Efficient targeting of homelessness prevention services for families

Temporary Financial Assistance for Housing Expenditures and Mortality and Suicide Outcomes Among US Veterans

INTRODUCTION

It is unclear whether interventions designed to increase housing stability can also lead to improved health outcomes such as reduced risk of death and suicide morbidity. The objective of this study was to estimate the potential impact of temporary financial assistance (TFA) for housing-related expenses from the US Department of Veterans Affairs (VA) on health outcomes including all-cause mortality, suicide attempt, and suicidal ideation.

METHODS

We conducted a retrospective national cohort study of Veterans who entered the VA Supportive Services for Veteran Families (SSVF) program between 10/2015 and 9/2018. We assessed the association between TFA and health outcomes using a multivariable Cox proportional hazards regression approach with inverse probability of treatment weighting. We conducted these analyses on our overall cohort as well as separately for those in the rapid re-housing (RRH) and homelessness prevention (HP) components of SSVF. Outcomes were all-cause mortality, suicide attempt, and suicidal ideation at 365 and 730 days following enrollment in SSVF.

RESULTS

Our analysis cohort consisted of 41,969 unique Veterans with a mean (SD) duration of 87.6 (57.4) days in the SSVF program. At 365 days following SSVF enrollment, TFA was associated with a decrease in the risk of all-cause mortality (HR: 0.696, p < 0.001) and suicidal ideation (HR: 0.788, p < 0.001). We found similar results at 730 days (HR: 0.811, p = 0.007 for all-cause mortality and HR: 0.881, p = 0.037 for suicidal ideation). These results were driven primarily by individuals enrolled in the RRH component of SSVF. We found no association between TFA and suicide attempts.

CONCLUSION

We find that providing housing-related financial assistance to individuals facing housing instability is associated with improvements in important health outcomes such as all-cause mortality and suicidal ideation. If causal, these results suggest that programs to provide housing assistance have positive spillover effects into other important aspects of individuals' lives.

Homelessness And Health: Factors, Evidence, Innovations That Work, And Policy Recommendations

On a single night in 2023, more than 653,000 people experienced homelessness in the United States. In this overview, we highlight structural and individual risk factors that can lead to homelessness, explore evidence on the relationship between homelessness and health, discuss programmatic and policy innovations, and provide policy recommendations. Health system efforts to address homelessness and improve the health of homeless populations have included interventions such as screening for social needs and medical respite programs. Initiatives using the Housing First approach to permanent supportive housing have a strong track record of success. Health care financing innovations using Medicaid Section 1115 waivers offer promising new approaches to improving health and housing for people experiencing homelessness. To substantially reduce homelessness and its many adverse health impacts, changes are needed to increase the supply of affordable housing for households with very low incomes. Health care providers and systems should leverage their political power to advocate for policies that scale durable, evidence-based solutions to reduce homelessness, including increased funding to expand housing choice vouchers and greater investment in the creation and preservation of affordable housing.

"Homeless Life to Hopeful Life of Elderly Beggars"-: Before and After Rehabilitation: A Qualitative Approach

This qualitative study explores the experiences of elderly beggars who transitioned from a life of homelessness to a hopeful life through rehabilitation programs. The aim is to gain insights into their lived experiences, challenges faced during their homeless phase, and the transformative effects of rehabilitation interventions. The study employs Case study approach applying thematic analysis to capture the narratives of elderly individuals who have undergone rehabilitation. The data was collected directly from the elderly using purposive sampling method. The in-depth interview guide was used to collect data from 30 elderly people in Atchayam Beggars Rehabilitation centre at Erode. From the findings, it was clear that homeless phase is characterized by extreme poverty, social exclusion, health issues, and a lack of basic necessities. The elderly beggars face numerous challenges, including stigma, discrimination, and a sense of hopelessness. The study documents the transformative journey of the elderly beggars, highlighting the positive changes they experience after rehabilitation. These changes include improved physical and mental well-being, restored self-esteem, regained social connections, and the acquisition of new skills. The elderly experience a renewed sense of hope, dignity, and empowerment as they move from vulnerability to independence and self-sufficiency. The study also highlights the significance of destigmatization efforts and community involvement in fostering the successful reintegration of elderly beggars into society. The study also contributes to the existing literature by shedding light on the possibilities for positive change and the journey from homeless life to a hopeful life among this vulnerable population.

The value of utility payment history in predicting first-time homelessness

Homelessness is a costly and traumatic condition that affects hundreds of thousands of people each year in the U.S. alone. Most homeless programs focus on assisting people experiencing homelessness, but research has shown that predicting and preventing homelessness can be a more cost-effective solution. Of the few studies focused on predicting homelessness, most focus on people already seeking assistance; however, these methods necessarily cannot identify those not actively seeking assistance. Providing aid before conditions become dire may better prevent homelessness. Few methods exist to predict homelessness on the general population, and these methods use health and criminal history information, much of which may not be available or timely. We hypothesize that recent financial health information based on utility payment history is useful in predicting homelessness. In particular, we demonstrate the value of utility customer billing records to predict homelessness using logistic regression models based on this data. The performance of these models is comparable to other studies, suggesting such an approach could be productionalized due to the ubiquity and timeliness of this type of data. Our results suggest that utility billing records would have value for screening a broad section of the general population to identify those at risk of homelessness.

