| | - Walter L Biffl
- Trauma Service, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., LJ601, La Jolla, CA, 92037, USA
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Djuric CM, Vottero B. Primary care services tailored for adult and adolescent homeless persons: a scoping review protocol. JBI Evid Synth 2020; 18:2031-2037. [DOI: 10.11124/jbisrir-d-19-00331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Gadermann AM, Karim ME, Norena M, Emerson SD, Hubley AM, Russell LB, Nisenbaum R, Hwang SW, Aubry T, Palepu A. The Association of Residential Instability and Hospitalizations among Homeless and Vulnerably Housed Individuals: Results from a Prospective Cohort Study. J Urban Health 2020; 97:239-249. [PMID: 32078728 PMCID: PMC7101457 DOI: 10.1007/s11524-019-00406-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The present study examined the association of residential instability with hospitalizations among homeless and vulnerably housed individuals over a 4-year time period. Survey data were linked to administrative records on hospitalizations. Specifically, we used data from the Health and Housing in Transition study, a prospective cohort study that tracked the health and housing status of homeless and vulnerably housed individuals in Canada. Responses from Vancouver-based participants (n = 378) from baseline and 3 follow-ups were linked to their administrative health records on hospitalizations (Discharge Abstract Database - Hospital Separation Files; 2008-2012). A generalized estimating equations model was used to examine associations between the number of residential moves and any hospitalizations during each year (none versus ≥ 1 hospitalizations). Analyses included demographic and health variables. Survey data were collected via structured interviews. Hospitalizations were derived from provincial administrative health records. A higher number of residential moves were associated with hospitalization over the study period (adjusted odds ratio: 1.14; 95% confidence interval: 1.01, 1.28). Transgender, female gender, perceived social support, better self-reported mental health, and having ≥ 3 chronic health conditions also predicted having been hospitalized over the study period, whereas high school/higher education was negatively associated with hospitalizations. Our results indicate that residential instability is associated with increased risk of hospitalization, illustrating the importance of addressing housing as a social determinant of health.
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Affiliation(s)
- Anne M Gadermann
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada.
- Human Early Learning Partnership, School of Population and Public Health, University of British Columbia, Vancouver, Canada.
| | - Mohammad Ehsanul Karim
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Monica Norena
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
| | | | - Anita M Hubley
- Department of Educational and Counselling Psychology, and Special Education, University of British Columbia, Vancouver, Canada
| | - Lara B Russell
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Tim Aubry
- School of Psychology and Centre for Research on Educational and Community Services, University of Ottawa, Ottawa, Canada
| | - Anita Palepu
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada
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12
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Hinds AM, Bechtel B, Distasio J, Roos LL, Lix LM. Public housing and healthcare use: an investigation using linked administrative data. Canadian Journal of Public Health 2018; 110:127-138. [PMID: 30547290 DOI: 10.17269/s41997-018-0162-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 11/25/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study investigated whether a move to public housing affects people's use of healthcare services. METHOD Using administrative data from Manitoba, the number of hospitalizations, general practitioner (GP), specialist and emergency department (ED) visits, and prescription drugs dispensed in the years before and after the housing move-in date (2012/2013) were measured for a public housing and matched cohort. Generalized linear models with generalized estimating equations tested for differences between the cohorts in utilization trends. The data were modeled using Poisson (rate ratio, RR), negative binomial (incident rate ratio, IRR), and binomial (odds ratio, OR) distributions. RESULTS GP visits (IRR = 1.04, 95% CI 1.01-1.06) and prescriptions (IRR = 1.04, 95% CI 1.02-1.05) increased, while ED visits (RR = 0.90, 95% CI 0.82-1.00) and hospitalizations (OR = 0.95, 95% CI 0.93-0.96) decreased over time. The public housing cohort had a significantly higher rate of GP visits (IRR = 1.08, 95% CI 1.04-1.13), ED visits (RR = 1.18, 95% CI 1.01-1.37), and prescriptions (IRR = 1.09, 95% CI 1.05-1.13), and was more likely to be hospitalized (OR = 1.39, 95% CI 1.21-1.61) compared to the matched cohort. The rate of inpatient days significantly decreased for the public housing cohort, but did not change for the matched cohort. CONCLUSION Healthcare use changed similarly over time (except inpatient days) for the two cohorts. Public housing provides a basic need to a population who has a high burden of disease and who may not be able to obtain and maintain housing in the private market.
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Affiliation(s)
- Aynslie M Hinds
- Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, Manitoba, R3E 0W3, Canada.
| | - Brian Bechtel
- Cross Ministry and Community Partnership Initiatives, Community and Social Services, 3rd floor, 10044-108 Street, Edmonton, Alberta, T5J 5E6, Canada
| | - Jino Distasio
- Department of Geography, University of Winnipeg, 515 Portage Avenue, Winnipeg, Manitoba, R3B 2E9, Canada
| | - Leslie L Roos
- Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, Manitoba, R3E 0W3, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, Manitoba, R3E 0W3, Canada
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13
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Trivedi AN, Jiang L, Johnson EE, Lima JC, Flores M, O'Toole TP. Dual Use and Hospital Admissions among Veterans Enrolled in the VA's Homeless Patient Aligned Care Team. Health Serv Res 2018; 53 Suppl 3:5219-5237. [PMID: 30151996 DOI: 10.1111/1475-6773.13034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the association between reliance on VA outpatient care and hospital admissions among Medicare-eligible Veterans enrolled in the Homeless Patient Aligned Care Team (H-PACT). DATA SOURCES/STUDY SETTING Registry of H-PACT enrollees linked to VA and Medicare utilization data for 2013. STUDY DESIGN After assigning Veterans to two groups according to whether they received >90 percent of outpatient care in VA (higher reliance) or <90 percent of outpatient care in VA (lower reliance), generalized linear models with inverse probability of treatment weights were used to estimate the association of reliance with Medicare and VA-financed hospital admissions. PRINCIPAL FINDINGS Compared with higher reliance Veterans, lower reliance Veterans had an equivalent number of annual VA hospitalizations (0.63 vs. 0.50; p = .14) but substantially greater Medicare hospitalizations (0.85 vs. 0.08; p < .001). Among Veterans in the highest tertile of outpatient visits, we observed statistically similar rates of VA hospital use but over 10-fold greater rates of Medicare-financed hospitalizations (1.31 for lower reliance vs. 0.15 for high reliance; p < .001). CONCLUSIONS Among Veterans receiving integrated care in VA's H-PACT, dual use of Medicare and VA outpatient care is strongly associated with acute hospitalizations financed by Medicare. Linking VA and non-VA data may identify a subset of homeless Veterans with fragmented outpatient care who are at increased risk of poor outcomes.
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Affiliation(s)
- Amal N Trivedi
- Providence VA Medical Center, Providence, RI.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
| | - Lan Jiang
- Providence VA Medical Center, Providence, RI
| | | | - Julie C Lima
- Providence VA Medical Center, Providence, RI.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
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14
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Llerena K, Gabrielian S, Green MF. Clinical and cognitive correlates of unsheltered status in homeless persons with psychotic disorders. Schizophr Res 2018; 197:421-427. [PMID: 29486957 DOI: 10.1016/j.schres.2018.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/22/2017] [Accepted: 02/16/2018] [Indexed: 12/18/2022]
Abstract
Homeless persons with psychosis are particularly susceptible to unsheltered homelessness, which includes living on the streets, in cars, and other places not meant for human habitation. Homeless persons with psychosis have distinct barriers to accessing care and comprise a high-need and hard-to-serve homeless subpopulation. Therefore, this study sought to understand unsheltered homelessness in persons with psychosis and its relationship to cognitive impairment, clinical symptoms, and community functioning, examined both categorically and dimensionally. This study included 76 homeless participants with a history of a psychotic diagnosis who were enrolled in a supported housing program but had not yet received housing. This study used two different housing stability thresholds (literally homeless at any point vs. literally homeless >20% of days) for comparing homeless Veterans with psychosis living in sheltered versus unsheltered situations on cognition, clinical symptoms, and community integration. Dimensional analyses also examined the relationship between percentage of days spent in unsheltered locations and cognition, clinical symptoms, and community integration. Sheltered and unsheltered Veterans with psychosis did not differ on clinical symptoms or community integration, but there was an inconsistent group difference on cognition depending on the threshold used for determining housing stability. In the unsheltered group, cognitive deficits in overall cognition, visual learning, and social cognition were related to more days spent in unsheltered locations. Rehabilitation efforts targeting specific cognitive deficits may be useful to facilitate greater access to care and successful interventions in this population.
