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PubMed2003

Measuring continuity of care for clients of public mental health systems.

OBJECTIVES: The aims of this research were to generate a set of time-variant measures of continuity of outpatient care using administrative data, and to evaluate the validity of these measures for persons in the community with serious mental illness (SMI) who use public mental health services. DATA SOURCES: Individuals with SMI were identified using multistage random sampling from shelters, streets, and public mental health clinics in Houston, Texas. STUDY DESIGN: The study design was observational, cross-sectional, and retrospective. Based on a review of the literature, five distinct conceptual dimensions of continuity of care were defined: timeliness, intensity, comprehensiveness, stability, and coordination. Repeated measures of continuity were generated for each day of the year. Construct validity was assessed by comparing continuity for housed persons and homeless persons based on the assumption that homelessness is a risk factor for low continuity of outpatient care. DATA COLLECTION: Subjects were interviewed to collect sociodemographic and clinical information. Service use was retrospectively tracked through the administrative records of multiple public sector agencies. PRINCIPAL FINDINGS: All five continuity measures demonstrated good construct validity by the fact that homelessness was significantly (p < 0.001) and substantially associated with lower continuity of care. DISCUSSION: The five continuity-of-care measures are relatively easy and inexpensive to generate using administrative data. The five continuity-of-care measures may be useful for identifying individuals at risk for poor outcomes and for evaluating the ability of public service systems to keep clients engaged in care over time.

Adult↗
PubMedDate not supplied

Health and lifestyle issues as risk factors for homelessness.

BACKGROUND: The objective of this study was to test the hypothesis that there are health and lifestyle issues among homeless persons that differentiate them from other segments of the population and that can be described as risk factors for homelessness. METHODS: This case-control study investigated health and lifestyle issues in a panel of patients visiting a health care clinic for homeless persons. The same information was collected from a panel of county indigent patients and an equal number of privately insured patients enrolled in a nearby academic family practice center. RESULTS: We found significant differences among these three groups. Differences in health problems were evident, as significantly more homeless persons reported mental health, drug and alcohol abuse, and smoking problems. There were no differences in the prevalence of other general medical conditions as listed by the patients. Homeless persons were younger than the control group respondents and more likely to be male, a member of a minority group, and unmarried. The childhood experiences of homeless persons were distinctive; they were more likely to have lived in a group home or some other nonfamily situation, considered themselves to have been delinquent, run away from home, been expelled from school, or been placed in reform school. The same held true for having been in jail as an adult. They had significantly less education, their job experiences were in manual and unskilled arenas, and they were more likely to have a gambling problem. A continuum of risk also appeared in that for the most part the characteristics and experiences of the indigent group members ranked in frequency between those of the homeless and insurance groups. CONCLUSIONS: Causes of homelessness appear to be multifactorial. Issues related to mental health, alcohol, nicotine, and other drug and substance abuse could be responsible for their medical problems, whereas other lifestyle issues might be regarded as risk factors for homelessness.

Adolescent↗
PubMed1990

Health care and the homeless: a political parable for our time.

The growth in the number of homeless persons is perhaps the most visible indicator of social disintegration in the 1980s, although health and health care are not the central issues of homelessness. This paper, which draws on the author's experience as chairman of the Committee on Health Care for Homeless People of the Institute of Medicine (IOM), describes what is known about the characteristics of homeless persons and the causes of homelessness, and about the health status of homeless persons, which is often not very good (but not significantly worse, it would appear, than that of other low-income persons). The contemporary history of health services targeted to homeless persons begins with the joint initiative of the Robert Wood Johnson Foundation and the Pew Charitable Trusts in 1985, which became the model for federal support through the Stewart B. McKinney Act of 1987. The McKinney Act, like the IOM report, demonstrates how, in contemporary American politics, there can be widespread political consensus not only about a problem but about solutions, while the resulting policy actions are largely symbolic.

Decision Making↗
PubMed1997

Breaking through the barriers: healthcare for the homeless.

National welfare reform is predicted to increase the number of homeless persons. This will affect the health care system by increasing the number of uninsured people and by multiplying the number of homeless persons seeking care in hospital emergency departments. Homeless persons have four major barriers to care: financial, bureaucratic, programmatic, and personal. The authors provide an overview of the homeless population, outline the barriers to health care for persons who are homeless, and highlight the major health care needs of this population. Finally, a community-based service delivery system developed by one agency in responding to the need of homeless persons is provided as a model of care.

Adult↗
PubMed1997

Causes of death in homeless adults in Boston.

