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PubMed1999

Social support and service use among homeless persons with serious mental illness.

It has been widely hypothesized that persons with greater social support use fewer health care services, although previous studies have shown variable results. This study examines the relationship between levels of social support and formal service use among clients entering 18 community treatment programs for homeless persons with serious mental illness as part of the ACCESS demonstration project of the U.S. Center for Mental Health Services. Baseline and follow-up data on 1,828 clients entering the ACCESS program were used to evaluate the relationship between individual client socio-demographic and clinical characteristics, seven measures of social support, and levels of formal service use in this population. Three measures of social support were positively related to the use of outpatient medical services and one each to the use of substance abuse services and the total days of service use. Six out of seven measures of social support were positively related to the receipt of multiple services. It appears that social support is most strongly associated with improved access to an array of different services--a very important need among this population.

Adult↗
PubMed1993

Collaborating to develop a community-based health service for rural homeless persons.

In the current healthcare environment, public health nursing administrators are called on to create and manage programs and services while reducing cost and improving access. Public health science provides a framework on which to base program planning and management. Using this approach, the authors describe the establishment of a health services center to meet an identified gap in service to homeless persons in a rural area.

Community Health Centers↗
PubMed2005

A modified therapeutic community for homeless persons with co-occurring disorders of substance abuse and mental illness in a shelter: an outcome study.

This article reports on a study conducted to determine the effectiveness of a modified therapeutic community (MTC) shelter on client outcomes. The seven-study hypotheses focused on whether greater effectiveness in the MTC would be demonstrated in longer periods of sobriety, fewer days of psychiatric hospitalization, shorter lengths of stay in a shelter, positive discharge from the shelter, medication compliance, housing placement within the first year, and appropriate housing placement according to level of functioning. The study utilized a quasi-experimental design with two groups: 1) an experimental group (E) homeless persons with co-occurring disorders (COD) of substance abuse/dependence and mental illness who reside in a modified therapeutic community (N = 70); and 2) a comparison group (C) of veterans with CODs living in a general shelter (N = 70). The data collection procedures involved a retrospective review of closed case records for subjects in the facilities from September 1, 1998-June 1, 2000 for the MTC shelter, and from June 1, 1999-June 1, 2000 for the general shelter. Baseline differences between the E and C groups were found in age, length of homelessness, years of education, years of work experience, veteran status, marital status, and psychiatric diagnosis; all except for veteran status were unrelated to outcomes and were controlled in subsequent analyses. Significant difference was found on medication compliance when controlled for both groups. Overall, this study showed some promise for the MTC approach. The study also raised a question as to the contribution of veteran status to the differences between groups and to treatment of CODs.

Adult↗
PubMed2002

Integration of service systems for homeless persons with serious mental illness through the ACCESS program. Access to Community Care and Effective Services and Supports.

OBJECTIVE: The aim of this study was to evaluate the first of the two core questions around which the ACCESS (Access to Community Care and Effective Services and Supports) evaluation was designed: Does implementation of system-change strategies lead to better integration of service systems? METHODS: The study was part of the five-year federal ACCESS service demonstration program, which sought to enhance integration of service delivery systems for homeless persons with serious mental illness. Data were gathered from nine randomly selected experimental sites and nine comparison sites in 15 of the nation's largest cities on the degree to which each site implemented a set of systems integration strategies and the degree of systems integration that ensued among community agencies across five service sectors: mental health, substance abuse, primary care, housing, and social welfare and entitlement services. Integration was measured across all interorganizational relationships in the local service networks (overall systems integration) and across relationships involving only the primary ACCESS grantee organization (project-centered integration). RESULTS: Contrary to expectations, the nine experimental sites did not demonstrate significantly greater overall systems integration than the nine comparison sites. However, the experimental sites demonstrated better project-centered integration than the comparison sites. Moreover, more extensive implementation of strategies for system change was associated with higher levels of overall systems integration as well as project-centered integration at both the experimental sites and the comparison sites. CONCLUSIONS: The ACCESS demonstration was successful in terms of project-centered integration but not overall system integration.

Community Mental Health Services↗
PubMed1997

Individual and community-level variation in intensity and diversity of service utilization by homeless persons with serious mental illness.