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Affiliation(s)
- Katiah Llerena
- Department of Veterans Affairs VISN 22 Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, United States; UCLA Semel Institute for Neuroscience & Human Behavior, David Geffen School of Medicine, United States; Department of Veterans Affairs VISN 21 Mental Illness Research, Education, and Clinical Center, San Francisco, CA, United States.
| | - Sonya Gabrielian
- Department of Veterans Affairs VISN 22 Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, United States; UCLA Semel Institute for Neuroscience & Human Behavior, David Geffen School of Medicine, United States
| | - Michael F Green
- Department of Veterans Affairs VISN 22 Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, United States; UCLA Semel Institute for Neuroscience & Human Behavior, David Geffen School of Medicine, United States
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15
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Van Voorhees EE, Resnik L, Johnson E, O'Toole T. Posttraumatic stress disorder and interpersonal process in homeless veterans participating in a peer mentoring intervention: Associations with program benefit. Psychol Serv 2018; 16:463-474. [PMID: 29369660 DOI: 10.1037/ser0000231] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Homelessness among veterans has dropped dramatically since the expansion of services for homeless veterans in 2009, and now engaging homeless veterans in existing programs will be important to continuing to make progress. While one promising approach for engaging homeless veterans in care is involving peer mentors in integrated services, posttraumatic stress disorder (PTSD) may diminish the effects of peer mentorship. This mixed methods study examined how interpersonal and emotional processes in homeless veterans with and without PTSD impacted their capacity to engage in relationships with peer mentors. Four focus groups of 5-8 homeless male veterans (N = 22) were drawn from a larger multisite randomized trial. Qualitative analysis identified five primary themes: disconnectedness; anger, hostility, or resentment; connecting with others; positive view of self; and feeling like an outsider. Thematic comparisons between participants with and without a self-reported PTSD diagnosis, and between those who did and did not benefit from the peer mentor program, were validated by using quantitative methods. Disconnectedness was associated with self-reported PTSD diagnosis and with lack of program benefit; feeling like an outsider was associated with program benefit. Results suggest that disruption to the capacity to develop and maintain social bonds in PTSD may interfere with the capacity to benefit from peer mentorship. Social rules and basic strategies for navigating interpersonal relationships may differ somewhat within the homeless community and outside of it; for veterans who feel disconnected from the domiciled community, a formerly homeless veteran peer may serve as a critical "bridge" between the two social worlds. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Elizabeth E Van Voorhees
- VISN 6 Mental Illness Research, Education and Clinical Center, Durham Veterans Affairs Medical Center
| | | | | | - Thomas O'Toole
- Department of Veterans Affairs National Center on Homelessness Among Veterans
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16
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Van Straaten B, Rodenburg G, Van der Laan J, Boersma SN, Wolf JRLM, Van de Mheen D. Changes in Social Exclusion Indicators and Psychological Distress Among Homeless People Over a 2.5-Year Period. SOCIAL INDICATORS RESEARCH 2018; 135:291-311. [PMID: 29398768 PMCID: PMC5785592 DOI: 10.1007/s11205-016-1486-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/07/2016] [Indexed: 05/13/2023]
Abstract
Although homelessness is inherently associated with social exclusion, homeless individuals are rarely included in conventional studies on social exclusion. Use of longitudinal survey data from a cohort study on homeless people in four major Dutch cities (n = 378) allowed to examine: changes in indicators of social exclusion among homeless people over a 2.5-year period after reporting to the social relief system, and associations between changes in indicators of social exclusion and changes in psychological distress. Multinomial logistic regression analysis was applied to investigate the associations between changes in indicators of social exclusion and changes in psychological distress. Improvements were found in various indicators of social exclusion, whereas financial debts showed no significant improvement. Changes in unmet care needs, health insurance, social support from family and relatedness to others were related to changes in psychological distress. This study demonstrated improvements in various indicators of social exclusion among homeless people over a period of 2.5 years, and sheds light on the concept of social exclusion in relation to homelessness.
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Affiliation(s)
- Barbara Van Straaten
- Erasmus Medical Centre, Rotterdam, The Netherlands
- IVO Addiction Research Institute, Heemraadssingel 194, 3021 DM Rotterdam, The Netherlands
| | - Gerda Rodenburg
- Erasmus Medical Centre, Rotterdam, The Netherlands
- IVO Addiction Research Institute, Heemraadssingel 194, 3021 DM Rotterdam, The Netherlands
| | - Jorien Van der Laan
- Impuls - Netherlands Center for Social Care Research, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Sandra N. Boersma
- Impuls - Netherlands Center for Social Care Research, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Judith R. L. M. Wolf
- Impuls - Netherlands Center for Social Care Research, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dike Van de Mheen
- Erasmus Medical Centre, Rotterdam, The Netherlands
- IVO Addiction Research Institute, Heemraadssingel 194, 3021 DM Rotterdam, The Netherlands
- Department of Health Promotion, Maastricht University, Maastricht, The Netherlands
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17
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Montgomery AE, Szymkowiak D, Culhane D. Gender Differences in Factors Associated with Unsheltered Status and Increased Risk of Premature Mortality among Individuals Experiencing Homelessness. Womens Health Issues 2017; 27:256-263. [PMID: 28456453 DOI: 10.1016/j.whi.2017.03.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 03/24/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Among individuals experiencing homelessness, unsheltered status is associated with poor health and access to care and an increased risk for premature death. Insufficient research has explored gender differences in these outcomes; the objective of this study was to address this gap in the research. METHODS This study used survey data collected during the 100,000 Homes Campaign. Chi-square tests identified differences in the characteristics of women, men, and transgender individuals. Generalized linear mixed models fit with demographic, homelessness, mental/behavioral health, institutional, and income characteristics were run separately for women and men to assess correlates of unsheltered status and increased risk of premature mortality. RESULTS Men reported more frequently experiencing unsheltered homelessness while women and transgender participants more frequently met the criteria for risk of premature mortality. Women reported less frequently than men a history of or current substance use, but it significantly increased their likelihood of unsheltered homelessness; reports of mental health issues were rarer among men but significantly increased their odds of unsheltered homelessness. The experience of a violent attack while homeless was most strongly related to increased risk of premature mortality for both women and men. CONCLUSIONS Interventions to reduce unsheltered homelessness among men should be particularly sensitive to mental health issues while for women there may need to be increased attention to substance use. A focus on experience of trauma and the provision of trauma-informed care is essential to address the increased risk of premature mortality among both men and women experiencing homelessness.
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Affiliation(s)
- Ann Elizabeth Montgomery
- Department of Health Behavior, University of Alabama at Birmingham, School of Public Health, Birmingham, Alabama; U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, Philadelphia, Pennsylvania.
| | - Dorota Szymkowiak
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, Philadelphia, Pennsylvania
| | - Dennis Culhane
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, Philadelphia, Pennsylvania; University of Pennsylvania, School of Social Policy & Practice, Philadelphia, Pennsylvania
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18
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Van Straaten B, Van der Laan J, Rodenburg G, Boersma SN, Wolf JRLM, Van de Mheen D. Dutch homeless people 2.5 years after shelter admission: what are predictors of housing stability and housing satisfaction? HEALTH & SOCIAL CARE IN THE COMMUNITY 2017; 25:710-722. [PMID: 27189388 DOI: 10.1111/hsc.12361] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/13/2016] [Indexed: 06/05/2023]
Abstract
Housing stability is an important focus in research on homeless people. Although definitions of stable housing differ across studies, the perspective of homeless people themselves is generally not included. Therefore, this study explored the inclusion of satisfaction with the participant's current housing status as part of the definition of housing stability and also examined predictors of housing stability with and without the inclusion of homeless person's perspective. Of the initial cohort consisting of 513 homeless participants who were included at baseline in 2011, 324 (63.2%) were also interviewed at 2.5-year follow-up. To determine independent predictors of housing stability, we fitted multivariate logistic regression models using stepwise backward regression. At 2.5-year follow-up, 222 participants (68.5%) were stably housed and 163 participants (51.1%) were stably housed and satisfied with their housing status. Having been arrested (OR = 0.36, 95% CI: 0.20-0.63), a high level of somatisation (physical manifestations of psychological distress) (OR = 0.52, 95% CI: 0.30-0.91) and having unmet care needs (OR = 0.77, 95% CI: 0.60-0.99) were negative predictors of housing stability. Having been arrested (OR = 0.43, 95% CI: 0.25-0.75), high debts (OR = 0.45, 95% CI: 0.24-0.84) and a high level of somatisation (OR = 0.49, 95% CI: 0.28-0.84) were negative predictors of stable housing when satisfaction with the housing status was included. Because inclusion of a subjective component revealed a subgroup of stably housed but not satisfied participants and changed the significant predictors, this seems a relevant addition to the customary definition of housing stability. Participants with characteristics negatively associated with housing stability should receive more extensive and individually tailored support services to facilitate achievement of housing stability.
