[Homeless persons and hospital emergencies in a UHC in Paris].
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Adult↗
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Letter: the homeless person and the psychiatric services.
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Delivery of Health Care↗
Characteristics of persons who are homeless for the first time.
The Pathways Into Homelessness project in Toronto interviewed 300 unaccompanied adult users of homeless shelters to identify characteristics of individuals who are homeless for the first time. The sample reflected the total population of homeless shelter users in terms of age, sex, level of use, and type of shelter. Two fifths of the sample were homeless for the first time. There were more similarities than differences between those who were homeless for the first time and those who had been homeless previously. The prevalence of psychiatric and substance use disorders and the rate of previous hospitalization did not differ between first-time homeless persons and those who had been homeless before. The two groups were distinguished by some childhood experiences related to housing. Both groups had multiple indicators of serious problems, suggesting that the need for intervention is as pressing for persons who are homeless for the first time as it is for the larger population of homeless persons.
Adult↗
Music: making the connection with persons who are homeless.
1. Persons who are homeless experience isolation and loneliness; many lack social skills or the ability to interact comfortably with others. A music program designed to increase socialization and relaxation of homeless persons using a multiservice shelter is described. 2. The use of music provides the psychiatric nurse an entry into therapeutic relationships and an opportunity to establish relationships with persons who often do not initiate contact with others. 3. Music promotes relaxation and interaction with others. Listening to music decreases loneliness and isolation. The music program was effective in fostering a sense of well-being and allowing the participants to join together in a meaningful activity.
Crisis Intervention↗
Review of programs for persons who are homeless and mentally ill.
Despite recent prosperity in the U.S., homelessness is still a widespread social problem. It is estimated that 25% of homeless persons have a serious mental illness. This article will review the literature evaluating prevention services and specialized outreach, treatment, and housing programs designed to reduce homelessness for individuals who are mentally ill. Although these interventions have been helpful in addressing the complex needs of the homeless mentally ill, it is difficult to measure how they have improved outcomes. It is even more challenging to determine whether the programs are cost-effective. Since public resources are used to maintain services for the homeless mentally ill, policy-makers must be informed about whether the best outcomes are achieved at the lowest possible cost. Following a discussion of the successes of the individual programs and the challenges they confront, several important questions are identified related to improving the efficiency of these programs. Although the establishment of such programs indicates that progress has been made toward alleviating the burdens facing people who are homeless and mentally ill, collaboration among all stakeholders-especially between the mental health community and consumer advocates-needs to be further enhanced. New research can be conducted in a way that improves how information is evaluated and used.
Adult↗
Successful systems integration strategies: the access program for persons who are homeless and mentally ill.
In 1993, the Access to Community Care and Effective Services and Supports (ACCESS) federal demonstration program was initiated. Using a quasi-experimental design, the 5-year demonstration program sought to assess the impact of integrated systems of care on outcomes for homeless persons with mental illness. The authors report on which integration strategies were chosen and how their implementation is quantified. Data collected primarily through annual site visits revealed that only two strategies were used by all nine systems. The systems integration strategies employed remained relatively stable over the 5 years. Successful implementation appears to be related to the strategies selected.
Delivery of Health Care, Integrated↗
Case management for persons who are homeless.
Comprehensive, client-centered continuous care with a multidisciplinary team using the case management model has proven to be essential in providing health care services to the homeless. Despite their heterogeneity, homeless persons share the common experiences of being poor, isolated, and in crisis. The process of case management is inherently therapeutic for its recipients and providers. It has the potential to be a source of human support for those who have none. Case management models can be effective systems for providing health care to these persons while addressing their special needs and characteristics.
Adult↗
The winner's group: a self-help group for homeless chemically dependent persons.
The homeless chemically addicted person presents many unique problems that cannot be addressed in standard treatment programs. Homeless clients are difficult to track and are not consistent in follow-up care. The health and mental health conditions found in this population are straining the resources of drug treatment programs, hospitals, the criminal justice system, and social agencies that serve the homeless (Bassuck, 1991). The Winner's Group located in an inner city soup kitchen demonstrates the adaptability and flexibility of nursing practice. The nurses exhibited creativity in developing methods to meet the diverse needs of homeless chemically addicted persons. The goals and objective that were achieved were neither successes nor failures, they were reflections of efforts to make lifestyle changes. Some of those persons responded in a very positive manner, while others continued to deteriorate. An overall desire was to instill a seed of hope and knowledge that there is always a potential for change and that recovery from chemical dependency is possible. Nurses who work with the homeless must be knowledgeable and realistic about the impact and importance of substance abuse. Nontraditional programs that meet the unique needs of a particular setting and a particular population can provide an opportunity to gain access to health care providers.