This study examines individual client- and community-level sources of variation in service use among clients entering 18 community treatment programs for homeless mentally ill persons as part of a national demonstration project. Assessment data on 1,828 clients were used to evaluate the relationship of a) individual client characteristics and b) site of entry, to both the intensity and diversity of service use. Hierarchical multiple regression was used to identify the relative importance of client characteristics and site of entry. Client characteristics explained only 2% to 3% of the variance in service use. Inter-site variation accounted for 2 to 3 times as much of the variance. Inter-site differences account for substantially more of the variance in service use among homeless persons with mental illness than individual client characteristics. Further studies are needed to identify specific community-level factors that account for these variations.

Adult↗
PubMed1998

[Morbidity spectrum and drug therapy of homeless persons in Munich].

In Germany there are currently approx. 200,000 homeless single people, and the trend is rising. As a result of the situation in which they find themselves, many of these persons are ill and in need of medical treatment. A study was performed in Munich/Germany, focussing on a medical practice providing care for the homeless, to investigate their illnesses and pharmacological therapy. The medical practice was located in a municipal shelter. Each year about 350 different destitute homeless men--about 15 per cent of all single homeless people in Munich--were cared for. The men, whose ages ranged from about 17 to 74 years were single and the majority lived in shelters, bed and breakfast accommodations, or shared apartments. About ten per cent lived on the street. For the study, 171 randomly selected medical records were analysed for the period of July 1994 to June 1995. The homeless men suffered principally from the following illnesses: psychiatric illnesses (36%), infectious and parasitic diseases (31%), skin diseases (30%), injuries (29%), diseases of the skeleton, of the muscles and of the connective tissues (28%), diseases of the respiratory organs (27%), cardiovascular diseases (24%), and diseases of the digestive organs (17%). Seventy-five per cent of the patients received drug treatment. In the case of 37% of the patients, wounds were treated and dressed in the medical practice itself. The most frequently prescribed drugs were: analgesics (12%), antibiotics (10%), antihypertensives (10%), gastrointestinal treatments (9%), treatments for colds (9%), and dermatopharmacological preparations (6%). It was surprising that only 16% of the psychic ill patients were treated with drugs, while over 60% of the other illnesses were mostly treated pharmacologically. The interaction with alcohol was the reason for that. The study showed that the practice did not sufficiently reach women and homeless people living on the street. The homeless situation, the personal and social difficulties faced by the homeless and the frequent misuse of alcohol caused many problems in medical treatment, such as low compliance. Special medical institutions like the Munich medical practice are capable of handling these problems. Co-operation with social relief organisations helps to improve the overall situation of the patient and also improves his state of health. These medical institutions are useful and necessary for providing good health care for the social fringe population, such as the homeless are.

Adolescent↗
PubMed1991

The epidemiology of alcohol, drug, and mental disorders among homeless persons.

This article describes recent research on the prevalence of alcohol, drug, and mental (ADM) disorders and the characteristics of homeless substance abusers and persons with mental illness. Methodological problems in homelessness research are reviewed, particularly in relation to definitions of homelessness and sampling- and case-ascertainment methods. Prevalence rates of ADM disorders are much higher in homeless groups than in the general population. As is true of homeless people in general, homeless substance abusers and mentally ill persons are characterized by extreme poverty; underutilization of public entitlements; isolation from family, friends, and other support networks; frequent contact with correctional agencies; and poor general health. Knowledge of these disadvantages should be used to advocate for better services to prevent homelessness and support homeless people.

Alcoholism↗
PubMedDate not supplied

Enhancing mental health services for homeless persons: state proposals under the MHSH Block Grant Program.

The Mental Health Services for the Homeless Block Grant Program has made available more than $57 million to the States in fiscal years 1987-89 to encourage States to develop and strengthen community services for homeless mentally ill persons. Funds were provided for five basic services, which include outreach, case management, mental health treatment, residential support services, and training for service providers. State applications for funds reflected considerable diversity among the services proposed. The manner in which States proposed to use the funds is described, including methods used to identify high need areas and distribute funds and plans for delivering services.

Community Mental Health Services↗
PubMed1996

Pulmonary tuberculosis in a homeless person.

