Access to Basic Needs and Healthcare by People Experiencing Unsheltered Homelessness

Access to primary care clinicians, including primary care physicians and nonphysician clinicians (nurse practitioners and physician assistants) is necessary to improving population health. However, rural-urban trends in primary care access in the US are not well studied. To assess the rural-urban trends in the primary care workforce from 2009 to 2017 across all counties in the US. In this cross-sectional study of US counties, county rural-urban status was defined according to the national rural-urban classification scheme for counties used by the National Center for Health Statistics at the Centers for Disease Control and Prevention. Trends in the county-level distribution of primary care clinicians from 2009 to 2017 were examined. Data were analyzed from November 12, 2019, to February 10, 2020. Density of primary care clinicians measured as the number of primary care physicians, nurse practitioners, and physician assistants per 3500 population in each county. The average annual percentage change (APC) of the means of the density of primary care clinicians over time was calculated, and generalized estimating equations were used to adjust for county-level sociodemographic variables obtained from the American Community Survey. The study included data from 3143 US counties (1167 [37%] urban and 1976 [63%] rural). The number of primary care clinicians per 3500 people increased significantly in rural counties (2009 median density: 2.04; interquartile range [IQR], 1.43-2.76; and 2017 median density: 2.29; IQR, 1.57-3.23; P < .001) and urban counties (2009 median density: 2.26; IQR. 1.52-3.23; and 2017 median density: 2.66; IQR, 1.72-4.02; P < .001). The APC of the mean density of primary care physicians in rural counties was 1.70% (95% CI, 0.84%-2.57%), nurse practitioners was 8.37% (95% CI, 7.11%-9.63%), and physician assistants was 5.14% (95% CI, 3.91%-6.37%); the APC of the mean density of primary care physicians in urban counties was 2.40% (95% CI, 1.19%-3.61%), nurse practitioners was 8.64% (95% CI, 7.72%-9.55%), and physician assistants was 6.42% (95% CI, 5.34%-7.50%). Results from the generalized estimating equations model showed that the density of primary care clinicians in urban counties increased faster than in rural counties (β = 0.04; 95% CI, 0.03 to 0.05; P < .001). Although the density of primary care clinicians increased in both rural and urban counties during the 2009-2017 period, the increase was more pronounced in urban than in rural counties. Closing rural-urban gaps in access to primary care clinicians may require increasingly intensive efforts targeting rural areas.

PH Roundtable: Disparities in PH

The main aim of the paper is to reveal the outcomes of a research based on the efficiency of primary health care providers. The scientific goal of the mentioned research was the development of an efficiency measurement model and verification of its usefulness in practice. Overall, the research found that it is possible to use the efficiency measurement model for health care providers. Besides, significant differences were discovered in the efficiency of public and nonpublic primary health care providers. The research was conducted in the West Pomeranian Voivodship in Poland. This paper contributes to the widespread debate on public and nonpublic ownership in the field of healthcare. Also, it has practical implications as the research findings may be useful for any healthcare sector stakeholder, from decision makers to patients. The research was based on the literature overview, which allowed to elaborate the efficiency measurement model. The empirical research (based on a form of questionnaires) allowed testing the proposed model. The described efforts allowed drawing conclusions on the efficiency of primary health care institutions in the West Pomeranian Voivodship. The following methods of data analysis are presented in the paper: synthetic measure of development (SMD), Ward’s method, and k-means method. According to the main conclusion of the research, it is possible to measure the efficiency of public and nonpublic health care providers of the Polish healthcare system. The proposed model for measuring the socioeconomic efficiency may be used as one of the tools used to measure the efficiency in the primary care. The verification of the usefulness of the model showed that nonpublic health care providers operating in the field of the public sector, outperformed public providers. The paper contributes to the theoretical field as it reveals a comprehensive approach to the efficiency measurement in the health care sector. The efficiency measurement model is based on the three major pillars of the healthcare sector, namely, income/resources, cost, and the social aspect. The elaborated efficiency measurement model for the healthcare sector was implemented and tested on a group of primary health care providers in the West Pomeranian Voivodship. The research allowed for positive conclusions regarding its usefulness in practice.

Older adults constitute the fastest-growing segment of the homeless population in the US. Previous research has found older homeless adults to have more chronic conditions, greater odds of physical disability, and experience accelerated aging compared to housed populations. Little is known about the role of street medicine in providing care and support to aged and aging patients experiencing unsheltered homelessness. The purpose of this study was to elicit the perspective of clinicians and unsheltered homeless patients on aging and managing serious illness. We conducted interviews with patients receiving street medicine and their clinicians. Interviews were guided by a semi-structured protocol, audio recorded, and transcribed verbatim. Data were analyzed following a thematic analysis approach. Eight clinicians and eight patients were interviewed. On average, clinicians were 41 years old, white (50%), and female (50%) with 1-16yrs street medicine experience. Patients were commonly male (63%), had 3+ chronic conditions (100%), and aged 56 years. Thematic analysis revealed four major paradoxical themes around: End-of-life, shelter, durable medical equipment, and community. The clinician and patient perspective on aging and managing serious illness while living outside offer insight into the significant and paradoxical challenges each face when balancing restrictions from the healthcare system, social services, and patient/self needs. Results highlight constraints placed on clinicians and patients by the rigid healthcare system and its incompatibility with the unique circumstances of unsheltered older adults. Findings from this study suggest actionable strategies that hold implications for policy and practice to better meet the needs of unsheltered homeless older adults.