Adult↗
Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness.
OBJECTIVES: Cost-effective programs are needed to assist homeless persons with severe mental illness in their transition from shelters to community living. The authors investigated the cost-effectiveness of the critical time intervention program, a time-limited adaptation of intensive case management, which has been shown to significantly reduce recurrent homelessness among men with severe mental illness. METHOD: S: Ninety-six study participants recruited from a psychiatric program in a men's public shelter from 1991 to 1993 were randomly assigned to the critical time intervention program or to usual services. Costs and housing outcomes for the two groups were examined over 18 months. RESULTS: Over the study period, the critical time intervention group and the usual services group incurred mean costs of 52,374 dollars and 51,649 dollars, respectively, for acute care services, outpatient services, housing and shelter services, criminal justice services, and transfer income. During the same period, the critical time intervention group experienced significantly fewer homeless nights than the usual care group (32 nights versus 90 nights). For each willingness-to-pay value--the additional price society is willing to spend for an additional nonhomeless night--greater than 152 dollars, the critical time intervention group exhibited a significantly greater net housing stability benefit, indicating cost-effectiveness, compared with usual care. CONCLUSION: S: Although difficult to conduct, studies of the cost-effectiveness of community mental health programs can yield rich information for policy makers and program planners. The critical time intervention program is not only an effective method to reduce recurrent homelessness among persons with severe mental illness but also represents a cost-effective alternative to the status quo.
Adult↗
No door to lock: victimization among homeless and marginally housed persons.
BACKGROUND: Homeless persons experience high rates of sexual and physical assault; homeless women are thought to be at highest risk. To determine the prevalence, distribution, and factors associated with sexual and physical assault, we surveyed homeless and marginally housed adults in San Francisco, Calif. METHODS: We interviewed 2577 respondents about their history of recent sexual and physical assault, housing history, sexual practices, substance use, health status, and criminal justice history. The main outcome measures were self-reported sexual and physical assault in the previous 12 months. RESULTS: Overall, 32.3% of women, 27.1% of men, and 38.1% of transgendered persons reported a history of either sexual or physical assault in the previous year; 9.4% of women, 1.4% of men, and 11.9% of transgendered persons reported sexual assault, and 30.6% of women, 26.6% of men, and 33.3% of transgendered persons reported physical assault. In multivariate models, being homeless (as opposed to marginally housed) was associated with sexual assault for women, but not for men (adjusted odds ratio for homeless women, 3.4 [1.2-9.7]). Housing status was not associated with physical assault for women or men. Mental illness and sex work were both common and associated with high rates of assault in multivariate analyses. CONCLUSIONS: Sexual and physical assault are common experiences for homeless and marginally housed persons. Housing is associated with lower rates of sexual assault among women. Strategies to decrease sexual and physical assault and its consequences are needed in this population.
Adolescent↗
Housing preferences and perceptions of health and functioning among homeless mentally ill persons.
OBJECTIVE: Most homeless persons who have received services for serious mental illness want to live on their own, but mental health professionals usually recommend group housing. This study examined the relationship between the types of residential arrangements preferred by homeless mentally ill persons and their demographic and clinical characteristics and perceptions of their health and functional status. METHODS: The study sample consisted of 118 homeless mentally ill persons living in publicly funded shelters in Boston who were enrolled in a research demonstration project that would provide them with housing. Before random assignment to housing, study participants were interviewed about their interest in moving, in staff support, and in living with others. Their clinical status and functional strengths and impairments were assessed using a variety of objective and subjective measures. RESULTS: Study participants reported a marked preference for independent living but expressed substantial interest in staff support. The desire for independent living was associated with a perceived ability to manage independent living, but was also associated with current substance abuse. Most indicators of clinical status and functional ability were not associated with housing preferences. CONCLUSIONS: Self-perceived functional ability may not be an influence on housing preferences, except when that ability is perceived as making independent living more difficult. Symptoms of mental illness did not appear to interfere with study participants' rational decision making about where to live. However, the study finding that substance abusers expressed a desire for independent living suggests the need for caution in adhering to homeless mentally ill persons' housing preferences, given the problems posed by substance abuse for their ability to maintain stable community housing.
Activities of Daily Living↗
Use of BCG vaccine in shelters for the homeless. A decision analysis.
As a result of many interacting variables, including crowded shelters and limited access to health care, homeless persons are at high risk for tuberculosis. Using traditional approaches, control of tuberculosis in this population has been difficult. Decision analysis was used to investigate the cost-effectiveness of BCG (bacillus Calmette-Guérin) vaccination in persons attending homeless shelters. This vaccination was cost-effective over a wide range of assumptions. Using conservative assumptions, a vaccine that was at least 40 percent effective would result in a net cost savings. If the efficacy of the vaccine were 50 percent, $4,000 would be saved, 12 life-years gained, and 23 cases of active tuberculosis prevented for every 1,000 persons vaccinated. Further study of the BCG vaccine in homeless persons and other populations at risk is warranted.