Tuberculosis disproportionately affects certain segments of society, such as the homeless, and can cause extremely serious disease among persons with severely impaired cellular immunity, especially those with HIV infection. Inhalation of droplet nuclei, which are the airborne residual of droplets expelled from an infected host, is the primary means of transmission. Factors associated with transmission in shelters for the homeless include crowding, inadequate ventilation, and poor compliance with drug therapy. One of the greatest challenges to treatment of this infection among the homeless is the provision of adequate follow-up of patients who have begun therapy. Many individuals do not complete their treatment regimen. This creates an environment in which the transmission of tuberculosis, including multi-drug-resistant strains, can occur. Prevention strategies should focus on rapid identification and treatment of persons with active disease and latent tuberculosis infections. Ventilation with good exchange of fresh air or the addition of air cleaning devices may aid in reducing risks of transmission of disease.

Adult↗
PubMed1976

The homeless person and the psychiatric services: an Edinburgh survey.

A representative sample (R.S.) of 79 subjects living in Edinburgh common lodging houses was compared with a clinical series (C.S.) of 44 patients from the same type of resisence. C.S. patients were more likely to be out of work, to be under 55 years of age, and to have been married as some time. They had spent much shorter times in lodging houses, in Edinburgh and at their current address. Alcoholism was rather more often diagnosed in the C.S., and personality disorder much more often. Schizophrenia tended to be found more in the R.S. The C.S. obtained higher Personal Illness and 'Character Disorder' scores. It is concluded that those subjects presenting to the psychiatric services are a highly selected group quite unrepresentative of homeless single persons in general.

Catechol O-Methyltransferase↗
PubMed2001

Vocational outcomes among formerly homeless persons with severe mental illness in the access program.

OBJECTIVE: This study examined the vocational outcomes of 4,778 formerly homeless individuals with severe mental illness who were enrolled in the Access to Community Care and Effective Services and Support (ACCESS) program, a multisite demonstration project designed to provide services to this population. METHODS: Participants were interviewed at the time of enrollment and again three months and 12 months later by trained researchers who were not part of the treatment team to determine their employment status. At 12 months, participants were also asked about the types of services they had received during the past 60 days. Multiple logistic regression analysis was used to predict employment at 12 months. RESULTS: ACCESS participants reported receiving relatively few job-related services. Nonetheless, modest but significant increases occurred between baseline and three months and between three months and 12 months in the total proportion of participants who were employed and who were employed full-time and in hourly earnings and estimated monthly earnings. The number of hours worked per week increased significantly between three months and 12 months. When the analysis controlled for site, study condition (whether the ACCESS site received or did not receive extra funds to improve service integration), minority status, addiction treatment, and mental health treatment, participants who were employed at 12 months were more likely to have received job training and job placement services. CONCLUSIONS: Programs that work with homeless mentally ill persons may better serve their clients by placing as great an emphasis on providing employment services as on providing housing and clinical treatment.

Adolescent↗
PubMed1997

Client and site characteristics as barriers to service use by homeless persons with serious mental illness.

Clients entering the Access to Community Care and Effective Services and Supports (ACCESS) program for homeless mentally ill persons in 18 U.S. communities identified barriers to service use. The most frequent barrier was not knowing where to go for a service (encountered by 32.4 percent of the 1,828 clients). It was followed by not being able to afford it (29.5 percent); experiencing too much confusion, hassle, or waiting to obtain it (27.1 percent); and having been previously denied the service (16.5 percent). Differences in the program site (that is, the 18 communities) explained two to three times more of the variance in encountering barriers use than did individual client characteristics.

Adult↗
PubMed1997

Creating integrated service systems for homeless persons with mental illness: the ACCESS Program. Access to Community Care and Effective Services and Supports.

The Access to Community Care and Effective Services and Supports (ACCESS) demonstration program was initiated in 1993 by the U.S. Department of Health and Human Services as part of a national agenda to end homelessness among persons with serious mental illness. Demonstration projects have been established in nine states to develop integrated systems of care for this population. This paper provides an overview of the ACCESS program and presents definitions of services integration and systems integration. Evaluating the effectiveness of integration strategies is a critical aspect of the program. The authors describe the evaluation design and the integration strategies being evaluated and summarize findings from a formative evaluation of the project's first two years. The evaluation revealed several problems that were addressed by providing technical assistance to the states. States were helped to articulate a broader mission of addressing system-level barriers, develop an expanded plan, strengthen the authority of interagency councils, involve leaders at the state and agency levels, and develop joint funding strategies.