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Affiliation(s)
- Barbara Van Straaten
- Erasmus Medical Centre, Rotterdam, the Netherlands
- IVO Addiction Research Institute, Rotterdam, the Netherlands
| | - Jorien Van der Laan
- Department of Primary and Community Care, Impuls - Netherlands Center for Social Care Research, Radboud University Medical Center, Nijmegen, the Netherlands
- Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
| | - Gerda Rodenburg
- Erasmus Medical Centre, Rotterdam, the Netherlands
- IVO Addiction Research Institute, Rotterdam, the Netherlands
| | - Sandra N Boersma
- Department of Primary and Community Care, Impuls - Netherlands Center for Social Care Research, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Judith R L M Wolf
- Department of Primary and Community Care, Impuls - Netherlands Center for Social Care Research, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dike Van de Mheen
- Erasmus Medical Centre, Rotterdam, the Netherlands
- IVO Addiction Research Institute, Rotterdam, the Netherlands
- Department of Health Promotion, Maastricht University, Maastricht, the Netherlands
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19
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Resnik L, Ekerholm S, Johnson EE, Ellison ML, O'Toole TP. Which Homeless Veterans Benefit From a Peer Mentor and How? J Clin Psychol 2016; 73:1027-1047. [DOI: 10.1002/jclp.22407] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 08/26/2016] [Accepted: 09/13/2016] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Marsha L. Ellison
- Edith Nourse Rogers Memorial Veterans Hospital (Bedford VA Medical Center)
- University of Massachusetts Medical School
| | - Thomas P. O'Toole
- Providence VA Medical Center
- Brown University
- VA National Center on Homelessness Among Veterans
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20
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Montgomery AE, Szymkowiak D, Marcus J, Howard P, Culhane DP. Homelessness, Unsheltered Status, and Risk Factors for Mortality: Findings From the 100 000 Homes Campaign. Public Health Rep 2016; 131:765-772. [PMID: 28123222 DOI: 10.1177/0033354916667501] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES People who live in unsheltered situations, such as the streets, often have poorer health, less access to health care, and an increased risk of premature mortality as compared with their sheltered counterparts. The objectives of this study were to (1) compare the characteristics of people experiencing homelessness who were sleeping primarily in unsheltered situations with those who were accessing homeless shelters and other sheltered situations, (2) identify correlates of unsheltered status, and (3) assess the relationship between unsheltered status and increased risk of mortality. METHODS Using primary data collected as part of the 100 000 Homes Campaign-a national effort to help communities find homes for vulnerable and chronically homeless Americans-we estimated 2 generalized linear mixed models to understand the correlates of unsheltered status and risk factors for mortality. Independent variables included demographic characteristics; history of homelessness, incarceration, foster care, and treatment for mental illness or substance use; sources of income; and past and present medical conditions. The study sample comprised 25489 people experiencing homelessness who responded to an assessment of their housing and health as part of the 100 000 Homes Campaign from 2008 to 2014. RESULTS In the full model, the following characteristics were associated with unsheltered status: being a veteran (adjusted odds ratio [aOR] = 1.10); having <high school education (aOR = 1.09); accessing informal income (aOR = 2.37); and having a history of foster care (aOR = 1.14), chronic homelessness (aOR = 1.36 for 1-5 years, aOR = 1.95 for >5 years), incarceration (aOR = 1.32), or substance use (aOR = 1.10 for ever abusing drugs or alcohol, aOR = 1.13 for ever using intravenous drugs, aOR = 1.98 for drinking alcohol every day for past month). Being unsheltered (aOR = 1.12), being female (aOR = 1.22), or receiving entitlements (aOR = 1.63) increased respondents' odds of having risk factors for mortality. CONCLUSIONS These findings highlight the need to assertively reach out to vulnerable populations and provide interventions to assist them during their transition-for example, as they exit incarceration or age out of foster care. Such a response could prevent unsheltered homelessness and thereby address increased mortality risk. Connecting people with resources to increase their access to employment, benefits, and other sources of income is especially important.
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Affiliation(s)
- Ann Elizabeth Montgomery
- Health Services Research, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA; National Center on Homelessness Among Veterans, Philadelphia, PA, USA; School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dorota Szymkowiak
- National Center on Homelessness Among Veterans, Philadelphia, PA, USA
| | - Jessica Marcus
- Data and Performance Management, Community Solutions, New York, NY, USA
| | - Paul Howard
- Data and Performance Management, Community Solutions, New York, NY, USA
| | - Dennis P Culhane
- National Center on Homelessness Among Veterans, Philadelphia, PA, USA; School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
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21
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van den Berk-Clark C, McGuire J. Trust in health care providers: factors predicting trust among homeless veterans over time. J Health Care Poor Underserved 2016; 25:1278-90. [PMID: 25130239 DOI: 10.1353/hpu.2014.0115] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We examined whether a combination of predisposing, enabling, need, and primary care experience variables would predict trust in medical health care providers for homeless veterans over 18 months. Linear mixed model analysis indicated that, among these variables, race, social support, service-connected disability status, and satisfaction and continuity with providers predicted trust in provider over time. Trust in providers improved during the initial stages of the relationship between patient and provider and then declined to slightly below baseline levels over time. Further research is needed to determine generalizability and effects of provider trust on patient health care status over longer periods of time.
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O'Toole TP, Johnson EE, Aiello R, Kane V, Pape L. Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration's "Homeless Patient Aligned Care Team" Program. Prev Chronic Dis 2016; 13:E44. [PMID: 27032987 PMCID: PMC4825747 DOI: 10.5888/pcd13.150567] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a "homeless medical home" initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. METHODS We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services. RESULTS More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies. CONCLUSION Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.
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Affiliation(s)
- Thomas P O'Toole
- National Center on Homelessness Among Veterans, Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02909.
| | - Erin E Johnson
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island
| | - Riccardo Aiello
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island
| | - Vincent Kane
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island and Lebanon VA Medical Center, Lebanon, Pennsylvania
| | - Lisa Pape
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island
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Byrne T, Montgomery AE, Fargo JD. Unsheltered Homelessness Among Veterans: Correlates and Profiles. Community Ment Health J 2016; 52:148-57. [PMID: 26289119 DOI: 10.1007/s10597-015-9922-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/10/2015] [Indexed: 10/23/2022]
Abstract
We identified correlates of unsheltered status among Veterans experiencing homelessness and described distinct subgroups within the unsheltered homeless Veteran population using data from a screening instrument for homelessness that is administered to all Veterans accessing outpatient care at a Veterans Health Administration (VHA) facility. Correlates of unsheltered homelessness included male gender, white race, older age, lower levels of VHA eligibility, substance use disorders, frequent use of VHA inpatient and infrequent use of VHA outpatient services, and residing in the West. We identified six distinct subgroups of unsheltered Veterans; the tri-morbid frequent users represented the highest need group, but the largest group was comprised of Veterans who made highly infrequent use of VHA healthcare services. Differences between sheltered and unsheltered Veterans and heterogeneity within the unsheltered Veteran population should be considered in targeting housing and other interventions.
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Affiliation(s)
- Thomas Byrne
- Boston University School of Social Work, 264 Bay State Rd., Boston, MA, 02215, USA. .,U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, 4100 Chester Ave, Suite 201, Philadelphia, PA, 19104, USA.
| | - Ann Elizabeth Montgomery
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, 4100 Chester Ave, Suite 201, Philadelphia, PA, 19104, USA.
| | - Jamison D Fargo
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, 4100 Chester Ave, Suite 201, Philadelphia, PA, 19104, USA. .,Department of Psychology, Utah State University, 2810 Old Main Hill, Logan, UT, 84322, USA.