BACKGROUND: Homeless persons have high mortality rates. OBJECTIVE: To ascertain causes of death in a group of homeless persons. DESIGN: Cohort study. PATIENTS: 17,292 adults seen by the Boston Health Care for the Homeless Program from 1988 to 1993. MEASUREMENTS: Cause-specific mortality rates adjusted for race and rate ratios that compare mortality rates in homeless persons with those in the general population of Boston. RESULTS: Homicide was the leading cause of death among men who were 18 to 24 years of age (mortality rate, 242.7 per 100000 person-years; rate ratio, 4.1). The acquired immunodeficiency syndrome was the major cause of death in men (mortality rate, 336.5 per 100000 person-years; rate ratio, 2.0) and women (mortality rate, 116.0 per 100000 person-years; rate ratio, 5.0) who were 25 to 44 years of age. Heart disease and cancer were the leading causes of death in persons who were 45 to 64 years of age. CONCLUSIONS: The most common causes of death among homeless adults who have contact with clinicians vary by age group. Efforts to reduce the rate of death among homeless persons should focus on these causes.

Acquired Immunodeficiency Syndrome↗
PubMed1990

Health and nutrition survey in a group of urban homeless adults.

Homeless persons eat foods from municipal and privately run shelters, fast-food restaurants, delicatessens, and garbage bins. Data on the adequacy of the diets and the nutritional status of homeless persons are sparse. Therefore, we surveyed the nutritional adequacy of the dietary intake, the quality of shelter meals, and objective clinical parameters indicative of nutritional status in a heterogeneous group of urban homeless persons. The group comprised mentally ill persons, alcohol and illicit drug users, and temporarily unemployed persons. Although 86 of the 96 subjects (90%) in our survey reported that they obtained enough to eat, a low dietary adequacy score, which was based on the basic four food groups, of 10.7 (norm = 16) indicated that the quality of their diets was inadequate. Shelter meals and diet records showed a high level of saturated fat and cholesterol. Serum cholesterol levels above the desirable limit of 5.17 mmol/L (200 mg) were observed in 79 subjects (82%). In addition to a prevalence of hypertension and obesity (observed in 37 subjects [39%], these homeless persons were at high risk for development of or worsening of cardiovascular disease. We conclude that homeless persons who obtain meals at shelters are getting enough to eat. However, the shelter meals should be modified to meet the nutritional needs and dietary prescriptions of the large number of clients who suffer from various health disorders.

Adult↗
PubMed2005

Interventions to improve the health of the homeless: a systematic review.

BACKGROUND: Homelessness is a widespread problem in the United States. The primary goal of this systematic review is to provide guidance in the development and organization of programs to improve the health of homeless people. METHODS: MEDLINE, CINAHL, HealthStar, PsycINFO, Sociological Abstracts, and Social Services Abstracts databases were searched from their inception through July 2004 using the following terms: homeless, homeless persons, and homelessness. References of key articles were also searched. 4564 abstracts were screened, and 258 articles underwent full review. Seventy-three studies conducted from 1988 to 2004 met inclusion criteria (use of an intervention, use of a comparison group, and the reporting of health-related outcomes). Two authors independently abstracted data from studies and assigned quality ratings using explicit criteria. RESULTS: Forty-five studies were rated good or fair quality. For homeless people with mental illness, case management linked to other services was effective in improving psychiatric symptoms, and assertive case management was effective in decreasing psychiatric hospitalizations and increasing outpatient contacts. For homeless people with substance abuse problems, case management resulted in greater decreases in substance use than did usual care. For homeless people with latent tuberculosis, monetary incentives improved adherence rates. Although a number of studies comparing an intervention to usual care were positive, studies comparing two interventions frequently found no significant difference in outcomes. CONCLUSIONS: Coordinated treatment programs for homeless adults with mental illness or substance abuse usually result in better health outcomes than usual care. Health care for homeless people should be provided through such programs whenever possible. Research is lacking on interventions for youths, families, and conditions other than mental illness or substance abuse.

Health Services↗
PubMed1993

The epidemiology of multidrug-resistant tuberculosis in the United States.

There has been a significant increase in the number of cases of MDR-TB in the United States. Although cases of MDR-TB have been reported from many areas of the country, the majority of the cases are concentrated in large urban areas. MDR-TB is difficult and expensive to treat. CDC has developed a National Action Plan to Combat Multidrug-Resistant Tuberculosis. The main elements of this plan include (1) greater surveillance and epidemiologic studies of drug-resistant TB; (2) initiatives to make the laboratory diagnosis of MDR-TB more rapid, sensitive, and reliable; (3) education of health care professionals about MDR-TB, its prevention, control, and treatment; and (4) measures to facilitate the development of new antituberculous drugs. CDC has published guidelines for the prevention of nosocomial spread of MDR-TB. to prevent the development and spread of MDR-TB, medical practitioners must suspect TB and make the diagnosis as rapidly as possible. Once a patient is diagnosed with TB, the most important step to prevent the development of drug-resistant disease is to ensure that patients take all of their medication. Directly observed therapy is the best way of ensuring this. In addition, more specific interventions, such as the use of incentives to improve compliance in certain situations, may need to be applied to groups in which high rates of drug resistance have been found, such as HIV-positive persons, IDUs, homeless persons, and persons who have been exposed to persons with MDR-TB. Quick and effective public health interventions targeted at these defined groups should help to control the spread of both drug-susceptible and drug-resistant TB.

