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PubMed2003

Involuntary outpatient commitment and homelessness in persons with severe mental illness.

This study took preliminary steps to explore the relationship between involuntary outpatient commitment (OPC) and the risk of homelessness among individuals with severe mental disorders. Involuntarily hospitalized patients were randomly assigned to be released or maintained under OPC following hospital discharge. Multivariate analyses demonstrated that involuntary OPC was associated with a significant decrease in the risk of homelessness during the first 4 months following hospital discharge for participants with severe functional impairment at baseline. OPC did not appear to affect risk of homelessness among participants with mild-to-moderate functional impairment. Co-occurring substance abuse, treatment nonadherence, and outpatient services intensity were found to be strongly associated with episodes of homelessness. This study suggests that involuntary OPC may provide a short-term reduction in the risk of homelessness among a subgroup of treatment-reluctant individuals with severe mental disorders combined with severe functional impairment.

Adult↗
PubMed1996

Pharmaceutical services for a homeless population.

Participation of pharmacist volunteers in the medication program of a countrywide health care program for homeless persons is described. Pharmacist volunteers were brought in to manage medications for a health care program serving homeless persons in Ramsey County, Minnesota. After the pharmacy program was structured, volunteers were recruited from the community. Pharmacists duties initially focused on product management but were expanded to include establishing and monitoring the program formulary; reviewing patient records and prescriptions for allergies, potential drug interactions, and appropriate dosage; counseling patients on medication use; and consulting with other members of the health care team. The pharmacists' efforts led to improvements in monitoring and stocking of necessary medications. The cost of the pharmacy program decreased from $1800 a month to as little as $300 a month. The value of donated supplies and medications increased from $8,600 in 1991 to over $122,000 in 1994. Pharmacist volunteers helped to improve the cost-effectiveness and quality of medication use in a homeless population.

Community Pharmacy Services↗
PubMed1987

Perceived health status among the new urban homeless.

Homelessness may be the leading social problem in the United States in the mid 1980s. While there may be anywhere from 250,000 to three million homeless persons, few empirically based published studies are available concerning the correlates of mental and physical health status among the homeless. Los Angeles, where the present study was conducted, has been designated by the U.S. Department of Housing and Urban Development to have one of the largest homeless populations (34,000-50,000) in the U.S. The current study is based on 269 in-depth interviews with homeless men and women in Los Angeles County, California. The homeless were found to be younger, better educated and disproportionately non-white compared to the profiles of the skidrow homeless of the past decades. Nearly half the men were veterans of military services, including 30% who were veterans of the Vietnam War. Respiratory infections and hypertension were the most prevalent health problems. The data suggest that a large segment of the homeless persons were depressed, 15.6% reported lifetime prevalence of hospitalization for emotional or nervous problems, and 12.6% reported hospitalization for substance abuse disorders. Multiple regression was utilized to test the validity of a perceived health status index as measured among the homeless and to identify the correlates of health. The health index reflect primarily an affliction by a chronic disease, the severity of an acute condition, the duration of depressed mood, and the alcoholism symptomatology. Length of unemployment, education, gender, and number of nights spent in a shelter were the best predictors of poor health in this population. Evidence from this study, as well as others, suggests that efforts should be made to avoid using the term homeless metaphorically. The causes of homelessness are multiple and complex and the resulting subgroups among the homeless population have different problems which require a variety of strategies to meet their needs.

Adult↗
PubMed2003

Associations between migrancy, health and homelessness: a cross-sectional study.

There is limited awareness of the link between differing health problems and migrancy of homeless people. The present cross-sectional study sought to quantify the extent of migrancy of homeless people from their place of birth (PLOB) and evaluate whether a history of problematic drug use, alcohol misuse or enduring mental health problems were associated with migrancy from their PLOB. The work was conducted at an inner-city health centre for the homeless in the north of England. Place of birth was created as an entry on the computerised registration records. The PLOB was collected and recorded for each homeless person registering with the service over the study period. Information was also extracted regarding diagnoses of problematic illicit drug use, problematic alcohol use and enduring mental health problems for each homeless person. The study identified statistically significant differences for the migration of homeless people from their PLOB for age, problematic drug use and problematic alcohol use. Problematic alcohol use is independently associated with an increased likelihood of migration from the PLOB. Conversely, a history of illicit drug use is associated with a reduced possibility of migration from the PLOB when accessing primary healthcare services. There was no significant difference for migration from the PLOB for mental health. Not all homeless people migrate from their PLOB and health problems of drug use, mental health or alcohol use are independently associated with different patterns of migration. Understanding the migrancy of homeless people is important when planning and targeting appropriate health and social services to address their varying health, social and psychological needs.

Adolescent↗
PubMed1990

Health, homelessness, and poverty. A study of clinic users.