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Yim LCL, Leung HCM, Chan WC, Lam MHB, Lim VWM. Prevalence of Mental Illness among Homeless People in Hong Kong. PLoS One 2015; 10:e0140940. [PMID: 26484889 PMCID: PMC4618481 DOI: 10.1371/journal.pone.0140940] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/30/2015] [Indexed: 11/22/2022] Open
Abstract
Metholodogy This study examined the prevalence and correlates of mental illness in homeless people in Hong Kong and explored the barriers preventing their access to health care. Ninety-seven Cantonese-speaking Chinese who were homeless during the study period were selected at random from the records of the three organisations serving the homeless population. The response rate was 69%. Seventeen subjects could not give valid consent due to their poor mental state, so their responses were excluded from the data analysis. A psychiatrist administered the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I) and the Mini -Mental State Examination. Consensus diagnoses for subjects who could not complete the SCID-I were established by three independent psychiatrists. Findings The point prevalence of mental illness was 56%. Seventy-one percent of the subjects had a lifetime history of mental illness, 30% had a mood disorder, 25% had an alcohol use disorder, 25% had a substance use disorder, 10% had a psychotic disorder, 10% had an anxiety disorder and 6% had dementia. Forty-one percent of the subjects with mental illness had undergone a previous psychiatric assessment. Only 13% of the subjects with mental illness were receiving psychiatric care at the time of interview. The prevalence of psychotic disorders, dementia and the rate of under treatment are hugely underestimated, as a significant proportion (18%) of the subjects initially selected were too ill to give consent to join the study. Conclusion The low treatment rate and the presence of this severely ill and unreached group of homeless people reflect the fact that the current mode of service delivery is failing to support the most severely ill homeless individuals.
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Affiliation(s)
- Larina Chi-Lap Yim
- Department of Psychiatry, Prince of Wales Hospital, Shatin, Hong Kong
- * E-mail:
| | | | - Wai Chi Chan
- Department of Psychiatry, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Marco Ho-Bun Lam
- Department of Psychiatry, Prince of Wales Hospital, Shatin, Hong Kong
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Dunne EM, Burrell LE, Diggins AD, Whitehead NE, Latimer WW. Increased risk for substance use and health-related problems among homeless veterans. Am J Addict 2015; 24:676-80. [PMID: 26359444 DOI: 10.1111/ajad.12289] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 07/31/2015] [Accepted: 08/28/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The first aim of this study was to compare self-reported causes of homelessness between veterans and nonveterans. A second aim examined whether homeless male veterans were more likely than homeless male nonveterans to experience current problems with addictions, mental health, and physical health. Additionally, a third aim was to compare frequency of emergency room visits and treatment needs between the two groups. METHODS Secondary data analyses compared male homeless veterans and nonveterans (N = 353) enrolled in the Alachua County Point in Time study in central Florida. Participants completed a questionnaire on demographics and health variables. Additional questions included recent emergency room visits and medical or other needs not being met. RESULTS Veterans reported higher rates of substance use and mental health problems as a primary cause of homelessness when compared to nonveterans. Homeless veterans were more likely than nonveterans to report current problems with addictions (OR = 6.29, 95% CI: 3.43-11.53, p < .001), mental health problems (OR = 4.12, 95% CI: 2.28-7.42, p < .001), and physical problems (OR = 1.83, 95% CI: 1.08-3.67, p < .01). Finally, over half of homeless veterans (53.1%) reported an ER visit in the past year compared to only 40.9% of nonveterans (OR = 1.73, 95% CI: 1.07-2.80, p < .05). CONCLUSION AND SCIENTIFIC SIGNIFICANCE Veterans may be more likely to become homeless due to addiction and mental health and over half of homeless veterans are presenting to hospital emergency rooms. Given the greater utilization among homeless veterans, emergency rooms may serve as a prime opportunity to provide brief treatment and referrals for needed services.
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Affiliation(s)
- Eugene M Dunne
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - Larry E Burrell
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - Allyson D Diggins
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - Nicole Ennis Whitehead
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
| | - William W Latimer
- Department of Health Sciences, Lehman College, City University of New York, Bronx, New York
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Leung AK, Nayyar D, Sachdeva M, Song J, Hwang SW. Chronically homeless persons' participation in an advance directive intervention: A cohort study. Palliat Med 2015; 29:746-55. [PMID: 25762580 DOI: 10.1177/0269216315575679] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronically homeless individuals have high rates of hospitalization and death, and they may benefit from the completion of advance directives. AIM To determine the rate of advance directive completion using a counselor-guided intervention, identify characteristics associated with advance directive completion, and describe end-of-life care preferences in a group of chronically homeless individuals. DESIGN Participants completed a survey and were offered an opportunity to complete an advance directive with a trained counselor. PARTICIPANTS A total of 205 residents of a shelter in Canada for homeless men (89.1% of those approached) participated from April to June 2013. RESULTS Duration of homelessness was ⩾12 months in 72.8% of participants, and 103 participants (50.2%) chose to complete an advance directive. Socio-demographic characteristics, health status, and health care use were not associated with completion of an advance directive. Participants were more likely to complete an advance directive if they reported thinking about death on a daily basis, believed that thinking about their friends and family was important, or reported knowing their wishes for end-of-life care but not having told anyone about these wishes. Among individuals who completed an advance directive, 61.2% named a substitute decision maker, and 94.1% expressed a preference to receive cardiopulmonary resuscitation in the event of a cardiorespiratory arrest if there was a chance of returning to their current state of health. CONCLUSION A counselor-guided intervention can achieve a high rate of advance directive completion among chronically homeless persons. Most participants expressed a preference to receive cardiopulmonary resuscitation in the event of a cardiorespiratory arrest.
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Affiliation(s)
- Alexander K Leung
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Dhruv Nayyar
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Manisha Sachdeva
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - John Song
- Center for Bioethics, University of Minnesota, Minneapolis, MN, USA
| | - Stephen W Hwang
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Canada
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Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial. J Gen Intern Med 2015; 30:886-98. [PMID: 25673574 PMCID: PMC4471019 DOI: 10.1007/s11606-015-3193-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 12/01/2014] [Accepted: 12/16/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Homeless individuals often have significant unmet health care needs that are critical to helping them leave homelessness. However, engaging them in primary and mental health care services is often elusive and difficult to achieve. OBJECTIVE We aimed to increase health-seeking behavior and receipt of health care among homeless Veterans. DESIGN This was a multi-center, prospective, community-based, two-by-two randomized controlled trial of homeless Veterans. PARTICIPANTS Homeless Veterans not receiving primary care participated in the study. INTERVENTIONS An outreach intervention that included a personal health assessment and brief intervention (PHA/BI), and/or a clinic orientation (CO) was implemented. MAIN MEASURE We measured receipt of primary care within 4 weeks of study enrollment. KEY RESULTS Overall, 185 homeless Veterans were enrolled: the average age was 48.6 years (SD 10.8), 94.6% were male, 43.0% were from a minority population, 12.0% were unsheltered, 25.5% were staying in a dusk-to-dawn emergency shelter, 26.1% were in transitional housing, while 27.7% were in an unstable, doubled-up arrangement. At one month, 77.3% of the PHA/BI plus CO group accessed primary care and by 6 months, 88.7% had been seen in primary care. This was followed by the CO-only group, 50.0% of whom accessed care in the first 4 weeks, the PHI/BI-only arm at 41.0% and the Usual Care arm at 30.6%. Chi-squared tests by group were significant (p < 0.001) at both 4 weeks and 6 months. There was no difference in attitudes about care at baseline and 6 months or in use patterns once enrolled in care. CONCLUSIONS Our findings suggest that treatment-resistant/avoidant homeless Veterans can be effectively engaged in primary and other clinical care services through a relatively low intensity, targeted and tailored outreach effort.