Identifying Predictors of Homelessness Among Adults in a Large Integrated Health System in Northern California

Introduction Homelessness contributes to worsening health and increased health care costs. There is little published research that leverages rich electronic health record (EHR) data to predict future homelessness risk and inform interventions to address it. The authors' objective was to develop a model for predicting future homelessness using individual EHR and geographic data covariates. Methods This retrospective cohort study included 2,543,504 adult members (≥ 18 years old) from Kaiser Permanente Northern California and evaluated which covariates predicted a composite outcome of homelessness status (hospital discharge documentation of a homeless patient, medical diagnosis of homelessness, approved medical financial assistance application for homelessness, and/or "homeless/shelter" in address name). The predictors were measured in 2018-2019 and included prior diagnoses and demographic and geographic data. The outcome was measured in 2020. The cohort was split (70:30) into a derivation and validation set, and logistic regression was used to model the outcome. Results Homelessness prevalence was 0.35% in the overall sample. The final logistic regression model included 26 prior diagnoses, demographic, and geographic-level predictors. The regression model using the validation set had moderate sensitivity (80.4%) and specificity (83.2%) for predicting future cases of homelessness and achieved excellent classification properties (area under the curve of 0.891 [95% confidence interval = 0.884-0.897]). Discussion This prediction model can be used as an initial triage step to enhance screening and referral tools for identifying and addressing homelessness, which can improve health and reduce health care costs. Conclusions EHR data can be used to predict chance of homelessness at a population health level.

Mental health prevention and treatment programs for infants experiencing homelessness: A systematic review

Experiencing homelessness in infancy has been linked to negative physical and mental health outcomes. Parental well-being and the parent-infant relationship can also be negatively impacted by experiencing homelessness. While numerous parent-based infant mental health programs have been identified by a recent review, the goal of this study was to further determine the extent to which these existing programs were developed and/or examined with at-risk populations such as families experiencing homelessness. Out of 60 programs identified by Hare et al., in press, only three had been implemented specifically in shelter settings with infants 0-12 months (Parent-Infant Psychotherapy, New Beginnings, and My Baby's First Teacher). Additionally, when examining programs that began in later infancy (after 12 months), only 2 programs were implemented in shelter settings (Incredible Years and Parent-Child Interaction Therapy). Implications for research, policy, and clinicians regarding implementation of evidence-based prevention/treatment programs for parents and their infants experiencing homelessness are discussed.

Prevalence of eviction, home foreclosure, and homelessness among low-income US veterans: the National Veteran Homeless and Other Poverty Experiences study

OBJECTIVES

Housing stability is essential for health and social well-being, and the United States is focused on preventing homelessness among veterans, so this study examined the prevalence of different events related to housing instability among low-income US veterans.

STUDY DESIGN

This was a nationally representative survey.

METHODS

Using a sample of 1004 low-income veterans in 2021, this study examined the lifetime prevalence and characteristics associated with eviction, home foreclosure, and homelessness among low-income US veterans.

RESULTS

In the total sample, 10.9% reported a lifetime history of eviction, 8.0% reported a lifetime history of home foreclosure, and 19.9% reported a lifetime history of homelessness. Among those with a history of homelessness, 39.2% also reported a history of eviction, and 13.9% reported a history of home foreclosure. Hierarchical logistic regression analyses found that for eviction, sociodemographic characteristics (e.g. being Hispanic, having private insurance, and being from the Northeast was associated with lower risk of eviction) together explained 26% of the variance, and clinical characteristics explained an incremental 12% additional variance. For homelessness, sociodemographic characteristics explained 18% of the variance, and clinical characteristics explained an incremental 20% (e.g. diagnosis of schizophrenia or bipolar disorder, any history of suicide attempt, and lower physical health scores were associated with higher risk of homelessness). For home foreclosure, sociodemographic, clinical, and psychosocial variables together only explained 14% of the variance.

CONCLUSION

Evictions, home foreclosures, and homelessness are discrete events and occur at relatively high rates among low-income veterans. In addition, homelessness was more associated with biosocial dysfunction, whereas eviction was more closely associated with socio-economic vulnerability, which may inform intervention efforts for both events.

ED-Home: Pilot feasibility study of a targeted homelessness prevention intervention for emergency department patients with drug or unhealthy alcohol use

BACKGROUND

Housing insecurity is prevalent among emergency department (ED) patients. Despite a surge of interest in screening for patients' social needs including housing insecurity, little research has examined ED social needs interventions. We worked together with government and community partners to develop and pilot test a homelessness prevention intervention targeted to ED patients with drug or unhealthy alcohol use.

METHODS

We approached randomly sampled patients at an urban public hospital ED, May to August 2019. Adult patients were eligible if they were medically stable, not incarcerated, spoke English, had unhealthy alcohol or any drug use, and were not currently homeless but screened positive for risk of future homelessness using a previously developed risk screening tool. Participants received a three-part intervention: (1) brief counseling and referral to treatment for substance use delivered through a preexisting ED program; (2) referral to Homebase, an evidence-based community homelessness prevention program; and (3) up to three troubleshooting phone calls by study staff. Participants completed surveys at baseline and 6 months.

RESULTS

Of 2183 patients screened, 51 were eligible and 40 (78.4%) participated; one later withdrew, leaving 39 participants. Participants were diverse in age, gender, race, and ethnicity. Of the 32 participants reached at 6 months, most said it was very or extremely helpful to talk to someone about their housing situation (n = 23, 71.9%) at the baseline ED visit. Thirteen (40.6%) said their housing situation had improved in the past 6 months and 16 (50.0%) said it had not changed. Twenty participants (62.5%) had made contact with a Homebase office. Participants shared ideas of how to improve the intervention.