When seeking medical care, homeless persons often turn to health centers that were designed to treat the poor who have homes. To provide for effective medical care, personnel in such facilities need to know how the health care needs of the homeless are different from those of other clinic users. To compare the physical health of these two groups, we conducted a health survey and screening physical examination of 464 patients who attended the general adult and homeless clinic sessions of one of the main neighborhood health centers in Los Angeles County, California. As compared with the poor who have homes, homeless persons were more likely to have dermatological problems (32% vs 21%), functional limitations (median, 2 vs 0 per person), seizures (14% vs 6%), chronic obstructive pulmonary disease (21% vs 12%), social isolation, serious vision problems (22% vs 12%), foot pain, and grossly decayed teeth (median, 1 vs 0 per person). We conclude that to care more optimally for homeless adults, health centers must pay attention to their functional disabilities, substance abuse, skin abnormalities, vision impairment, dental problems, and foot problems.

Adult↗
PubMedDate not supplied

A public health approach to reducing morbidity and mortality among homeless people in Boston.

Urban homeless populations suffer disproportionately high rates of premature death. In response to a wave of highly publicized deaths on the streets of Boston during the winter of 1998-1999, the Massachusetts Department of Public Health (MDPH) convened a task force to investigate these deaths and implement an integrated response to this public health crisis. Comprised of a broad coalition of public and private agencies as well as homeless persons and advocacy groups, the MDPH Task Force reviewed the circumstances surrounding the 13 deaths, monitored subsequent deaths among homeless persons in Boston, and implemented a comprehensive plan to address critical needs and prevent further deaths. Contrary to the task force's initial assumption, the 13 decedents had multiple recent contacts with the medical, psychiatric, and substance abuse systems. In response to this finding, the MDPH Task Force sought to improve continuity of care and prevent future deaths among Boston's street population. Coordination of needed services was achieved through the creation of new, and often unconventional, partnerships. This case study exemplifies a public health practice response to the vexing health care challenges confronting homeless people who must struggle to survive on the streets and in shelters.

Boston↗
PubMed1988

Mental health, alcohol and drug use, and criminal history among homeless adults.

As part of a community-based survey of 529 homeless adults, the authors analyzed factors associated with their use of mental health services. Homeless persons who had had a previous psychiatric hospitalization were the least likely to sleep in an emergency shelter, had been homeless nearly twice as long as the rest of the sample, had the worst mental health status, used alcohol and drugs the most, and were the most involved in criminal activities. The majority had not made an outpatient mental health visit in 5 years. It is suggested that diverse systems of care are needed for homeless persons.

Adolescent↗
PubMed1989

Involuntary medication and the case of Joyce Brown.

In October 1987, Joyce Brown became the first homeless person removed from New York City's streets and hospitalized under a city initiative that authorized evaluation of "gravely disabled" homeless persons for admission to inpatient psychiatric treatment. Miss Brown's highly publicized and ultimately successful court battle to prevent a course of forced medication is described. Her refusal of medication was upheld based on her capacity to understand the proposed treatment and to express a partially rational opinion about it. The author, who served as independent psychiatric consultant to the court on the decision about Miss Brown's involuntary medication, uses the case to illustrate some of the problems of involuntary psychiatric intervention, including the commitment of competent patients and the lack of a coherent approach to persistent treatment refusal.

Adult↗
PubMed2000

Service learning: a strategy for conducting a health needs assessment of the homeless.

An agency providing health care services for homeless persons and a nursing department at a liberal arts college established a service-learning partnership to complete a health needs assessment of homeless persons. Under the guidance of agency staff and a nursing faculty member, seven nursing students surveyed shelter residents (n = 101) in four urban shelters and conducted a focus group to identify residents' perceptions of health, health care needs, and health care service delivery. The service-learning partnership expanded the agency's services by providing research consultation and data collection that resulted in recommendations to improve health care services for the homeless. The agency contributed to the education of health professionals by providing students with a meaningful community service experience.

Adolescent↗
PubMed1991

Nontuberculous respiratory infections among the homeless.

In contrast to the extensive studies of pulmonary tuberculosis among homeless persons, virtually no data are available on nontuberculous respiratory infections in this population. This article reviews the literature on pulmonary infections and homelessness. The clinical experience of the Boston Health Care for the Homeless Program is detailed, with emphasis on the role of multidisciplinary teams of physicians, nurses, and case workers in the integration of hospital- and shelter-based clinics necessary to provide primary care to a fragmented and transient population. The shelters facilitate the transmission of airborne pathogens, and homeless persons are often debilitated and susceptible hosts. Outbreaks of specific respiratory infections are examined, including pneumococcal pneumonia, Haemophilus influenzae type b pneumonia, and influenza.