Adult↗
Healthcare for the homeless. A public health agency, a business, and a Catholic provider open a clinic.
In some communities, hospital emergency departments are the only places that provide healthcare services to homeless persons. In Dayton, OH, homeless persons have another option--the Samaritan: A Healthcare Clinic for the Homeless. The clinic is a collaborative venture involving the area's public health department, a Fortune 500 business, and a Catholic hospital. In 1991 Dayton's public health department, the Combined Health District (CHD) of Montgomery County, received an anonymous $50,000 donation to provide primary healthcare services to homeless persons. With the goal of generating a number of stakeholders to invest in the community (which would translate into additional volunteers and donations), CHD asked Good Samaritan Hospital, Dayton, if it would become a partner in launching the clinic. Good Samaritan agreed, seeing this as an opportunity to provide a much-needed community service and to fulfill its mission of providing care to the area's needy citizens. In addition, the project was consistent with the hospital's increased focus on primary care. Sponsors of the Samaritan: A Healthcare Clinic for the Homeless anticipate three outcomes resulting from this collaborative effort. First, the cost of healthcare for Dayton's citizens should decrease. Second, providing healthcare services to the homeless enhances the possibility of breaking the cycle of homelessness. Finally, it is critical that healthcare for the homeless become a community focus.
Catholicism↗
Strategies to decrease tuberculosis in us homeless populations: a computer simulation model.
CONTEXT: The rate of tuberculosis (TB) among US homeless persons may be 20 times that of the general adult population. Studies suggest that the majority of urban homeless TB cases are attributable to ongoing transmission of TB. Optimal TB-control strategies in both chronically and transiently homeless populations are not known. OBJECTIVE: To examine the effects of TB-control strategies on projected TB cases and deaths in US homeless populations using a computer-based simulation model. DESIGN, SETTING, AND POPULATION: The US general population and a theoretical population of 2 million homeless individuals in 1995 were divided into 18 clinical states based on the risk for or presence of TB and human immunodeficiency virus (HIV) infection in a semi-Markov model. MAIN OUTCOME MEASURES: Prevalence of transiently and chronically homeless individuals with active TB and deaths from TB as a function of public health measures taken to control and eliminate TB, including improvement of treatment effectiveness, improvement in access to treatment, and vaccination with BCG. RESULTS: A 10% increase in access to treatment among homeless persons with active TB produced larger declines in predicted TB cases and deaths after 10 years (cases and deaths among chronically homeless persons decreased 12.5% and 19.8% and among transiently homeless persons dropped 35.9% and 32.4%, respectively) than improvements in the effectiveness of treatment programs (cases and deaths among chronically homeless persons declined 7.2% and 3.1% and among transiently homeless persons dropped 10.9% and 4.1%, respectively). A 10% increase in access to treatment among homeless persons with latent TB infection led to a 6.7% decline in TB among chronically homeless persons and a 5.7% decline among transiently homeless persons, while a 10% improvement in effectiveness of treatment for latent TB infection was associated with declines of 3.0% and 3.3%, respectively. When treatment for latent TB infection was modeled to be the same in vaccinated and nonvaccinated populations, BCG vaccination led to TB case declines of 15.4% and 21.5% in chronically and transiently homeless populations, respectively. CONCLUSIONS: Overcoming barriers faced by homeless individuals in accessing TB treatment programs will be crucial to reducing the burden of TB in this high-risk group. Increased treatment access, improvement in the effectiveness of treatment programs, and BCG vaccination of HIV-negative homeless individuals have the best chance to markedly decrease TB morbidity and mortality.
Antitubercular Agents↗
Nutrition and health services needs among the homeless.
This review discusses nutrition and related health problems among homeless Americans, summarizes recent information, and identifies needs for services and future research. The nature of homelessness today provides a context for the discussion. Many homeless persons eat fewer meals per day, lack food more often, and are more likely to have inadequate diets and poorer nutritional status than housed U.S. populations. Yet many homeless people eligible for food stamps do not receive them. While public and private agencies provide nutritious food and meals for homeless persons, availability of the services to homeless persons is limited. Many homeless people lack appropriate health care, and certain nutrition-related health problems are prevalent among them. Compared with housed populations, alcoholism, anemia, and growth problems are more common among homeless persons, and pregnancy rates are higher. The risks vary among homeless persons for malnutrition, nutrition-related health problems, drug and alcohol abuse, and mental illness. For example, among homeless persons, fewer heads of families than single adults are substance abusers, and mental illness varies in prevalence among single men, single women, and parents in homeless families. Homeless persons need improved access to food, nutrition, and health services. More nutrition education needs to be available to them and to service providers. Use of representative samples and validation of self-reported nutrition and health data will help future investigators to clarify the relationships between the characteristics of the homeless and their nutritional status.