CONCLUSIONS

This pilot intervention was feasible and well received by participants though it required a large amount of screening to identify potentially eligible patients. Our findings will inform a larger future trial and may be informative for others seeking to develop similar interventions.

Association Between Housing Affordability and Severe Maternal Morbidity

IMPORTANCE

The number of people living in unaffordable housing (relative to income) is projected to continue increasing as housing cost inflation outpaces incomes in the US. Although reproductive-aged women have disproportionately high housing costs, particularly around the time of childbirth, data on associations between housing costs and maternal health and the role of publicly supported affordable housing programs in mitigating those associations are lacking.

OBJECTIVE

To estimate associations between area-level rental housing costs and severe maternal morbidity (SMM) and assess the potential mitigating role of publicly supported affordable housing.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study linked New Jersey birth files from January 1, 2008, to December 31, 2018, to maternal hospital discharge records and municipal-level housing and demographic data from the state of New Jersey and the US Census Bureau. Data were analyzed from January to September 2022. The birth files contained records for all births in New Jersey, and the hospital discharge records contained information from all inpatient hospitalizations over the study period. A total of 1 004 000 birth records were matched to maternal discharge records and municipal-level data.

EXPOSURES

Municipal-level rental costs relative to income (housing cost burden), availability of publicly supported affordable housing, and housing subsidy per person with an income lower than the federal poverty level.

MAIN OUTCOMES AND MEASURES

Severe maternal morbidity was identified using diagnosis and procedure codes developed by the US Centers for Disease Control and Prevention to measure SMM.

RESULTS

Of 1 004 000 mothers (mean [SD] age at birth, 29.8 [5.9] years; 44.7% White), 20 022 (2.0%) experienced SMM. Higher municipal rental housing costs were associated with greater odds of SMM (odds ratio [OR], 1.27; 95% CI, 1.01-1.60), particularly among mothers with less than a high school education (OR, 1.81; 95% CI, 1.06-3.10), and the positive associations decreased at higher levels of affordable housing availability. Among mothers with less than a high school education, the risk of SMM was 8.0% lower (risk ratio, 0.92; 95% CI, 0.85-1.00) for each additional $1000 annual municipal-level housing subsidy per person with an income lower than poverty level after controlling for rental costs and other characteristics, which translated to a 20.7% lower educational disparity in SMM.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, living in a municipality with higher rental housing costs was associated with higher odds of SMM, except when there was high availability of publicly supported affordable housing. These results suggest that greater availability of publicly supported affordable housing has the potential to mitigate the association between rental housing costs and SMM and reduce socioeconomic disparities in SMM.

Predicting Homelessness Among U.S. Army Soldiers No Longer on Active Duty

INTRODUCTION

The ability to predict and prevent homelessness has been an elusive goal. The purpose of this study was to develop a prediction model that identified U.S. Army soldiers at high risk of becoming homeless after transitioning to civilian life based on information available before the time of this transition.

METHODS

The prospective cohort study consisted of observations from 16,589 soldiers who were separated or deactivated from service and who had previously participated in 1 of 3 baseline surveys of the Army Study to Assess Risk and Resilience in Servicemembers in 2011-2014. A machine learning model was developed in a 70% training sample and evaluated in the remaining 30% test sample to predict self-reported homelessness in 1 of 2 Longitudinal Study surveys administered in 2016-2018 and 2018-2019. Predictors included survey, administrative, and geospatial variables available before separation/deactivation. Analysis was conducted in November 2020-May 2021.

RESULTS

The 12-month prevalence of homelessness was 2.9% (SE=0.2%) in the total Longitudinal Study sample. The area under the receiver operating characteristic curve in the test sample was 0.78 (SE=0.02) for homelessness. The 4 highest ventiles (top 20%) of predicted risk included 61% of respondents with homelessness. Self-reported lifetime histories of depression, trauma of having a loved one murdered, and post-traumatic stress disorder were the 3 strongest predictors of homelessness.

CONCLUSIONS

A prediction model for homelessness can accurately target soldiers for preventive intervention before transition to civilian life.

The Determinants of Length of Homeless Shelter Stays: Evidence-Based Regression Analyses

Objective: To identify determinants that contribute to the length of homeless shelter stay.

Methods: We utilized a unique dataset from the Homeless Management Information Systems from Boston, Massachusetts, United States, which contains 44,197 shelter stays for 17,070 adults between Jan. 2014 and May 2018.

Results: Our statistical analyses and regression model analyses show that factors that contribute to the length of a homeless shelter stay include being female, senior, disability, being Hispanic, or being Asian or Black African. A significant fraction of homeless shelter stays (76%) are experienced by individuals with at least one of three disabilities: physical disability, mental health issues, or substance use disorder. Recidivism also contributes to longer homeless shelter stays.

Conclusion: The results suggest possible program and policy implications. Several factors that contribute to longer homeless shelter stay, such as gender, age, disability, race, and ethnicity, may have funding implications. Age may point to the need for early interventions. Disability is developmental and may benefit from treatment and intervention. Finally, we find that length of stay and recidivism are not independent, and may form a vicious cycle that requires additional investigation.