Aged↗
PubMed1989

Self-help efforts in a squatter community: implications for addressing contemporary homelessness.

This analysis addresses the nature of contemporary homelessness in the United States, the historical foundations of the shelter system, and survival strategies utilized by homeless persons in meeting their physical, social, and psychological needs. A framework that examines the degree of publicness/privateness and permanency/temporariness of spaces utilized by homeless persons is applied to a case study of a self-help squatter community living on an empty lot in New York City. By looking at the members of the group, their relationship to their neighbors and the local community, and their approaches in dealing with their needs, an assessment is made of this labor-intensive, self-help effort for providing shelter. Implications of self-help approaches are related to policy development and further research.

Activities of Daily Living↗
PubMed2005

[The specific features of the detection, clinical manifestations, and treatment of tuberculosis in the HIV-infected].

The present study has explored the specific features of the detection, clinical manifestations, and treatment of tuberculosis (TB) in 425 patients with TB and HIV infection. According to the time of joining the infections, the patients with TB and HIV infection are divided into 2 basic groups: 1) HIV infection is primary, TB develops at any stage of HIV infection and 2) TB is primary, HIV injections joins different forms of TB at its any stage. The social makeup of patients with TB/HIV infection is unfavorable: the unemployed, 50%; homeless persons, 26.5%; employees, 5%; workers, 9%; pensioners, 1.5%; the disabled, 5%; pupils, 3%. As compared with Group 2, Group 1 shows more employees and pupils and fewer homeless persons, which is associated with the younger age of patients in this group and their greater social security. In the pattern of clinical forms of tuberculosis in Group 1, there are prevalent forms of primary tuberculosis with lesion of intrathoracic and peripheral lymph nodes (12.8%), acutely progressive disseminated and miliary tuberculosis of the lung and extrapulmonary systems and organs (49%), among them, meningitis accounts for 4%, lesions of the liver, spleen, kidney, and other organs form 17%. In patients with tuberculosis and HIV infection, bacterial isolation has been established in 58% of cases; primary and multidrug resistances have been found in 53 and 8.9%, respectively. Multidrug resistance tends to increase: 2% in 2001, 3.4% in 2002, 4.6% in 2003, and 8.9% in 2004. Bacteria have been more frequently isolated in Group 2 than in Group 1 (81% vs 19%), which is accounted for by the magnitude of destructive changes in them in the presence of infiltrative TB and by the high incidence of fibrocavernous tuberculosis. The patients with TB/HIV infection have a concomitance of 3 infectious diseases: HIV infection, TB, and, in 74% of the patients, sexually transmitted infections (syphilis, chlamydiosis, gonorrhea) that, in accordance with Resolution No. 188 passed by the Government on April 2, 2003, are in the list of infectious diseases constitute a serious hazard to other people. The proportion of TB/HIV patients with drug abuse (65%), hepatitis B and C (47%), and nervous and mental diseases is extremely high, which makes these patients more hazardous to the healthy population. The efficiency of treatment for TB and HIV infection is satisfactory. Continuous therapy for 4 months or more provides positive clinical and X-ray changes in most patients; bacterial isolation ceases in 75%, and decay cavities close in 44% of cases. Abacillation and cavity closures have been observed in 76.3 and 38% and 47 and 14% of cases in Groups 1 and 2, respectively. Six-eight-month therapy with first-line drugs in combination with reserve ones in patients with pulmonary TB and HIV infection is well tolerated and highly effective. A decision on the duration of anti-TB treatment for the HIV infected should be taken into account the program resources and the probability of refusing long-term therapy in 50% of cases. Mortality rates in patients with TB and HIV infection are gradually on the rise and equal to 11.2% of the treated patients in 2001, 5% in 2002, 15.2% in 2003, and 19.6% in 2004. In patients with HIV/TB, the rates are higher than those in patients with TB/HIV and are 19.2 and 14.5%, respectively. Acutely progressive pulmonary TB and miliary TB of the lung and extrapulmonary organs and systems are a cause of death in most (76%) patients with TB/HIV.

AIDS-Related Opportunistic Infections↗
PubMed2005

Tuberculosis transmission in a homeless shelter population--New York, 2000-2003.

In 2003, the incidence of tuberculosis (TB) cases in the United States declined for the eleventh consecutive year to a record low of 5.1 cases per 100,000 population. In 2003, 6.3% of reported TB cases in the United States were among homeless persons. Compared with the general population, this group has a greater risk for latent TB infection (LTBI) and progression to active disease. This report summarizes a recent outbreak of TB and highlights the challenges of preventing TB among homeless persons, particularly when multiple chains of transmission are occurring and multiple jurisdictions are involved. The findings underscore the complementary role of rapid DNA genotyping in the detection of possible TB transmission in homeless populations. To ensure early detection of unsuspected TB transmission in homeless populations, health department TB-control programs are encouraged to use CDC's universal Mycobacterium tuberculosis rapid genotyping system.