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Hwang SW, Chambers C, Katic M. Accuracy of Self-Reported Health Care Use in a Population-Based Sample of Homeless Adults. Health Serv Res 2015; 51:282-301. [PMID: 26119335 DOI: 10.1111/1475-6773.12329] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To assess the accuracy of self-reported ambulatory care visits, emergency department (ED) encounters, and overnight hospitalizations in a population-based sample of homeless adults. DATA SOURCE Self-report survey data and administrative health care utilization databases. STUDY DESIGN Self-reported health care use in the past 12 months was compared to administrative encounter records among 1,163 homeless adults recruited in 2004-2005 from shelters and meal programs in Toronto, Ontario. DATA EXTRACTION METHODS Self-reported health care use was assessed using a structured face-to-face survey. Each participant was linked to administrative databases using a unique personal health number or their first name, last name, sex, and date of birth. PRINCIPAL FINDINGS The sensitivity of self-report for ambulatory care visits, ED encounters, and overnight hospitalizations was 89, 80, and 73 percent, respectively; specificity was 37, 83, and 91 percent. The mean difference between self-reported and documented number of encounters in the past 12 months was +1.6 for ambulatory care visits (95 percent CI = 0.4, 2.8), -0.6 for ED encounters (95 percent CI = -0.8, -0.4), and 0.0 for hospitalizations (95 percent CI = 0.0, 0.1). CONCLUSIONS Adults experiencing homelessness are quite accurate reporters of their use of health care, especially for ED encounters and hospitalizations.
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Affiliation(s)
- Stephen W Hwang
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.,Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Catharine Chambers
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Marko Katic
- Department of Research Design and Biostatistics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Bernstein RS, Meurer LN, Plumb EJ, Jackson JL. Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis. Am J Public Health 2015; 105:e46-60. [PMID: 25521899 DOI: 10.2105/ajph.2014.302330] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
We estimated hypertension and diabetes prevalence among US homeless adults compared with the general population, and investigated prevalence trends. We systematically searched 5 databases for published studies (1980-2014) that included hypertension or diabetes prevalence for US homeless adults, pooled disease prevalence, and explored heterogeneity sources. We used the National Health Interview Survey for comparison. We included data from 97366 homeless adults. The pooled prevalence of self-reported hypertension was 27.0% (95% confidence interval=23.8%, 29.9%; n=43 studies) and of diabetes was 8.0% (95% confidence interval=6.8%, 9.2%; n=39 studies). We found no difference in hypertension or diabetes prevalence between the homeless and general population. Additional health care and housing resources are needed to meet the significant, growing burden of chronic disease in the homeless population.
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Affiliation(s)
- Rebecca S Bernstein
- Rebecca S. Bernstein and Linda N. Meurer are with Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee. Ellen J. Plumb is with Department of Family and Community Medicine, Thomas Jefferson University Hospital, Philadelphia, PA. Jeffrey L. Jackson is with Medical College of Wisconsin and Department of Internal Medicine, Division of General Internal Medicine, Zablocki VA Medical Center, Milwaukee
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Bowe A, Rosenheck R. PTSD and substance use disorder among veterans: characteristics, service utilization and pharmacotherapy. J Dual Diagn 2015; 11:22-32. [PMID: 25513763 DOI: 10.1080/15504263.2014.989653] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE While there has been considerable concern about veterans with dually diagnosed posttraumatic stress disorder (PTSD) and comorbid substance use disorders, a national study of clinical characteristics, service utilization, and psychotropic medication use of such veterans in Veterans Affairs (VA) has yet to be conducted. We hypothesized that veterans having both PTSD and substance use disorder would have lower socioeconomic status, greater medical and psychiatric comorbidity, higher medical service utilization, and more psychotropic pharmacotherapy fills. METHODS National VA data from fiscal year 2012 were used to compare veterans with dually diagnosed PTSD and substance use disorder to veterans with PTSD without substance use disorder on sociodemographic characteristics, psychiatric and medical comorbidities, mental health and medical service utilization, and psychotropic pharmacotherapy. Comparisons were based on bivariate and Poisson regression analyses. RESULTS The sample included all 638,451 veterans who received the diagnosis of PTSD in the VA in fiscal year 2012: 498,720 (78.1%) with PTSD alone and 139,731 (21.9%) with dually diagnosed PTSD and a comorbid substance use disorder. Veterans with dual diagnoses were more likely to have been homeless and to have received a VA disability pension. Medical diagnoses that were more strongly associated with veterans with dual diagnosis included seizure disorders, liver disease, and human immunodeficiency virus (HIV). Psychiatric comorbidities that distinguished veterans with dual diagnoses included bipolar disorder and schizophrenia. Veterans with dually diagnosed PTSD and substance use disorder also had a greater likelihood of having had mental health inpatient treatment. There were no substantial differences in other measures of service use or prescription fills for psychotropic medications. CONCLUSIONS Several substantial differences were observed, each of which represented more severe medical and psychiatric illness among veterans with dually diagnosed PTSD and substance use disorder compared to those with PTSD alone. However, effective treatments are available for these disorders and special efforts should be made to ensure that veterans with dual diagnoses receive them.
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Affiliation(s)
- Adina Bowe
- a Department of Psychiatry, Yale Medical School , New Haven , Connecticut , USA
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Hwang SW, Chambers C, Chiu S, Katic M, Kiss A, Redelmeier DA, Levinson W. A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance. Am J Public Health 2013; 103 Suppl 2:S294-301. [PMID: 24148051 PMCID: PMC3969141 DOI: 10.2105/ajph.2013.301369] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2013] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We comprehensively assessed health care utilization in a population-based sample of homeless adults and matched controls under a universal health insurance system. METHODS We assessed health care utilization by 1165 homeless single men and women and adults in families and their age- and gender-matched low-income controls in Toronto, Ontario, from 2005 to 2009, using repeated-measures general linear models to calculate risk ratios and 95% confidence intervals (CIs). RESULTS Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum = 141.1), 2.0 emergency department (ED) encounters (maximum = 104.9), 0.2 medical-surgical hospitalizations (maximum = 14.9), and 0.1 psychiatric hospitalizations per person-year (maximum = 4.8). Rate ratios for homeless participants compared with matched controls were 1.76 (95% CI = 1.58, 1.96) for ambulatory care encounters, 8.48 (95% CI = 6.72, 10.70) for ED encounters, 4.22 (95% CI = 2.99, 5.94) for medical-surgical hospitalizations, and 9.27 (95% CI = 4.42, 19.43) for psychiatric hospitalizations. CONCLUSIONS In a universal health insurance system, homeless people had substantially higher rates of ED and hospital use than general population controls; these rates were largely driven by a subset of homeless persons with extremely high-intensity usage of health services.
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Affiliation(s)
- Stephen W Hwang
- Stephen W. Hwang, Catharine Chambers, and Shirley Chiu are with the Centre for Research on Inner City Health, part of the Keenan Research Centre in the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario. Marko Katic and Alex Kiss are with the Department of Research Design and Biostatistics, Sunnybrook Health Sciences Centre, Toronto. Donald A. Redelmeier is with the Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto. Wendy Levinson is with the Department of Medicine, University of Toronto
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Chambers C, Katic M, Chiu S, Redelmeier DA, Levinson W, Kiss A, Hwang SW. Predictors of medical or surgical and psychiatric hospitalizations among a population-based cohort of homeless adults. Am J Public Health 2013; 103 Suppl 2:S380-8. [PMID: 24148040 PMCID: PMC3969145 DOI: 10.2105/ajph.2013.301646] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2013] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We identified factors associated with inpatient hospitalizations among a population-based cohort of homeless adults in Toronto, Ontario. METHODS We recruited participants from shelters and meal programs. We then linked them to administrative databases to capture hospital admissions during the study (2005-2009). We used logistic regression to identify predictors of medical or surgical and psychiatric hospitalizations. RESULTS Among 1165 homeless adults, 20% had a medical or surgical hospitalization, and 12% had a psychiatric hospitalization during the study. These individuals had a total of 921 hospitalizations, of which 548 were medical or surgical and 373 were psychiatric. Independent predictors of medical or surgical hospitalization included birth in Canada, having a primary care provider, higher perceived external health locus of control, and lower health status. Independent predictors of psychiatric hospitalization included being a current smoker, having a recent mental health problem, and having a lower perceived internal health locus of control. Being accompanied by a partner or dependent children was protective for hospitalization. CONCLUSIONS Health care need was a strong predictor of medical or surgical and psychiatric hospitalizations. Some hospitalizations among homeless adults were potentially avoidable, whereas others represented an unavoidable use of health services.