Actuarial prediction versus clinical prediction of exits from a national supported housing program

The accurate identification of persons at risk of exiting permanent supportive housing could help maximize client success and minimize attrition and premature exits from such housing. Thus, in the present study, we developed and tested multivariable prediction models of negative and positive exits from the U.S. Department of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program using logistic regression and random forests. We compared the performance of these models with clinical predictions made by HUD-VASH program case managers. We selected a cohort of all 92,196 Veterans who entered HUD-VASH nationwide between October 1, 2014 and September 30, 2019, 70% of whom were randomly selected to serve as the development cohort and the remaining 30% of whom served as the validation cohort. Negative and positive exits were measured until September 30, 2019. A subset of 1,264 Veterans was used to compare performance of models with clinical judgment. Predictor variables included sociodemographic characteristics, health and behavioral health diagnoses, homeless/housing history, and VA service utilization history. Performance of models and clinical judgment were assessed using an array of metrics including area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, and positive predictive value. The logistic regression and random forest models had similar, modest performance in predicting negative and positive exits. These models were substantially more sensitive, yet far less specific in predicting exits than clinician ratings. Study findings highlight the challenges and tradeoffs in using actuarial models or case manager predictions to target interventions to Veterans at risk of exiting HUD-VASH. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Vaccination coverage among young homeless children compared to US national immunization survey data

INTRODUCTION

Comprehensive vaccination coverage among homeless children in the United States (US) is largely unknown although a few studies suggest low coverage with single vaccinations. This study compared vaccination coverage with a combined 7-vaccines series among homeless children in the District of Columbia (DC) to coverage among other US children.

MATERIALS AND METHODS

A cross-sectional survey of homeless children in DC was conducted from 2018 to 2019. Recruitment occurred at housing shelters, social services centers, and a diaper dispensary, and through limited chain referral. English-speaking parents of a child aged 19 to 35 months who spent the majority of the last 30 nights homeless were recruited. Participants consented for their child's healthcare providers to submit vaccination records. The vaccination coverage estimate of this sample was compared with estimates of three populations in the 2018 National Immunization Survey (NIS): children in DC (NIS DC), children in the US (NIS US), and children in the US below the federal poverty level (NIS poor).

RESULTS

Most of the 135 children had experienced at least two lifetime episodes (63.7%) and 12 months (57%) of homelessness. The estimated percent up to date was 52.6% (95% CI: 43.8%, 61.3%). This estimate was 20.4 (95% CI: 11.9, 28.8, p < .0001), 20 (95% CI: 11.5, 28.4, p < .0001), and 11.5 (95% CI: 3.1, 20, p < .01) percentage points lower than estimates for the NIS DC, NIS US and NIS poor populations, respectively. After adjusting for child's age and race/ethnicity, vaccination coverage of the NIS DC sample was below that of NIS US (p < .01) and NIS poor samples (p < .05).

CONCLUSION

Children experiencing homelessness may be at risk of under-vaccination, even when compared to a general population of children in poverty. Awareness of this heightened risk may allow for more precise targeting of vaccination delivery support specifically to children experiencing homelessness.

Development of a homelessness risk screening tool for emergency department patients

OBJECTIVE

To develop a screening tool to identify emergency department (ED) patients at risk of entering a homeless shelter, which could inform targeting of interventions to prevent future homelessness episodes.

DATA SOURCES

Linked data from (1) ED patient baseline questionnaires and (2) citywide administrative homeless shelter database.

STUDY DESIGN

Stakeholder-informed predictive modeling utilizing ED patient questionnaires linked with prospective shelter administrative data. The outcome was shelter entry documented in administrative data within 6 months following the baseline ED visit. Exposures were responses to questions on homelessness risk factors from baseline questionnaires.

DATA COLLECTION/EXTRACTION METHODS

Research assistants completed questionnaires with randomly sampled ED patients who were medically stable, not in police/prison custody, and spoke English or Spanish. Questionnaires were linked to administrative data using deterministic and probabilistic matching.

PRINCIPAL FINDINGS

Of 1993 ED patients who were not homeless at baseline, 5.6% entered a shelter in the next 6 months. A screening tool consisting of two measures of past shelter use and one of past criminal justice involvement had 83.0% sensitivity and 20.4% positive predictive value for future shelter entry.

CONCLUSIONS

Our study demonstrates the potential of using cross-sector data to improve hospital initiatives to address patients' social needs.

Turning Off the Tap: A Typology for Homelessness Prevention

As states move beyond simply managing their homelessness crises to looking for ways to reduce and ultimately end homelessness, broad-scale efforts to prevent homelessness are lacking. Experiences of homelessness are often harmful, traumatic, and costly, making a compelling case for why homelessness prevention should be prioritized. In recent years, countries such as Australia, Finland, and Wales have shifted their focus to prevention, but there remains a conceptual and systematic gap in our collective knowledge about what precisely homelessness prevention is, what policies, programs, and interventions are captured in a homelessness prevention strategy, and how to build a framework for orienting our response to homelessness towards prevention. This article begins to fill that gap by providing a definition and typology of homelessness prevention (THP). Our definition offers a schema to clarify the nature of homelessness prevention and to develop a collective response between various policies and practices that can and should be framed as homelessness prevention. Building off of the public health model of prevention and pre-existing homelessness prevention classification systems, our THP complements the definition by specifying the pragmatic nature of prevention initiatives and the range of sectors, stakeholders, and levels of government required to respond to the causes of homelessness. Our typology is made up of five interrelated elements: structural, systems, early intervention, evictions prevention, and housing stabilization. Each of these elements contains actionable strategies that cut across primary, secondary, and tertiary prevention to ensure that people at various levels of risk have access to the tools and resources necessary to find and maintain safe, appropriate, and suitable housing. Together the definition and THP are useful tools to envision a new way forward in how we respond to homelessness.