Street medicine is a health delivery model designed to provide direct patient care to people experiencing unsheltered homelessness where they are physically located, whether that be on the streets or in encampments. The model has developed in response to the barriers people experiencing homelessness (PEH) encounter when accessing care through traditional points of access such as primary care clinics. Street medicine programs are rapidly emerging across the United States (U.S.) in response to the health needs and challenges associated with care access and coordination for unsheltered homeless individuals. Although street medicine is a rapidly growing field, existing street medicine programs have rarely been studied collectively, limiting our understanding of the nature, scope, and range of street medicine programs in the U.S. This study examined 13 programs from across the U.S. to develop a broad characterization of street medicine programs. Results from interviews with representatives from each of the 13 programs show that there is a high degree of variability among the structure, operations, and scope of care of street medicine programs. However, consistent among street medicine programs is the adoption of a patient-centered approach to care and the use of harm-reduction principles. Street medicine programs are also highly engaged with community partners and affiliate organizations that work in their local and regional areas. Because street medicine programs often serve as a bridge between formal healthcare entities and PEH, street medicine offers a strategy for reconnecting individuals to vital healthcare services.

Background: While both public health entities and primary care play key roles in health promotion and prevention, complex challenges, such as lack of role clarity, gaps in governance and coordination, and resource constraints hinder health system integration efforts. Approach: We aim to explore opportunities to facilitate integration across public health and primary care for health promotion and prevention initiatives in Alberta. The study aim was informed through consultation with public health and primary care staff, leadership, and providers. Patient Co-Investigators play an important role in carrying out the following objectives:. Examine the landscape of public health and primary care integration internationally through an environmental scan. We identified factors influencing integration efforts between public health and primary care for health promotion and prevention initiatives in the academic and grey literature.2. Identify policy, system, and individual-level barriers and facilitators for integrating efforts in Alberta through qualitative interviews with public health and primary care staff, leadership, and providers. Interviews were conducted with patients and caregivers to understand their experiences with receiving care and support for health promotion and prevention. Results: This study is in progress, with Objectives and 2 underway. Preliminary findings from Objective include the identification of 72 initiatives across 6 countries, with two multi-country initiatives. System-level (macro) initiatives (e.g., pandemic response or national service coordination) accounted for 27% of initiatives. Organizational-level (meso) initiatives comprised 24% of initiatives (e.g., interdisciplinary care teams). Patient-provider-level (micro) initiatives were described in 49% of initiatives, including integrated behavioral health initiatives (e.g., health promotion education). To date, we interviewed 0 public health and primary care staff, leaders, and providers, and 5 patients and caregivers. Key factors influencing implementation of integration identified from Objectives and 2 include: shared vision/goals around health promotion and prevention, clarity around organizational and provider roles and responsibilities, differences in organizational/professional cultures, quality of relationships and partnerships (co-design as an important facilitator), financial compensation/reimbursement for integrated models, the need for governance, organizational structures, and processes for data sharing to support collaboration, and availability of staff. Patients and caregivers identified family doctors as a critical support for their health promotion and prevention goals, while other healthcare providers can also play an important role (e.g. pharmacists). Patients and caregivers emphasized the need for accessible, trusting, person-centred, and culturally sensitive care. Patients and caregivers reported needing to advocate for themselves; they want the system to provide accessible and reliable information. Implications: Based on the findings from Objectives and 2, we will conduct a consensus workshop with public health and primary care leaders, healthcare providers, and patients to co-design solutions towards health system integration in Alberta. These solutions need to address patient and caregiver needs regarding health promotion and prevention, including addressing system-level gaps to address issues related to accessibility of information and coordination of services. This project aligns with ongoing provincial initiatives to improve patient experiences and outcomes, and can provide practical guidance for strengthening integration efforts between public health and primary care organizations in Alberta.

Geographic Distribution of Otolaryngology Advance Practice Providers and Physicians.