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Affiliation(s)
- Catharine Chambers
- Catharine Chambers, Shirley Chiu, and Stephen W. Hwang are with the Centre for Research on Inner City Health, part of the Keenan Research Centre in the Li Ka Shing Knowledge Institute at St Michael's Hospital, Toronto, Ontario. Marko Katic and Alex Kiss are with the Department of Research Design and Biostatistics, Sunnybrook Health Sciences Centre, Toronto. Donald A. Redelmeier is with the Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto. Wendy Levinson is with the Department of Medicine, University of Toronto, Toronto
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O'Toole TP, Bourgault C, Johnson EE, Redihan SG, Borgia M, Aiello R, Kane V. New to care: demands on a health system when homeless veterans are enrolled in a medical home model. Am J Public Health 2013; 103 Suppl 2:S374-9. [PMID: 24148042 DOI: 10.2105/ajph.2013.301632] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use. METHODS We used case-control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011. RESULTS We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage. CONCLUSIONS Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use.
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Affiliation(s)
- Thomas P O'Toole
- Thomas P. O'Toole, Claire Bourgault, Erin E. Johnson, Stephen G. Redihan, and Matthew Borgia are with the Providence Veterans Affairs (VA) Medical Center, Warren Alpert Medical School at Brown University, and VA National Center on Homelessness Among Veterans, Providence, RI. Riccardo Aiello and Vincent Kane are with the National Center on Homeless Among Veterans, Providence. Vincent Kane is also a guest editor for this supplement issue
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Chambers C, Chiu S, Katic M, Kiss A, Redelmeier DA, Levinson W, Hwang SW. High utilizers of emergency health services in a population-based cohort of homeless adults. Am J Public Health 2013; 103 Suppl 2:S302-10. [PMID: 24148033 DOI: 10.2105/ajph.2013.301397] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We identified predictors of emergency department (ED) use among a population-based prospective cohort of homeless adults in Toronto, Ontario. METHODS We assessed ED visit rates using administrative data from the Institute for Clinical Evaluative Sciences (2005-2009). We then used logistic regression to identify predictors of ED use. Frequent users were defined as participants with rates in the top decile (≥ 4.7 visits per person-year). RESULTS Among 1165 homeless adults, 892 (77%) had at least 1 ED visit during the study. The average rate of ED visits was 2.0 visits per person-year, whereas frequent users averaged 12.1 visits per person-year. Frequent users accounted for 10% of the sample but contributed more than 60% of visits. Predictors of frequent use in adjusted analyses included birth in Canada, higher monthly income, lower health status, perceived unmet mental health needs, and perceived external health locus of control from powerful others; being accompanied by a partner or dependent children had a protective effect on frequent use. CONCLUSIONS Among homeless adults with universal health insurance, a small subgroup accounted for the majority of visits to emergency services. Frequent use was driven by multiple predisposing, enabling, and need factors.
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Affiliation(s)
- Catharine Chambers
- Catharine Chambers, Shirley Chiu, and Stephen W. Hwang are with the Centre for Research on Inner City Health, the Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario. Marko Katic and Alex Kiss are with the Department of Research Design and Biostatistics, Sunnybrook Health Sciences Centre, Toronto. Donald A. Redelmeier is with the Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto. Wendy Levinson is with the Department of Medicine, University of Toronto, Toronto
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Oliveira LDP, Pereira ML, Azevedo A, Lunet N. Risk factors for cardiovascular disease among the homeless and in the general population of the city of Porto, Portugal. CAD SAUDE PUBLICA 2013; 28:1517-29. [PMID: 22892971 DOI: 10.1590/s0102-311x2012000800010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 03/27/2012] [Indexed: 11/22/2022] Open
Abstract
We described the distribution of risk factors for cardiovascular disease among homeless people living in the city of Porto, Portugal. Comparisons were made between subsamples of homeless people recruited in different settings and between the overall homeless sample group and a sample of the general population. All "houseless" individuals attending one of two homeless hostels or two institutions providing meal programs on specific days were invited to participate and were matched with subjects from the general population. We estimated sex, age and education-adjusted prevalence ratios or mean differences. The prevalence of previous illicit drug consumption and imprisonment was almost twice as high among the homeless from institutions providing meal programs. This group also showed lower mean systolic and diastolic blood pressure. Prevalence of smoking was almost 50% higher in the overall homeless group. Mean body mass index and waist circumference were also lower in the homeless group and its members were almost five times less likely to report dyslipidemia. Our findings contribute to defining priorities for interventions directed at this segment of society and to reducing inequalities in this extremely underprivileged population.
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Lako DAM, de Vet R, Beijersbergen MD, Herman DB, van Hemert AM, Wolf JRLM. The effectiveness of critical time intervention for abused women and homeless people leaving Dutch shelters: study protocol of two randomised controlled trials. BMC Public Health 2013; 13:555. [PMID: 25927562 PMCID: PMC3682860 DOI: 10.1186/1471-2458-13-555] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 06/03/2013] [Indexed: 11/10/2022] Open
Abstract
Background One of the main priorities of Dutch organisations providing shelter services is to develop evidence-based interventions in the care for abused women and homeless people. To date, most of these organisations have not used specific intervention models and the interventions which have been implemented rarely have an empirical and theoretical foundation. The present studies aim to examine the effectiveness of critical time intervention (CTI) for abused women and homeless people. Methods In two multi-centre randomised controlled trials we investigate whether CTI, a time-limited (nine month) outreach intervention, is more effective than care-as-usual for abused women and homeless people making the transition from shelter facilities to supported or independent housing. Participants were recruited in 19 women’s shelter facilities and 22 homeless shelter facilities across The Netherlands and randomly allocated to the intervention group (CTI) or the control group (care-as-usual). They were interviewed four times in nine months: once before leaving the shelter, and then at three, six and nine months after leaving the shelter. Quality of life (primary outcome for abused women) and recurrent loss of housing (primary outcome for homeless people) as well as secondary outcomes (e.g. care needs, self-esteem, loneliness, social support, substance use, psychological distress and service use) were assessed during the interviews. In addition, the model integrity of CTI was investigated during the data collection period. Discussion Based on international research CTI is expected to be an appropriate intervention for clients making the transition from institutional to community living. If CTI proves to be effective for abused women and homeless people, shelter services could include this case management model in their professional standards and improve the (quality of) services for clients. Trial registration NTR3463 and NTR3425
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Affiliation(s)
- Danielle A M Lako
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, Nijmegen, The Netherlands.
| | - Renée de Vet
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, Nijmegen, The Netherlands.
| | - Mariëlle D Beijersbergen
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, Nijmegen, The Netherlands.
| | - Daniel B Herman
- Silberman School of Social Work, Hunter College, 2180 Third Avenue, New York, NY, USA.
| | - Albert M van Hemert
- Department of Psychiatry, Leiden University Medical Centre, Albinusdreef 2, Leiden, The Netherlands.
| | - Judith R L M Wolf
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, Nijmegen, The Netherlands.
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37
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Burke CW. Bridging Academic Research and Community Action: The First Annual Forum on Health, Homelessness, and Poverty. WORLD MEDICAL & HEALTH POLICY 2013. [DOI: 10.1002/wmh3.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Forchuk C, Godin M, Hoch JS, Kingston-Macclure S, Jeng MS, Puddy L, Vann R, Jensen E. Preventing homelessness after discharge from psychiatric wards: perspectives of consumers and staff. J Psychosoc Nurs Ment Health Serv 2013; 51:24-31. [PMID: 23394964 DOI: 10.3928/02793695-20130130-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 01/09/2013] [Indexed: 11/20/2022]
Abstract
After spending time in the hospital, psychiatric clients are often discharged to homeless shelters or the streets, which can place a burden on health care systems. This study examined the effects of an intervention in which psychiatric clients from acute (n = 219) and tertiary (n = 32) sites were provided with predischarge assistance in securing housing. A program evaluation design was used to examine the effectiveness of the intervention. Qualitative data were available through interviews, focus groups, and monthly meetings. The results highlight several benefits of the intervention and show that homelessness can be reduced by connecting housing support, income support, and psychiatric care.
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Affiliation(s)
- Cheryl Forchuk
- Arthur Labatt Family School of Nursing, University of Western Ontario, Ontario, Canada.
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39
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Lebrun-Harris LA, Baggett TP, Jenkins DM, Sripipatana A, Sharma R, Hayashi AS, Daly CA, Ngo-Metzger Q. Health status and health care experiences among homeless patients in federally supported health centers: findings from the 2009 patient survey. Health Serv Res 2012; 48:992-1017. [PMID: 23134588 DOI: 10.1111/1475-6773.12009] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts. DATA SOURCES/STUDY SETTING Nationally representative data from the 2009 Health Center Patient Survey. STUDY DESIGN Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients' health care experiences. DATA COLLECTION Computer-assisted personal interviews were conducted with health center patients. PRINCIPAL FINDINGS Homeless patients had worse health status-lifetime burden of chronic conditions, mental health problems, and substance use problems-compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24-3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37-2.92). CONCLUSIONS There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.