Adult↗
Homelessness: health service use and related costs.
OBJECTIVES: This study examines health service use and costs for homeless and domiciled veterans hospitalized in psychiatric and substance abuse units at Department of Veterans Affairs (VA) medical centers, nationwide. METHODS: A national survey of residential status at the time of admission was conducted on all VA inpatients hospitalized in acute mental health care units on September 30, 1995. Survey data were merged with computerized workload data bases to assess service use and cost during the 6 months before and after the date of discharge from the index hospitalization. RESULTS: Of 9,108 veterans with complete survey data, 1,797 (20%) had been literally homeless at the time of admission, and 1,380 (15%) were doubled up temporarily, for a total homelessness rate of 35%. Combining patients from general psychiatry and substance abuse programs, the average annual cost of care for homeless veterans, after adjusting for other factors, was $27,206; $3,196 (13.3%) higher than the cost of care for domiciled veterans (P < 0.0001). Approximately 26% of annual inpatient VA mental health expenditures ($404 million) are spent on the care of homeless persons. CONCLUSIONS: Homelessness adds substantially to the cost of health care services for persons with mental illness in VA, and most likely, in other "safety net" systems that serve the poor. These high costs, along with the prospect of declining public funding for health and social welfare programs, and an anticipated increase in the numbers of homeless mentally ill persons, portend a difficult time ahead for both homeless patients and the organizations that care for them.
Adult↗
Tuberculosis and homelessness in the United States, 1994-2003.
CONTEXT: Tuberculosis (TB) rates among US homeless persons cannot be calculated because they are not included in the US Census. However, homelessness is often associated with TB. OBJECTIVES: To describe homeless persons with TB and to compare risk factors and disease characteristics between homeless and nonhomeless persons with TB. DESIGN AND SETTING: Cross-sectional analysis of all verified TB cases reported into the National TB Surveillance System from the 50 states and the District of Columbia from 1994 through 2003. MAIN OUTCOME MEASURES: Number and proportion of TB cases associated with homelessness, demographic characteristics, risk factors, disease characteristics, treatment, and outcomes. RESULTS: Of 185,870 cases of TB disease reported between 1994 and 2003, 11,369 were among persons classified as homeless during the 12 months before diagnosis. The annual proportion of cases associated with homelessness was stable (6.1%-6.7%). Regional differences occurred with a higher proportion of TB cases associated with homelessness in western and some southern states. Most homeless persons with TB were male (87%) and aged 30 to 59 years. Black individuals represented the highest proportion of TB cases among the homeless and nonhomeless. The proportion of homeless persons with TB who were born outside the United States (18%) was lower than that for nonhomeless persons with TB (44%). At the time of TB diagnosis, 9% of homeless persons were incarcerated, usually in a local jail; 3% of nonhomeless persons with TB were incarcerated. Compared with nonhomeless persons, homeless persons with TB had a higher prevalence of substance use (54% alcohol abuse, 29.5% noninjected drug use, and 14% injected drug use), and 34% of those tested had coinfection with human immunodeficiency virus. Compared with nonhomeless persons, TB disease in homeless persons was more likely to be infectious but not more likely to be drug resistant. Health departments managed 81% of TB cases in homeless persons. Directly observed therapy, used for 86% of homeless patients, was associated with timely completion of therapy. A similar proportion in both groups (9%) died from any cause during therapy. CONCLUSIONS: Individual TB risk factors often overlap with risk factors for homelessness, and the social contexts in which TB occurs are often complex and important to consider in planning TB treatment. Nevertheless, given good case management, homeless persons with TB can achieve excellent treatment outcomes.
Adult↗
The educational opportunities in a departmental program of health care for the homeless.
Persons who live on the streets and are homeless present many challenges to providers of health care. This paper describes a 14-year ongoing project in the Department of Family, Community, and Emergency Medicine at the University of New Mexico School of Medicine. This small clinic started in an inner-city rescue mission and subsequently has progressed to a much larger health care project for the homeless. Experience in this setting demonstrates that such a site can provide service to the homeless, while at the same time providing educational experiences for medical students and residents and an opportunity for academic research. This project can be duplicated in any academic medical center to provide both service and education.
Education, Medical, Continuing↗