Survivors Achieving Stable Housing: Implementation, Challenges, and Lessons Learned

There is a movement toward permanent housing as an alternative to emergency shelter for survivors of intimate partner violence (IPV). Through a case study, this article illuminates the challenges survivors encountered at multiple levels after being offered one of 25 permanent housing choice vouchers (HCVs) as part of the Survivors Achieving Stable Housing project. Obtaining an HCV is a complicated and lengthy process; survivors transitioning from emergency shelter may face time limits on shelter stays while awaiting this permanent housing option. This article identifies challenges, such as difficulties with landlords, moving costs, and a lack of affordable housing, similar to issues reported in previous research. However, specific to IPV survivors, intersecting U.S. Department of Housing and Urban Development and Violence Against Women Reauthorization Act of 2013 (S. 47) policies led to challenges in implementing and interpreting rules and guidance for IPV survivors. Survivor safety from an abusive partner and across other aspects of their lives is of particular concern to survivors as they consider housing options. Given the overlap of homelessness and IPV, social workers in both systems must be knowledgeable about the intersecting issues survivors face as well as the policies affecting them so they can advocate effectively for their clients.

Understanding Mechanisms Driving Family Homeless Shelter Use and Child Mental Health

Homeless shelters throughout the U.S. are overcrowded and under-resourced. Families with children face substantial barriers to timely, successful shelter exit, and prolonged shelter stays threaten child mental health. This community-based system dynamics study explored barriers to timely, successful shelter exit and feedback mechanisms driving length of stay and child mental health risk. Group model building - a participatory systems science tool - and key informant interviews were conducted with clients (N = 37) and staff (N = 6) in three family homeless shelters in a Midwestern region. Qualitative content analysis with emergent coding identified key themes feedback loops. Findings indicated overcrowding delayed successful shelter exit; longer stays exacerbated crowding and stress in a vicious cycle. Furthermore, longer stays exacerbated child risk for mental disorder both directly and indirectly via crowding and caregiver stress. Capacity constraints limited families served, while contributing to ongoing unmet need. Future research should investigate the roles of these dynamic feedback relationships in the persistent vulnerability of homeless families. Service design should prioritize interventions that alleviate crowding and subsequent threats to mental health such as private or scattered-site shelter accommodations, affordable child care, and homelessness prevention to facilitate successful shelter exit and mitigate child mental health risk.

When Crises Converge: Hospital Visits Before And After Shelter Use Among Homeless New Yorkers

People who are homeless use more hospital-based care than average, yet little is known about how hospital and shelter use are interrelated. We examined the timing of emergency department (ED) visits and hospitalizations relative to entry into and exit from New York City homeless shelters, using an analysis of linked health care and shelter administrative databases. In the year before shelter entry and the year following shelter exit, 39.3 percent and 43.3 percent, respectively, of first-time adult shelter users had an ED visit or hospitalization. Hospital visits-particularly ED visits-began to increase several months before shelter entry and declined over several months after shelter exit, with spikes in ED visits and hospitalizations in the days immediately before shelter entry and following shelter exit. We recommend cross-system collaborations to better understand and address the co-occurring health and housing needs of vulnerable populations.

Infants Exposed To Homelessness: Health, Health Care Use, And Health Spending From Birth To Age Six

Homeless infants are known to have poor birth outcomes, but the longitudinal impact of homelessness on health, health care use, and health spending during the early years of life has received little attention. Linking Massachusetts emergency shelter enrollment records for the period 2008-15 with Medicaid claims, we compared 5,762 infants who experienced a homeless episode with a group of 5,553 infants matched on sex, race/ethnicity, location, and birth month. Infants born during a period of unstable housing resulting in homelessness had higher rates of low birthweight, respiratory problems, fever, and other common conditions; longer neonatal intensive care unit stays; more emergency department visits; and higher annual spending. Differences in most health conditions persisted for two to three years. Asthma diagnoses, emergency department visits, and spending were significantly higher through age six. While screening and access to health care can be improved for homeless infants, long-term solutions require a broader focus on housing and income.

Family homelessness, subsequent CWS involvement, and implications for targeting housing interventions to CWS-involved families

BACKGROUND

Homelessness is a risk factor for family involvement with child welfare services (CWS). Housing interventions are promising-but reasons for this are not well understood, and housing resources could be better targeted to families at risk of increased CWS involvement.

OBJECTIVE

We sought to better understand the relationship between homelessness and CWS involvement and examine whether homeless shelter data could combine with CWS data to enhance intervention targeting.

PARTICIPANTS AND SETTING

For 4 years, we followed 2063 families investigated by the San Francisco Human Services Agency in 2011.

METHODS

Matching CWS data to homeless shelter data, we fit Cox models to examine the relationship between shelter use and subsequent CWS outcomes and produced ROC curves to judge model accuracy with and without shelter information.

RESULTS

Absent CWS covariates (family demographics, CWS history, and family safety and risk), past shelter entry predicted repeat maltreatment referral (HR = 1.92, p < .001), in-home case opening (HR = 1.51, p < .05), and child removal (HR = 1.95, p < .01), but not child reunification. With CWS covariates, past shelter use no longer predicted case opening and child removal, but still predicted referral (HR = 1.58, p < .01). Shelter data did not contribute to models' predictive accuracy.

CONCLUSIONS

We find mixed evidence that shelter use independently leads to CWS involvement. Housing interventions might help by addressing present housing problems and family experiences correlated with past shelter use. However, we find no evidence that data matches with shelter systems could enhance targeting.

Homeless Shelter Entry in the Year After an Emergency Department Visit: Results From a Linked Data Analysis

STUDY OBJECTIVE

Housing instability is prevalent among emergency department (ED) patients and is known to adversely affect health. We aim to determine the incidence and timing of homeless shelter entry after an ED visit among patients who are not currently homeless.