Adolescent↗
PubMed2000

Tuberculosis screening, referral, and treatment in an inner city homeless shelter in Orleans parish.

Tuberculosis screening and preventive therapy among the homeless has been a challenge because of the lack of coordinated follow-up. Homeless persons at a homeless shelter in inner city New Orleans were screened for tuberculosis infection and referred for follow-up evaluation and preventive therapy. Fifty-two percent of the 104 persons screened completed the initial evaluation. Twenty-two percent of these patients had latent tuberculosis infection. Forty-two percent of infected patients completed the referral and follow-up process. Patients during the second 3 months of the program were twice as likely to complete the initial evaluation, the referral, and the follow-up process as were patients during the first 3 months due to enhanced awareness and increased educational intervention. A competent referral system for homeless persons may be achieved by implementing a single-clinic, on-site tuberculosis screening and follow-up system with the active participation and coordination of state agencies, the medical community, and organizations which operate homeless facilities.

Adult↗
PubMed1994

Down and out in New York and London: a cross-national comparison of homelessness.

OBJECTIVE: This study compared homelessness in New York City and London to examine the relative roles of individual pathology and structural forces in causing homelessness, the effect of sociopolitical and cultural differences on policy decisions toward solving homelessness, and the effect of broader structural forces on service programs for the homeless. METHODS: A review of the scholarly literature and news reports was combined with interviews of staff members and homeless persons associated with various community agencies in London and New York City. Homelessness in the two cities was compared in relation to definition, demography, nonpsychiatric and psychiatric etiological factors, public policy, governmental responses, financial support, service strategies, and the practicalities of securing services and entitlements. RESULTS AND CONCLUSIONS: The results indicate that characterizations of homelessness as a trait rather than a state reflect the tensions between social justice, public concepts, and a nation's economic resources. The absolute numbers of homeless persons, including those who are mentally ill, primarily reflect structural factors such as the availability of low-cost housing and public benefits. The commonalities that mentally ill homeless persons share with other vulnerable groups generally outweight their differences. The statutory rights to entitlements may be vitiated in times of shortage, especially for the least capable citizens. In both countries, efforts have been made to use the voluntary sector to serve the homeless, although it has been used much more extensively in Britain.

Cost Allocation↗
PubMed1991

Hypertension management in health care for the homeless clinics: results from a survey.

BACKGROUND: With the exception of alcohol abuse, hypertension is the most common chronic physical health problem encountered among homeless persons. The material conditions of homelessness greatly complicate the management of this disorder. Some of the complications and their solutions are discussed here, based on the experiences of health clinics for the homeless in large US cities. METHODS: In 1988, the Stewart B. McKinney Homeless Assistance Act established health care clinics for homeless persons in 108 cities. We surveyed medical directors in these clinics, asking about the management of hypertension in this difficult-to-treat population; 65 responded. RESULTS: Comparisons between our survey data and those obtained in two recent surveys of clinicians in "normal" clinical practice provide interesting lessons in how medical practice is adapted to respond to the unique needs and problems of the urban homeless. Although therapeutic goals are similar, the means chosen to achieve them often are not. CONCLUSIONS: The treatment of homeless hypertensives illustrates the problems inherent in strict biomedical models of disease and its alleviation. Preferred treatments, course of disease, and success of intervention are powerfully affected by social factors.

Ambulatory Care Facilities↗
PubMed1993

Black and white homeless men: differences in self-actualization, willingness to use services, history of being homeless, and subjective health ratings.

In this analysis of racial confounds in the study of homelessness and self-actualization, 100 black and 71 white homeless men from a mission and a street environment were compared to test the hypothesis that the prototypes of black and white homeless men are different. Discriminant analysis of items from the Short Index of Self-actualization of Jones and Crandall, willingness to use services, history of homelessness, and self-reported health ratings correctly classified 83.6% of black and white homeless men (Wilks' lambda = .46, p < .0001). The prototypic black homeless person and the prototypic white homeless person have strong differences so race must be evaluated in studies of such groups.

Black or African American↗
PubMed2004

Suicide among the homeless: a 9-year case-series analysis.

