Risk factors for unplanned hospital admission in a specialist homeless general practice population: case-control study to investigate the relationship with tri-morbidity

Improving uptake of population health management through scalable analysis of linked electronic health data

Population Health Management - often abbreviated to PHM - is a relatively new approach for healthcare planning, requiring the application of analytical techniques to linked patient level data. Despite expectations for greater uptake of PHM, there is a deficit of available solutions to help health services embed it into routine use. This paper concerns the development, application and use of an interactive tool which can be linked to a healthcare system's data warehouse and employed to readily perform key PHM tasks such as population segmentation, risk stratification, and deriving various performance metrics and descriptive summaries. Developed through open-source code in a large healthcare system in South West England, and used by others around the country, this paper demonstrates the importance of a scalable, purpose-built solution for improving the uptake of PHM in health services.

Homeless people: a review of personality disorders

Personality disorders in homeless people pose a challenge to the medical community and society, requiring specialized approaches for these super-difficult patients. The prevalence of personality disorders is higher in homeless populations than in the general population. However, there is a knowledge gap regarding personality disorders among people experiencing homelessness, and the implications of this lack of recognition are substantial. This paper provides a brief narrative review of personality disorders among homeless individuals. The primary importance and specificity of these disorders in this population remain unexplored. We searched PubMed and Web of Science databases in February and November 2023 using the keywords 'homeless' and 'personality disorder', and selected fifty-eight studies to be included in this literature review. The main themes of the results were personality disorders in homeless individuals and comorbid psychiatric disorders; risk factors and other psychological and behavioral data; clinical and intervention outcomes; and challenges linked to assessment, treatment, and intervention. The homeless population experiences significant diagnostic variability and the diagnosis of personality disorders is still evolving, contributing to difficulties in diagnosis, assessment, and treatment. A future challenge is to raise clinical awareness and optimize research knowledge, assessment, and intervention in personality disorders among homeless individuals with comorbid psychiatric disorders.

Understanding aims, successes and challenges of palliative care and homelessness initiatives across the UK: an exploratory study

BACKGROUND

Due to the recognition that people experiencing homelessness (PEH) often die young and unsupported, a growing number of initiatives focusing on palliative care and homelessness are emerging across the UK. However, there has been no systematic exploration of the nature and landscape of this work.

AIMS

To understand the range, aims, successes and challenges of current initiatives within the field of palliative care and homelessness in the UK, by exploring existing projects and initiatives.

METHOD

An online survey was distributed to members of an Extension for Community Healthcare Outcomes network focusing on palliative care and homelessness for a mixed professional audience. The survey collated the aims, successes and challenges of initiatives aiming to improve palliative care for PEH. Responses were summarised using descriptive statistics, and free-text responses were analysed using thematic analysis.

RESULTS

162 professionals completed the survey. Of these, 62% reported involvement in at least one palliative care and homelessness initiative. Initiatives focused on service delivery (59%), training (28%) and research (28%). Themes for success included improved service engagement, relationship formation, housing provision, honouring end-of-life wishes, upskilling staff and enabling safe hospital discharge. The main challenges included stigma around substance misuse, securing funding, staff capacity, equipment and facilities, and engaging communities.

CONCLUSION

The number and scope of initiatives aiming to support PEH with advanced ill health and palliative care needs across the UK is growing, with a range of professionals engaging in the field. Future research may benefit from exploring initiatives in more detail to understand the specific drivers of impact on PEH and the staff and services supporting them.

Models of dental care for people experiencing homelessness in the UK: a scoping review of the literature

Background People who experience homelessness have poor oral health and face barriers to accessing care. Recommendations have been outlined for health services to address their needs, termed 'inclusion health'. The Smile4Life report recommended three 'tiers' of dental service: emergency, ad hoc and routine care. Other medical services have developed into different models of care, for example mainstream practices with enhanced services for people who experience homelessness. There is little understanding of how inclusion health recommendations have been implemented across dental settings.Aims To describe and compare dental services that exist for people who experience homelessness in the UK.Methods Two Medline searches were performed in October 2020 to assess the models of dental care for people who experience homelessness in the UK.Results Nine dental services in the UK were identified who treated people who experience homelessness. Most did not explore definitions of homelessness. There were a mixture of models, including using blended approaches, such as different sites and appointment types, to flex to the needs of their population.Conclusion Many services that are dedicated to treat this population are based in the community dental services which allows for flexible models of care due to sporadic patient attendance, high treatment requirements and complex needs. More research is required to determine how other settings can accommodate these patients, as well as understanding how more rural populations access dental care.