METHODS

We conducted a random-sample survey of ED patients at an urban public hospital from November 2016 to September 2017. Patients provided identifying information and gave informed consent for us to link their survey data with the New York City Department of Homeless Services shelter database. Shelter use was followed prospectively for 12 months after the baseline ED visit. We examined timing of shelter entry in the 12 months after the ED visit, excluding patients who were homeless at baseline.

RESULTS

Of 1,929 unique study participants who were not currently homeless, 96 (5.0%) entered a shelter within 12 months of their baseline ED visit. Much of the shelter entry occurred in the first month after the ED visit, with continued yet slower rates of entry in subsequent months. Patients in our sample who entered a shelter were predominantly men and non-Hispanic black, and commonly had past shelter and frequent ED use.

CONCLUSION

In this single-center study, 5.0% of urban ED patients who were not currently homeless entered a homeless shelter within the year after their ED visit. Particularly if replicated elsewhere, this finding suggests that ED patients may benefit from efforts to identify housing instability and direct them to homelessness prevention programs.

Permanent Housing Placement and Reentry to Services Among Family Recipients of Homelessness Prevention and Rapid Re-Housing Program (HPRP) Assistance

The Homelessness Prevention and Rapid Re-Housing Program (HPRP) provided individuals and families who were either at-risk or currently experiencing homelessness with time-limited financial and housing support services. Evaluations of HPRP showed a high rate of family placement into permanent housing. However, little research has explored immediate and longitudinal outcomes for families enrolled in HPRP. Using Homeless Management Information System data from Indianapolis, Indiana, we examined demographic and program-related predictors of families entering permanent housing and their risk of reentry into homeless services following HPRP participation. The sample included 511 families who enrolled in the program from 2009 to 2012, with an average follow-up period of 4.5 years. We conducted analyses separately for Homelessness Prevention (HP) recipients (n = 357) and Rapid Re-Housing (RRH) recipients (n = 154). Results revealed that HP families were more likely to enter permanent housing if they: included adults who were older in age, were enrolled longer in the program, were provided rental arrear services and utility payments, and did not receive legal services. RRH families receiving rental assistance services had significantly greater odds of entering permanent housing. Among permanently housed families, at least one family member in 10.9% of HP recipients and 18.8% of RRH recipients reentered homeless services. HP families with younger children and one veteran family member were at increased risk of reentry to homelessness services. RRH recipients who did not receive moving cost services and had more children were at greater risk of reentry. Study findings suggest a need for future research on HP and RRH interventions that identify unique service needs among families who are experiencing housing instability or homelessness.

Solving Homelessness from a Complex Systems Perspective: Insights for Prevention Responses

Homelessness represents an enduring public health threat facing communities across the developed world. Children, families, and marginalized adults face life course implications of housing insecurity, while communities struggle to address the extensive array of needs within heterogeneous homeless populations. Trends in homelessness remain stubbornly high despite policy initiatives to end homelessness. A complex systems perspective provides insights into the dynamics underlying coordinated responses to homelessness. A constant demand for housing assistance strains service delivery, while prevention efforts remain inconsistently implemented in most countries. Feedback processes challenge efficient service delivery. A system dynamics model tests assumptions of policy interventions for ending homelessness. Simulations suggest that prevention provides a leverage point within the system; small efficiencies in keeping people housed yield disproportionately large reductions in homelessness. A need exists for policies that ensure reliable delivery of coordinated prevention efforts. A complex systems approach identifies capacities and constraints for sustainably solving homelessness.

Applying a prevention framework to address homelessness as a population health issue

This paper presents a population health framework for homelessness prevention. Rooted in the Los Angeles County Homeless Initiative, the framework includes strategies that affect social determinants of health that influence a broad range of health outcomes prevalent among the homeless. For each prevention level, we consider the purpose of prevention, the sub-population of interest, and evidence of the effectiveness of interventions in addressing factors that affect health and health outcomes. Our review highlights the importance of cross-cutting strategies and the limits of our knowledge about more targeted preventive interventions. We note that a prevention orientation requires attention to the social and physical environments that affect homelessness plus connections between the homelessness services sector and mainstream systems of care and support.

Timing and Duration of Pre- and Postnatal Homelessness and the Health of Young Children

: media-1vid110.1542/5804912861001PEDS-VA_2017-4254Video Abstract OBJECTIVES: Prenatal homelessness is associated with elevated risks of adverse neonatal outcomes. How the timing and duration of homelessness during pregnancy and/or a child's early life relate to postnatal child health is unclear.

METHODS

We interviewed 20 571 low-income caregivers of children <4 years old in urban pediatric clinics and/or emergency departments in 5 US cities. Categories of homelessness timing were prenatal, postnatal, both, or never; postnatal duration was >6 months or <6 months.

RESULTS

After controlling for birth outcomes and other potential confounders, compared with never-homeless children, children who were homeless both pre- and postnatally were at the highest risk of the following: postneonatal hospitalizations (adjusted odds ratio [aOR] 1.41; confidence interval [CI] 1.18-1.69), fair or poor child health (aOR 1.97; CI 1.58-2.47), and developmental delays (aOR 1.48; CI 1.16-1.89). There was no significant association with risk of underweight (aOR 0.95; CI 0.76-1.18) or overweight status (aOR 1.07; CI 0.84-1.37). Children <1 year old with >6 months of homelessness versus those who were never homeless had high risks of fair or poor health (aOR 3.13; CI 2.05-4.79); children 1 to 4 years old who were homeless for >6 months were at risk for fair or poor health (aOR 1.89; CI 1.38-2.58).