BACKGROUND: Among the homeless there are high rates of mortality and a significant number of attempted and completed suicides. In Tel-Aviv, Israel, there is an ongoing municipal outreach program for the homeless. OBJECTIVE: The aim of the present study was to describe the subgroup of homeless persons who had died by suicide. METHOD: Over a 9-year period the records of each homeless person who had died were assessed by two psychiatrists and a clinical criminologist. The project was undertaken in a large city and was feasible due to close cooperation between the municipal welfare department and mental health consultants. RESULTS: Of the 1,192 homeless persons located and contacted, 156 persons had died (13.1%). Nine of the deaths were by completed suicide (5.8%). All were male. Mean age for the suicide subgroup was 34 +/- 8.7 years, significantly younger than those who died of other causes (p < .01). The majority had completed high school education. While the majority of deaths were drug or alcohol related, in only 1 of 9 deaths by suicide was there a history of drug abuse. Psychiatric comorbidity was recorded in 4 of the 9 persons. The majority of persons (6/9) had died of suicide by hanging. CONCLUSION: Suicide is not a negligible cause of death among the homeless population.

Adolescent↗
PubMed2002

Employing people with psychiatric disabilities to engage homeless individuals through supported socialization: the Buddies Project.

This article describes the Buddies Project, a small time-limited grant that employed two part-time formerly homeless persons on a community-based mental health outreach team to participate in social activities with "difficult to engage" homeless individuals. We offer clinical examples that point to the success of this small supported socialization project. We suggest that employing people with psychiatric disabilities to participate in social activities with homeless persons with psychiatric disabilities can be an important tool to decrease homeless persons' social isolation and engage them into mental health treatment and independent housing.

Community Mental Health Services↗
PubMed1992

Homeless mentally ill or mentally ill homeless?

Mainstream psychiatry conceptualizes people who are homeless and mentally ill as distinct from other homeless persons because it is thought that their status stems from their mental disorder and the poor implementation of deinstitutionalization. The authors believe this dichotomy is illusory. They present data indicating that recent socioeconomic and political shifts contributed greatly to homelessness among all groups, regardless of mental illness; that those with and without mental illness have similar biographical and demographic profiles; that high levels of mental distress are common to all homeless persons; and that few mentally ill homeless persons require involuntary hospitalization. This perspective suggests novel responses that de-emphasize clinical solutions and focus on empowerment, consumerism, entitlement, community-level interventions, and closer alliances with other advocates for the homeless.

Ill-Housed Persons↗
PubMed2001

Educating the public about mental illness and homelessness: a cautionary note.

OBJECTIVE: To determine whether the viewing of a video depicting the successful struggles of homeless persons with mental illness in finding and maintaining housing can have a positive impact on attitudes toward homeless persons with mental illness. METHOD: Five hundred and seventy-five high school students attending a brief educational session on mental illness participated in 1 of 3 comparison versions of the 2-hour program (control, video, video plus discussion). All completed an "Attitudes toward Homelessness and Mental Illness Questionnaire." Demographic and prior exposure variables were entered as a covariates in between-group analyses of variance. RESULTS: Females and subjects who had more prior encounters with homeless persons were found to have the most positive attitudes. After controlling for these effects, the video alone had a negative impact on attitudes relative to the other groups, while the video followed by a discussion with one of the people featured in it had a largely positive impact. CONCLUSIONS: The apparent immediacy and the evocative power of video presentations cannot substitute for direct contact for the purpose of promoting positive attitude change. The findings are consistent with prior research emphasizing the importance of direct interaction with members of stigmatized groups to reduce negative attitudes. Education programs trying to destigmatize mental illness and homelessness using videos should proceed with caution.

Adolescent↗
PubMed2005

HIV/AIDS and homelessness, Part 1: background and barriers to care.

Co-occurrence of homelessness and HIV/AIDS poses a complex and multidimensional challenge to the health care provider's clinical and system integration skills. Existing data support the high prevalence of HIV/AIDS among homeless persons and a high percentage of persons living with HIV/AIDS being either homeless or at imminent risk for homelessness. There are special considerations and challenges health care providers may face in caring for homeless persons with HIV/AIDS. An integrated, flexible, interdisciplinary, community-based system of care addressing the full array of medical, psychiatric/substance abuse, and housing services would optimize clinical care for this population. Areas that deserve particular attention include HIV/AIDS prevention, access to comprehensive HIV and health care, use of antiretroviral therapy, and adherence to treatment. Research is needed to better understand the multifaceted needs of this population and to develop prevention and treatment strategies applicable to daily clinical care.

Female↗
PubMed2000

Homelessness among persons with serious mental illness in an enhanced community-based mental health system.

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.

Acute Disease↗