Clinical characteristics, attendance outcomes and deaths of homeless persons in the emergency department: implications for primary health care and community prevention programmes

OBJECTIVES

Persons experiencing homelessness (PEH) are known to be often excluded from primary health care and community prevention programmes leading to high use of hospital emergency departments (EDs). This study aimed to identify demographic features, clinical characteristics and attendance outcomes of PEH presenting to ED.

STUDY DESIGN

Analysis of routinely collected data set.

METHODS

Clinical presentations and drug prescription data of PEH who presented a major ED in the West Midlands region of England from 2014 to 2019 were extracted and analysed using descriptive and inferential statistics.

RESULTS

During the study period, 3271 of 596,198 presentations were made by PEH; 74% PEH attendees were male. Drug- and alcohol-related conditions, as well as pain and injury constituted the most frequent reasons for presentation, contributing to over half of all presentations. A significantly higher proportion of males (n = 481, 20.3%) presented with drug and alcohol problems than females (n = 93, 11.2%) (P ≤ 0.001). However, pain was the primary reason for presentation for twice as many female patients (n = 189, 22.8%) compared with males (n = 305, 12.9%) (P < 0.001). Nearly one in five left the ED before being assessed and a total of 39 patients (1.2%) died in the ED and 785 (24.0%) required in-patient admissions to the same hospital.

CONCLUSIONS

Drug, alcohol and pain including the need of opioid analgesics constituted the majority of presentations made by PEH in ED. The observed rate of death of PEH in ED is 12 times higher than the general population. A very high proportion of PEH also leave the ED before being treated. Future research should focus on strengthening community interventions, particularly to improve access to those at risk of dual diagnoses of substance misuse and mental health problems. Interventions involving multisector collaborations are needed to improve seamless discharge from ED and minimise repeat attendance. Gender differences in the nature of presentations and ED outcomes needs to be investigated further.

Trends in Trimorbidity Among Adults Experiencing Homelessness in Minnesota, 2000-2018

BACKGROUND

Earlier and more severe onset of chronic health conditions contributes to the increased risk of premature death among adults experiencing homelessness. Trimorbidity, a subset of multimorbidity representing overlap of physical health, mental health, and substance use conditions, disproportionately impacts adults experiencing homelessness. We know of no longitudinal data comparing trimorbidity trends among adults experiencing homelessness.

OBJECTIVE

To characterize 19-year trimorbidity trends among adults experiencing homelessness.

RESEARCH DESIGN

Repeated longitudinal, statewide survey administered every 3 years.

SUBJECTS

Adults living throughout Minnesota experiencing homelessness.

MEASURES

Reported diagnoses of chronic health conditions within 3 categories: physical health conditions (hypertension, heart disease, asthma, diabetes); mental health conditions (depression, posttraumatic stress disorder, bipolar disorder, schizophrenia/other paranoid, and delusional disorders); and substance use conditions (alcohol and illicit substances).

RESULTS

A total of 25,552 surveys were completed by adults at 3-year intervals in a total of 7 waves. Participants reported increasing frequency and duration of homelessness, and more nights slept outside/in a car. 77.3% of adults experiencing homelessness in 2018 had one or more chronic health condition in any domain. From 2000 to 2018, bimorbidity and trimorbidity surpassed morbidity within a single domain. This was driven by increases in mental health conditions. In 2018, 31.7% of participants reported bimorbidity and 16.3% of adults reported trimorbidity.

CONCLUSIONS

Adults experiencing homelessness bear a substantial and growing burden of bimorbidity and trimorbidity. Ensuring accessible, high quality care that includes robust services that can address all 3 categories of health is critical. Such care is best delivered in combination with affordable supportive housing.