CONCLUSIONS

After controlling for birth outcomes, the stress of prenatal and postnatal homelessness was found to be associated with an increased risk of adverse pediatric health outcomes relative to those who were never homeless. Interventions to stabilize young families as quickly as possible in adequate and affordable housing may result in improved pediatric health outcomes.

Predictive modeling of housing instability and homelessness in the Veterans Health Administration

OBJECTIVE

To develop and test predictive models of housing instability and homelessness based on responses to a brief screening instrument administered throughout the Veterans Health Administration (VHA).

DATA SOURCES/STUDY SETTING

Electronic medical record data from 5.8 million Veterans who responded to the VHA's Homelessness Screening Clinical Reminder (HSCR) between October 2012 and September 2015.

STUDY DESIGN

We randomly selected 80% of Veterans in our sample to develop predictive models. We evaluated the performance of both logistic regression and random forests-a machine learning algorithm-using the remaining 20% of cases.

DATA COLLECTION/EXTRACTION METHODS

Data were extracted from two sources: VHA's Corporate Data Warehouse and National Homeless Registry.

PRINCIPAL FINDINGS

Performance for all models was acceptable or better. Random forests models were more sensitive in predicting housing instability and homelessness than logistic regression, but less specific in predicting housing instability. Rates of positive screens for both outcomes were highest among Veterans in the top strata of model-predicted risk.

CONCLUSIONS

Predictive models based on medical record data can identify Veterans likely to report housing instability and homelessness, making the HSCR screening process more efficient and informing new engagement strategies. Our findings have implications for similar instruments in other health care systems.

Homelessness in the child welfare system: A randomized controlled trial to assess the impact of housing subsidies on foster care placements and costs

Inadequate housing and homelessness among families represent a substantial challenge for child and adolescent well-being. Child welfare services confront housing that threatens placement into foster care with little resources and evidence to guide practice. The present study provides the first rigorous test of the Family Unification Program (FUP) - a federal program that offers housing subsidies for inadequately housed families under investigation for child maltreatment. A randomized controlled trial assesses program impact on foster care placement and costs. The experiment referred intact child welfare-involved families whose inadequate housing threatened foster placement in Chicago, IL to FUP plus housing advocacy (n = 89 families with 257 children) or housing advocacy alone (n = 89 families with 257 children). Families were referred from 2011 to 2013, and administrative data recorded dates and costs of foster placements over a 3-year follow-up. Intent-to-treat analyses suggested families randomly assigned for FUP exhibited slower increases in rates of foster placement following housing intervention compared with families referred for housing advocacy alone. The program generates average savings of nearly $500 per family per year to the foster care system. Housing subsidies provide the foster care system small but significant benefits for keeping homeless families together. Findings inform the design of a coordinated child welfare response to housing insecurity.

Health Care Utilization and Expenditures of Homeless Family Members Before and After Emergency Housing

OBJECTIVES

To describe longitudinal health service utilization and expenditures for homeless family members before and after entering an emergency shelter.

METHODS

We linked Massachusetts emergency housing assistance data with Medicaid claims between July 2008 and June 2015, constructing episodes of health care 12 months before and 12 months after families entered a shelter. We modeled emergency department visits, hospital admissions, and expenditures over the 24-month period separately for children and adults.

RESULTS

Emergency department visits, hospital admissions, and expenditures rose steadily before shelter entry and declined gradually afterward, ending, in most cases, near the starting point. Infants, pregnant women, and individuals with depression, anxiety, or substance use disorder had significantly higher rates of all outcomes. Many children's emergency department visits were potentially preventable.

CONCLUSIONS

Increased service utilization and expenditures begin months before families become homeless and are potentially preventable with early intervention. Infants are at greater risk. Public Health Implications. Early identification and intervention to prevent homeless episodes, focusing on family members with behavioral health disorders, who are pregnant, or who have young children, may save money and improve family health.

Families' Experiences of Doubling Up After Homelessness

This study examined experiences of doubling up among families after episodes of homelessness. Doubling up refers to two or more adults or families residing in the same housing unit, which has been an increasing trend in the United States in recent decades. Within the past 14 years, the number of households containing more than one family, related or unrelated, has more than tripled. Although doubling up is increasingly common among families at all income levels, this study seeks to understand the experiences of doubling up among families who have been homeless. Through qualitative interviews with caregivers of 29 families, we analyzed advantages and disadvantages of doubling up with the caregiver's parent, other family, and nonfamily. Experiences were rated on a four-point scale-(1) mostly negative, (2) negative mixed, (3) positive mixed, and (4) mostly positive-and coded for various positive and negative themes. Overall, we found that doubling up was a generally negative experience for families in our sample, regardless of their relationship to their hosts. Common themes included negative effects on children, undesirable environments, interpersonal tension, and feelings of impermanence and instability. For formerly sheltered families in this study, doubling up after shelter did not resolve their period of housing instability and may be only another stop in an ongoing cycle of homelessness.

Can Housing and Service Interventions Reduce Family Separations for Families Who Experience Homelessness?