Disease Outbreaks↗
PubMedDate not supplied

Factors limiting evaluation of health care programs for the homeless.

The problem of homelessness and the need for health care by homeless people does not seem to be subsiding. All indications are that current legislation to implement dramatic welfare reform will eventually increase the number of homeless persons. Evaluation to guide, monitor, and select the most effective approaches in the provision of health care will remain a key element in health care delivery. Although barriers regarding evaluation of homeless health care have been reported by previous researchers as similar, the results in this study document findings elicited from administrators in the field. The administrators have the expertise to address some of the more common barriers and reduce them. Ways to approach this endeavor and to support staff in participating in and successfully integrating evaluation activities into health care provision will require attention of funding agencies, program administrators, and inclusion of staff and clients in planning. As the era of managed care becomes the focus of how health care is delivered, evaluation of existing programs will be essential to their survival. The descriptive information obtained in this exploratory study provides useful instruction for considering issues that need to be addressed in planning and implementing evaluation of health care to homeless persons.

Administrative Personnel↗
PubMed1999

[Pneumonia among the homeless].

Although there are some studies concerning tuberculosis among the homeless persons in Japan, almost no detailed analysis is available about non-tuberculous lung infections in this population. We retrospectively studied the clinical features and microbial etiology of pneumonia among the homeless. This series included twenty so-called homeless persons, 19 male and one female, who were admitted to our hospital with a clinical diagnosis of pneumonia from April 1993 to July 1996. The average age was 56 years-old. All patients were transferred by ambulance. Most of them were admitted night in the winters, and had respiratory failure together with other serious complications such as gastrointestinal disease, liver failure and cerebrovascular disease. Chest X ray revealed so-called lobar pneumonia in 8 of 20 cases (40%). Microbial etiologic agents were found in 14 patients (70%). Pneumococcus amounted to 80% of all the speculated pathogens. Despite intensive care after admission, 6 of 20 patients (30%) died subsequently. Although fatal pneumococcal pneumonia were reported to have decreased in the general population in Japan, morbidity and mortality of pneumococcal pneumonia was very high in this series.

Adult↗
PubMed1994

Clinical and treatment correlates of access to Section 8 certificates for homeless mentally ill persons.

OBJECTIVE: The study assessed how clients' housing preference and other variables were related to the acquisition of Section 8 certificates, facilitating independent living, for homeless persons with severe mental illness who were being served by an experimental assertive community treatment team. METHODS: For 77 clients, demographic and clinical differences between receivers and nonreceivers of certificates were examined, and correlates of time from referral to the team to completion of the Section 8 application were analyzed. Reasons clients did not receive certificates and housing outcomes were summarized in relation to client preference. RESULTS: The 34 clients who received certificates (44 percent) had significantly less psychopathology after three months than did nonreceivers and tended to have affective disorders rather than schizophrenia. Of the 43 nonreceivers, the two largest groups were 19 clients who did not want certificates and ten clients who wanted certificates but whom staff considered unable to live safely in an unsupervised apartment. The mean +/- SD length of time for application for a certificate was 5.7 +/- 5.8 months. Longer time to apply was significantly associated with having schizophrenia, having the team as a representative payee, and showing increased psychotic symptoms at referral and at three months. CONCLUSIONS: The study suggests that it is possible to honor the housing preferences of the majority of homeless persons with severe mental illness if adequate resources are provided. However, staff may view persons who have schizophrenia and more symptoms as needing more supervision than those clients prefer. Homeless mentally ill persons may also take longer than more symptomatic persons to pursue independent living through a Section 8 certificate.

Adult↗
PubMed1990

Homelessness among adults raised as foster children: a survey of drop-in center users.

74 homeless persons were asked if they had ever been in foster care. Twelve (16%) answered affirmatively. Compared with the estimated baseline of adults who had been in foster care in the same locality, these homeless persons reported histories of foster care at four times the base rate in the general population. This finding suggests that children in foster care are at risk of serious dysfunction as adults.

Adolescent↗
PubMed2000

[Respiratory tuberculosis and effectiveness of its treatment in some high-risk groups].

Comparative study of respiratory tuberculosis morbidity in 3 risk groups revealed its highest rates suggesting its epidemic in prisoners. There were its quite high incidence rates in pregnant and postpartum women. It was low in medical staff though it was greater than in the region's general population. Poor clinical patterns were found in former prisoners, homeless persons, and in females during gestation, and in postpartum period in particular. The outcomes of treatment were the best in medical staff. They were the worst in socially disoriented groups. Former prisoners and homeless persons had a high risk of ineffective treatment.

Adult↗