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Affiliation(s)
- Lydie A Lebrun-Harris
- US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Primary Health Care, Rockville, MD 20857, USA.
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40
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Canavan R, Barry MM, Matanov A, Barros H, Gabor E, Greacen T, Holcnerová P, Kluge U, Nicaise P, Moskalewicz J, Díaz-Olalla JM, Strassmayr C, Schene AH, Soares JJF, Gaddini A, Priebe S. Service provision and barriers to care for homeless people with mental health problems across 14 European capital cities. BMC Health Serv Res 2012; 12:222. [PMID: 22838503 PMCID: PMC3441802 DOI: 10.1186/1472-6963-12-222] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 07/13/2012] [Indexed: 11/15/2022] Open
Abstract
Background Mental health problems are disproportionately higher amongst homeless people. Many barriers exist for homeless people with mental health problems in accessing treatment yet little research has been done on service provision and quality of care for this group. The aim of this paper is to assess current service provision and identify barriers to care for homeless people with mental health problems in 14 European capital cities. Method Two methods of data collection were employed; (i) In two highly deprived areas in each of the 14 European capital cities, homeless-specific services providing mental health, social care or general health services were assessed. Data were obtained on service characteristics, staff and programmes provided. (ii) Semi-structured interviews were conducted in each area with experts in mental health care provision for homeless people in order to determine the barriers to care and ways to overcome them. Results Across the 14 capital cities, 111 homeless-specific services were assessed. Input from professionally qualified mental health staff was reported as low, as were levels of active outreach and case finding. Out-of-hours service provision appears inadequate and high levels of service exclusion criteria were evident. Prejudice in the services towards homeless people, a lack of co-ordination amongst services, and the difficulties homeless people face in obtaining health insurance were identified as major barriers to service provision. Conclusions While there is variability in service provision across European capital cities, the reported barriers to service accessibility are common. Homeless-specific services are more responsive to the initial needs of homeless people with mental health problems, while generic services tend to be more conducive to long term care. Further research is needed to determine the effectiveness of different service delivery models, including the most effective coordination of homeless specific and generic services.
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Affiliation(s)
- Réamonn Canavan
- Health Promotion Research Centre, National University of Ireland Galway, Galway, Ireland.
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41
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Hall YN, Choi AI, Himmelfarb J, Chertow GM, Bindman AB. Homelessness and CKD: a cohort study. Clin J Am Soc Nephrol 2012; 7:1094-102. [PMID: 22700883 DOI: 10.2215/cjn.00060112] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES This study examined the associations between homelessness and clinical outcomes of CKD among adults from the urban healthcare safety net. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective cohort study examined 15,343 adults with CKD stages 3-5 who received ambulatory care during 1996-2005 from the Community Health Network of San Francisco. Main outcome measures were time to ESRD or death and frequency of emergency department visits and hospitalizations. RESULTS Overall, 858 persons (6%) with CKD stages 3-5 were homeless. Homeless adults were younger, were disproportionately male and uninsured, and suffered from far higher rates of depression and substance abuse compared with adults with stable housing (P<0.001 for all comparisons). Over a median follow-up of 2.8 years (interquartile range=1.4-6.1), homeless adults experienced significantly higher crude risk of ESRD or death (hazard ratio=1.82, 95% confidence interval=1.49-2.22) compared with housed adults. This elevated risk was attenuated but remained significantly higher (adjusted hazard ratio=1.28, 95% confidence interval=1.04-1.58) after controlling for differences in sociodemographics, comorbid conditions, and laboratory variables. Homeless adults were also far more likely to use acute care services (median [interquartile range] number of emergency department visits was 9 [4-20] versus 1 [0-4], P<0.001) than housed counterparts. CONCLUSIONS Homeless adults with CKD suffer from increased morbidity and mortality and use costly acute care services far more frequently than peers who are stably housed. These findings warrant additional inquiry into the unmet health needs of the homeless with CKD to provide appropriate and effective care to this disadvantaged group.
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Affiliation(s)
- Yoshio N Hall
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA 98104, USA.
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42
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O'Toole TP, Pirraglia PA, Dosa D, Bourgault C, Redihan S, O'Toole MB, Blumen J. Building care systems to improve access for high-risk and vulnerable veteran populations. J Gen Intern Med 2011; 26 Suppl 2:683-8. [PMID: 21989622 PMCID: PMC3191220 DOI: 10.1007/s11606-011-1818-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND For many high-risk patients, accessing primary care is challenged by competing needs and priorities, socioeconomics, and other circumstances. The resulting lack of treatment engagement makes these vulnerable patient populations susceptible to poor health outcomes and an over-reliance on emergency department-based care. METHODS We describe a quasi-experimental pre-post study examining a vulnerable population-based application of the patient-centered medical home applied to four high-risk groups: homeless veterans, cognitively impaired elderly, women veterans and patients with serious mental illness. We measured 6-month primary care, emergency department and inpatient care use and chronic disease management when care was based in a general internal medicine clinic (2006) and in a population-specific medical home (2008). RESULTS Overall 457 patients were studied, assessing care use and outcomes for the last 6 months in each study year. Compared with 2006, in 2008 there was a significant increase in primary care use (p < 0.001) and improvement in chronic disease monitoring and diabetes control (2006 HBA1C: 8.5 vs. 2008 HBA1C 6.9) in all four groups. However, there was also an increase in both emergency department use and hospitalizations, albeit with shorter lengths of stay in 2008 compared with 2006. Most of the increased utilization was driven by a small proportion of patients in each group. CONCLUSION Tailoring the medical home model to the specific needs and challenges facing high-risk populations can increase primary care utilization and improve chronic disease monitoring and diabetes management. More work is needed in directing this care model to reducing emergency department and inpatient use.
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Affiliation(s)
- Thomas P O'Toole
- Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI 02918, USA. Thomas.O'
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43
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Small LFF. Determinants of physician utilization, emergency room use, and hospitalizations among populations with multiple health vulnerabilities. Health (London) 2010; 15:491-516. [PMID: 21169208 DOI: 10.1177/1363459310383597] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Understanding the factors that influence differing types of health care utilization within vulnerable groups can serve as a basis for projecting future health care needs, forecasting future health care expenditures, and influencing social policy. In this article the Behavioral Model for Vulnerable Populations is used to evaluate discretionary (physician visits) and non-discretionary (emergency room visits, and hospitalizations) health utilization patterns of a sample of 1466 respondents with one or more vulnerable health classification. Reported vulnerabilities include: (1) persons with substance disorders; (2) homeless persons; (3) persons with mental health problems; (4) victims of violent crime; (5) persons diagnosed with HIV/AIDS; (6) and persons in receipt of public benefits. Hierarchical logistic regression is used on three nested models to model factors that influence physician visits, emergency room visits, and hospitalizations. Additionally, bivariate logistic regression analyses are completed using a vulnerability index to evaluate the impact of increased numbers of vulnerability on all three forms of health care utilization. Findings from this study suggest the Behavioral Model of Vulnerable Populations be employed in future research regarding health care utilization patterns among vulnerable populations. This article encourages further research investigating the cumulative effect of health vulnerabilities on the use of non-discretionary services so that this behavior could be better understood and appropriate social policies and behavioral interventions implemented.
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O'Toole TP, Buckel L, Bourgault C, Blumen J, Redihan SG, Jiang L, Friedmann P. Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes. Am J Public Health 2010; 100:2493-9. [PMID: 20966377 DOI: 10.2105/ajph.2009.179416] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We compared a population-tailored approach to primary care for homeless veterans with a usual care approach. METHODS We conducted a retrospective prolective cohort study of homeless veterans enrolled in a population-tailored primary care clinic matched to a historical sample in general internal medicine clinics. Overall, 177 patients were enrolled: 79 in the Homeless-Oriented Primary Care Clinic and 98 in general internal medicine primary care. RESULTS Homeless-oriented primary care-enrolled patients had greater improvements in hypertension, diabetes, and lipid control, and primary care use was higher during the first 6 months (5.96 visits per person vs 1.63 for general internal medicine) but stabilized to comparable rates during the second 6 months (2.01 vs 1.31, respectively). Emergency department (ED) use was also higher (2.59 vs 1.89 visits), although with 40% lower odds for nonacute ED visits than for the general internal medicine group (95% confidence interval = 0.2, 0.8). Excluding substance abuse and mental health admissions, hospitalizations were reduced among the homeless veterans between the 2 periods (28.6% vs 10.8%; P < .01) compared with the general internal medicine group (48.2% vs 44.4%; P = .6; difference of differences, P < .01). CONCLUSIONS Tailoring primary care to homeless veterans can decrease unnecessary ED use and medical admissions and improve chronic disease management.