Family break-up is common in families experiencing homelessness. This paper examines the extent of separations of children from parents and of partners from each other and whether housing and service interventions reduced separations and their precursors among 1,857 families across 12 sites who participated in the Family Options Study. Families in shelters were randomized to offers of one of three interventions: permanent housing subsidies that reduce expenditures for rent to 30% of families' income, temporary rapid re-housing subsidies with some services directed at housing and employment, and transitional housing in supervised facilities with extensive psychosocial services. Each group was compared to usual care families who were eligible for that intervention but received no special offer. Twenty months later, permanent housing subsidies almost halved rates of child separation and more than halved rates of foster care placements; the other interventions did not affect separations significantly. Predictors of separation were primarily homelessness and drug abuse (all comparisons), and alcohol dependence (one comparison). Although housing subsidies reduced homelessness, alcohol dependence, intimate partner violence, and economic stressors, the last three variables had no association with child separations in the subsidy comparison; thus subsidies had indirect effects via reductions in homelessness. No intervention reduced partner separations.

Housing and Child Welfare: Emerging Evidence and Implications for Scaling up Services

Inadequate housing threatens family stability in communities across the United States. This study reviews emerging evidence on housing interventions in the context of scale-up for the child welfare system. In child welfare, scale-up refers to the extent to which fully implemented interventions sustainably alleviate family separations associated with housing instability. It incorporates multiple aspects beyond traditional measures of effectiveness including costs, potential reach, local capacities for implementation, and fit within broader social services. The framework further encompasses everyday circumstances faced by service providers, program administrators, and policymakers who allocate resources under conditions of scarcity and uncertainty. The review of current housing interventions reveals a number of systemic constraints for scale-up in child welfare. Reliance on rental assistance programs limits capacity to address demand, while current practices that target the most vulnerable families may inadvertently diminish effectiveness of the intervention and increase overall demand. Alternative approaches that focus on homelessness prevention and early intervention must be tested in conjunction with community initiatives to increase accessibility of affordable housing. By examining system performance over time, the scalability framework provides an opportunity for more efficient coordination of housing services within and outside of the child welfare system.

Risk Models for Returns to Housing Instability Among Families Experiencing Homelessness

This study developed risk models for returns to housing instability (that is, homelessness and unstable doubling-up situations) among families exiting emergency shelter. Participants included 446 families randomly assigned to receive priority offers of long-term housing subsidies and 578 families randomly assigned to usual care in the Family Options Study, a multisite experiment designed to test the impact of various housing and service interventions for homeless families. Relationships between family features recorded at shelter entry and returns to housing instability 20 months later were examined empirically. Correlation, hierarchical logistic regression, and receiver operating characteristic curves were used to combine family features into predictive risk models. Results indicated that few observable family features beyond previous housing instability offered predictive utility. Access to long-term housing subsidies appears to reduce housing instability. Further research should examine whether disability benefits, reliable employment, or effective substance dependence treatment reduce housing instability.

Homelessness prevention in New York City: On average, it works

This study evaluates the community impact of the first four years of Homebase, a homelessness prevention program in New York City. Family shelter entries decreased on average in the neighborhoods in which Homebase was operating. Homebase effects appear to be heterogeneous, and so different kinds of averages imply different-sized effects. The (geometric) average decrease in shelter entries was about 5% when census tracts are weighted equally, and 11% when community districts (which are much larger) are weighted equally. This study also examines the effect of foreclosures. Foreclosures are associated with more shelter entries in neighborhoods that usually do not send large numbers of families to the shelter system.

Personal, dyadic, and contextual resilience in parents experiencing homelessness

Adopting a developmental psychopathology (DP) perspective, the present study systematically reviewed the quantitative literature on positive functioning and outcomes in parents experiencing homelessness. Studies were identified from PubMed, PsycInfo, and Web of Science using an exhaustive list of key terms. Of 3443 total studies screened, 219 were inspected, 176 were excluded, and 43 were included. Included studies fell into three outcome categories: the ability to function well personally (cope effectively, meet basic family needs, experience reduced psychopathology); dyadically (demonstrate positive parenting practices and promote child adjustment); and contextually (exit episodes of homelessness and avoid shelter re-entry). Results also reflected personal, dyadic, and contextual independent variables associated with each positive outcome category. Many parents experiencing homelessness display positive outcomes, and many factors support positive functioning. Future research should replicate these findings and examine multilevel parental functioning to help bridge the gap between the DP theoretical perspective and the quantitative evidence for parental resilience as a process.

Development and validation of an instrument to assess imminent risk of homelessness among veterans

OBJECTIVES

Veterans are overrepresented within the homeless population compared with their non-veteran counterparts, particularly when controlling for poverty. The U.S. Department of Veterans Affairs (VA) aims to prevent new episodes of homelessness by targeting households at greatest risk; however, there are no instruments that systematically assess veterans' risk of homelessness. We developed and tested a brief screening instrument to identify imminent risk of homelessness among veterans accessing VA health care.

METHODS

The study team developed initial assessment items, conducted cognitive interviews with veterans experiencing homelessness, refined pilot items based on veterans' and experts' feedback and results of psychometric analyses, and assigned weights to items in the final instrument to indicate a measure of homelessness risk.

RESULTS

One-third of veterans who responded to the field instrument reported imminent risk of homelessness (i.e., housing instability in the previous 90 days or expected in the next 90 days). The reliability coefficient for the instrument was 0.85, indicating good internal consistency. Veterans who had a recent change in income, had unpaid housing expenses, were living temporarily with family and friends, needed help to get or keep housing, and had poor rental and credit histories were more likely to report a risk of homelessness than those who did not.

CONCLUSION

This study provides the field with an instrument to identify individuals and households at risk of or experiencing homelessness, which is necessary to prevent and end homelessness. In addition, it supports VA's investment in homelessness prevention and rapid rehousing services for veterans who are experiencing or are at risk for homelessness.