Adult↗
PubMed1998

Affiliation, gender, and parental status among homeless persons.

Affiliation, loss of affiliation, and the associated effects on homeless individuals were assessed via a survey of 230 homeless adults in Florida. Women accompanied by dependent children, unaccompanied women, and unaccompanied men were compared regarding levels of affiliation and associations among affiliation, self-esteem, and locus of control. The women accompanied by children maintained more family contacts and had higher levels of self-esteem; for the group, locus of control was more external than for either the unaccompanied women or the unaccompanied men. Women with children also had the lowest median number of days homeless and the highest average monthly incomes.

Adult↗
PubMed2000

Correlates of improvement in quality of life among homeless persons with serious mental illness.

Longitudinal data from 4,331 homeless mentally ill clients at 18 sites participating in the Access to Community Care and Effective Services and Supports program were used to assess participants' quality of life over a one-year period. At baseline higher quality of life was associated with less severe depressive and psychotic symptoms, less use of alcohol and drugs, and more social support. At 12 months improved quality of life was associated with decreased psychotic and depressive symptoms, reduced substance abuse, fewer days of homelessness, and increased social support, income, employment, and service use.

Adult↗
PubMed1986

Homeless persons and health care.

Health care is generally unavailable for the homeless. This heterogeneous group of men and women, including long-term street dwellers, residents of shelters, the chronically mentally ill, the economically debased, and alienated youth, are subject to a broad range of acute and chronic diseases, intensified by unsuitable living conditions, stress, and sociopathic behavior. Trauma, pulmonary tuberculosis, infestations, and peripheral vascular disease are common problems among the homeless; incomplete and fragmentary medical care permits exacerbation of chronic disorders. Outreach programs imaginatively constructed by teams of physicians, nurses, and social workers can effectively reestablish and maintain health services for these disenfranchised persons.

Chronic Disease↗
PubMed2001

Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness.

OBJECTIVES: This study evaluated the influence of features of community social environment and service system integration on service use, housing, and clinical outcomes among homeless people with serious mental illness. STUDY SETTING: A one-year observational outcome study was conducted of homeless people with serious mental illness at 18 sites. DATA SOURCES: Measures of community social environment (e.g., social capital) were based on local surveys and voting records. Housing affordability was assessed with housing survey data. Service system integration was assessed through interviews with key informants at each site to document interorganizational transactions. Standardized clinical measures were used to assess clinical and housing outcomes in face-to-face interviews. RESEARCH DESIGN: Structural equation modeling was used to determine the relationship between (1) characteristics of the social environment (social capital, housing affordability); (2) the level of integration of the service system for persons who are homeless in each community; (3) access to and use of services by individual clients; and (4) successful exit from homelessness or clinical improvement. PRINCIPAL FINDINGS: Social capital was associated with greater service systems integration, which was associated in turn with greater access to assistance from a public housing agency and to a greater probability of exiting from homelessness at 12 months. Housing affordability also predicted exit from homelessness. Neither environmental factors nor systems integration predicted outcomes for psychiatric problems, substance abuse, employment, physical health, or income support. CONCLUSION: Community social capital and service system integration are related through a series of direct and indirect pathways with better housing outcomes but not with superior clinical outcomes for homeless people with mental illness. Implications for designing improved service systems are discussed.

Case Management↗
PubMedDate not supplied

[Morbidity and cause of death in homeless persons].

The Hamburg Institute of Forensic Medicine analysed 388 deaths of homeless people between 1990 and 1998 considering demographic data, post-mortem results and autopsy findings. The manner of death was either unnatural or unascertained; the autopsy rate amounted to 43.8%. The results confirm the observation discussed in the last few years that homeless people are usually in a poor state of health. In relation to the average age of death, which is 44.5 years, the number of previous diseases is high. Unnatural causes (excluding homicides) account for a high percentage, viz. 62.6%, primarily intoxications. The most frequent natural cause of death is infection (16.8%). Women account for 8.5% of the deaths with their organ findings and causes of deaths being different from those of homeless men in terms of distribution and incidence. The data presented in this report may be helpful for the improvement of the present system of medical help in Hamburg.

Adolescent↗