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Affiliation(s)
- Thomas P O'Toole
- Providence Veterans Affairs Medical Center for Systems, Outcomes, and Quality in Chronic Disease and Rehabilitation, Providence, RI 02908-4799, USA.
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45
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Baggett TP, O'Connell JJ, Singer DE, Rigotti NA. The unmet health care needs of homeless adults: a national study. Am J Public Health 2010; 100:1326-33. [PMID: 20466953 DOI: 10.2105/ajph.2009.180109] [Citation(s) in RCA: 301] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the prevalence and predictors of past-year unmet needs for 5 types of health care services in a national sample of homeless adults. METHODS We analyzed data from 966 adult respondents to the 2003 Health Care for the Homeless User Survey, a sample representing more than 436,000 individuals nationally. Using multivariable logistic regression, we determined the independent predictors of each type of unmet need. RESULTS Seventy-three percent of the respondents reported at least one unmet health need, including an inability to obtain needed medical or surgical care (32%), prescription medications (36%), mental health care (21%), eyeglasses (41%), and dental care (41%). In multivariable analyses, significant predictors of unmet needs included food insufficiency, out-of-home placement as a minor, vision impairment, and lack of health insurance. Individuals who had been employed in the past year were more likely than those who had not to be uninsured and to have unmet needs for medical care and prescription medications. CONCLUSIONS This national sample of homeless adults reported substantial unmet needs for multiple types of health care. Expansion of health insurance may improve health care access for homeless adults, but addressing the unique challenges inherent to homelessness will also be required.
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Affiliation(s)
- Travis P Baggett
- General Medicine Division, Massachusetts General Hospital, Boston, MA 02114, USA.
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Gordon AJ, Haas GL, Luther JF, Hilton MT, Goldstein G. Personal, Medical, and Healthcare Utilization Among Homeless Veterans Served by Metropolitan and Nonmetropolitan Veteran Facilities. Psychol Serv 2010; 7:65-74. [PMID: 21152352 DOI: 10.1037/a0018479] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study assessed differences in personal, medical, and health care utilization characteristics of homeless veterans living in metropolitan versus nonmetropolitan environments. Data were obtained from a Veterans Health Administration (VHA) network sample of homeless veterans. Chi-square tests were used to assess differences in demographics, military history, living situation, medical history, employment status, and health care utilization. Moderator analyses determined whether predictors of health care utilization varied by metropolitan status. Of 3,595 respondents, 60% were residing in metropolitan areas. Age, sex, and marital status were similar between metropolitan and nonmetropolitan homeless. Metropolitan homeless were less likely to receive public financial support or to be employed, to have at least one medical problem, one psychiatric problem, or current alcohol dependency, but more likely to be homeless longer. Of the 52% of the sample who used VHA care in the last 6 months, 53% were metropolitan versus 49% nonmetropolitan (p = .01). Metropolitan status predicted at least one VHA visit within the prior 6 months (OR:1.3, CI:1.1, 1.6). Significant differences occur in the personal, medical, and health care utilization characteristics of homeless veterans in metropolitan versus nonmetropolitan areas.
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Affiliation(s)
- Adam J Gordon
- Mental Illness Research, Education, and Clinical Center and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and University of Pittsburgh School of Medicine
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Stein JA, Nyamathi AM, Zane JI. Situational, psychosocial, and physical health-related correlates of HIV/AIDS risk behaviors in homeless men. Am J Mens Health 2009; 3:25-35. [PMID: 19430589 DOI: 10.1177/1557988307307862] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A biopsychosocial perspective is employed to assess associations among situational and psychosocial variables related to health, health care, and HIV/AIDS risk behaviors among 479 homeless men (aged 18-64 years). Poor health was not significantly associated with sexual risk behaviors and was only modestly associated with injection drug use (IDU). Health care was not significantly associated with sexual risk behavior or IDU. HIV/AIDS risk behaviors were highly associated with homelessness severity and posttraumatic stress disorder. IDU was significantly associated with greater emotional distress and was more likely among younger men and among White men. Sexual risk behavior was more frequent among those who had particularly poor-quality housing such as living on the street or in abandoned buildings. Because interactions with the medical community are limited and not associated with HIV/AIDS risk, outreach in areas in which homeless men congregate, mental health and substance abuse treatment, and permanent supportive housing may help reduce HIV risk among homeless men more effectively.
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Affiliation(s)
- Judith A Stein
- Department of Psychology, University of California-Los Angeles, 405 Hilgard Avenue, Los Angeles, CA 90095-1563, USA.
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Bonin JP, Fournier L, Blais R, Perreault M, White ND. Health and Mental Health Care Utilization by Clients of Resources for Homeless Persons in Quebec City and Montreal, Canada: A 5-Year Follow-Up Study. J Behav Health Serv Res 2009; 37:95-110. [DOI: 10.1007/s11414-009-9184-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Accepted: 06/30/2009] [Indexed: 12/01/2022]
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Copeland LA, Miller AL, Welsh DE, McCarthy JF, Zeber JE, Kilbourne AM. Clinical and demographic factors associated with homelessness and incarceration among VA patients with bipolar disorder. Am J Public Health 2009; 99:871-7. [PMID: 19299667 DOI: 10.2105/ajph.2008.149989] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the association between homelessness and incarceration in Veterans Affairs patients with bipolar disorder. METHODS We used logistic regression to model each participant's risk of incarceration or homelessness after we controlled for known risk factors. RESULTS Of 435 participants, 12% reported recent homelessness (within the past month), and 55% reported lifetime homelessness. Recent and lifetime incarceration rates were 2% and 55%, respectively. In multivariate models, current medication adherence (based on a 5-point scale) was independently associated with a lower risk of lifetime homelessness (odds ratio [OR] = 0.80 per point, range 0-4; 95% confidence interval [CI] = 0.66, 0.96), and lifetime incarceration increased the risk of lifetime homelessness (OR = 4.4; 95% CI = 2.8, 6.9). Recent homelessness was associated with recent incarceration (OR = 26.4; 95% CI = 5.2, 133.4). Lifetime incarceration was associated with current substance use (OR = 2.6; 95% CI = 2.7, 6.7) after control for lifetime homelessness (OR = 4.2; 95% CI = 2.7, 6.7). CONCLUSIONS Recent and lifetime incarceration and homelessness were strongly associated with each other. Potentially avoidable or treatable correlates included current medication nonadherence and substance use. Programs that better coordinate psychiatric and drug treatment with housing programs may reduce the cycle of incarceration, homelessness, and treatment disruption within this vulnerable patient population.
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McGuire J, Gelberg L, Blue-Howells J, Rosenheck RA. Access to primary care for homeless veterans with serious mental illness or substance abuse: a follow-up evaluation of co-located primary care and homeless social services. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2009; 36:255-64. [PMID: 19280333 DOI: 10.1007/s10488-009-0210-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Accepted: 02/23/2009] [Indexed: 11/29/2022]
Abstract
To examine the hypothesis that a demonstration clinic integrating homeless, primary care, and mental health services for homeless veterans with serious mental illness or substance abuse would improve medical health care access and physical health status. A quasi-experimental design comparing a 'usual VA care' group before the demonstration clinic opened (N = 130) and the 'integrated care' group (N = 130). Regression models indicated that the integrated care group was more rapidly enrolled in primary care, received more prevention services and primary care visits, and fewer emergency department visits, and was not different in inpatient utilization or in physical health status over 18 months. The demonstration clinic improved access to primary care services and reduced emergency services but did not improve perceived physical health status over 18 months. Further research is needed to determine generalizability and longer term effects.
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Affiliation(s)
- James McGuire
- Department of Veterans Affairs Northeast Program Evaluation Center (NEPEC), Los Angeles, CA, USA.
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