The Future of Nursing 2020–2030: Charting a path to achieve health equity

Older adults constitute the fastest-growing segment of the homeless population in the US. Previous research has found older homeless adults to have more chronic conditions, premature mortality, greater odds of physical disability, and experience accelerated aging compared to housed populations. To inform programs to better serve this population, improved understanding of how they meet their basic needs is warranted. The purpose of this study was to explore the experience of unsheltered homeless older adults with meeting their basic needs for food, drinking water, toilet, hygiene, and healthcare in Los Angeles County. From 2021-2023 (24-months), we conducted a cross-sectional survey using the HOUSED BEDS assessment with people experiencing unsheltered homelessness and initiating care with Street Medicine (N=637). Quantitative data were analyzed to compare adults (18-49 yrs) and older adults (50+ years). Findings show that 40.3% of those sampled were older adults. Most older adults experiencing unsheltered homelessness identified as male (70%), Hispanic/Latino (46.6%), or Black/African American (25.6%). The majority of older adults had health insurance (79%) yet few (22%) had a primary care provider. Older adults lacked 24-hr bathroom access (22.3%), were forced to practice open defecation (82%), and relied on purchased food (50%) and drinking water (40.6%). Maslow’s hierarchy of needs explains that time and energy spent meeting basic needs of survival (including food, hydration, and sanitation) means time and energy not spent elsewhere, such as seeking healthcare. Results of this study suggest a need for scaling Street Medicine which provides basic needs and comprehensive, accessible primary care.

<h3>Context:</h3> Individuals experiencing unsheltered homelessness experience higher rates of disease burden, limited access to healthcare, and inability to abide by COVID-19 public health recommendations (i.e. handwashing, stay-at-home-orders), leaving them at significant risk for COVID-19 infection and complications. <h3>Objective:</h3> To describe a cohort of unsheltered homeless from Los Angeles County participating in Project RoomKey (PRK). <h3>Study Design:</h3> Case series <h3>Setting:</h3> PRK temporarily housed individuals in hotels/motels due to COVID-19 pandemic. Participants eligible if unhoused and: age 65+, had underlying medical conditions, or were medically compromised. Sample of 35 patients provided primary care by USC Street Medicine at single PRK site from July-September 2020. Sample comprised 62.9% male, 54.3% age 50+, 40% Hispanic/Latinx, 40% White, and 94.3% English-speaking. <h3>Population Studied:</h3> Individuals experiencing unsheltered homelessness most likely to need hospitalization or critical care if infected with COVID-19. Study patients referred to street medicine when unmet health care needs identified or medical care requested by patient or PRK staff. Overall sample of n=35. <h3>Instrument:</h3> HOUSED BEDS+ clinical tool for taking history on unsheltered homeless patients. <h3>Results:</h3> Participants were asked to respond about their lives prior to entering PRK. All patients had ≥1 medical condition, 64.7% had ≥1 mental health condition, and 59.4% with tri-morbid condition. HOUSED BEDS framework revealed: Homeless history (H): 5.2 mean years homeless with 44.8% living on street and 34.5% combination of street, car, and/or shelter. Outreach (O): 92.6% received outreach. Utilization (U): 5.9 mean emergency department visits in past 6 months. Salary (S): 82.1% received government income. Eat (E): 73.7% received ≥7 meals per week. Drink (D): 80% reported clean water access. Bathroom (B): 86.4% reported bathroom access. Encampment (E): 61.9% reported safety concerns while living outside. Daily routine (D): 89.7% had access to a phone, 39.3% received social support from family and 28.6% from combination of family, friends, and/or partner. First priority for 25.9% was housing, 22.2% was income, 18.5% was social relationships, and 18.5% was health. Substance use (S): 93.1% had past or current substance use. <h3>Conclusions:</h3> Analyses highlight importance of housing, income, social relationships, and health to adults over age 50 experiencing unsheltered homelessness.

Approximately 60 million persons in the United States live in rural counties, representing almost one fifth (19.3%) of the population.* In September 2020, COVID-19 incidence (cases per 100,000 population) in rural counties surpassed that in urban counties (1). Rural communities often have a higher proportion of residents who lack health insurance, live with comorbidities or disabilities, are aged ≥65 years, and have limited access to health care facilities with intensive care capabilities, which places these residents at increased risk for COVID-19-associated morbidity and mortality (2,3). To better understand COVID-19 vaccination disparities across the urban-rural continuum, CDC analyzed county-level vaccine administration data among adults aged ≥18 years who received their first dose of either the Pfizer-BioNTech or Moderna COVID-19 vaccine, or a single dose of the Janssen COVID-19 vaccine (Johnson & Johnson) during December 14, 2020-April 10, 2021 in 50 U.S. jurisdictions (49 states and the District of Columbia [DC]). Adult COVID-19 vaccination coverage was lower in rural counties (38.9%) than in urban counties (45.7%) overall and among adults aged 18-64 years (29.1% rural, 37.7% urban), those aged ≥65 years (67.6% rural, 76.1% urban), women (41.7% rural, 48.4% urban), and men (35.3% rural, 41.9% urban). Vaccination coverage varied among jurisdictions: 36 jurisdictions had higher coverage in urban counties, five had higher coverage in rural counties, and five had similar coverage (i.e., within 1%) in urban and rural counties; in four jurisdictions with no rural counties, the urban-rural comparison could not be assessed. A larger proportion of persons in the most rural counties (14.6%) traveled for vaccination to nonadjacent counties (i.e., farther from their county of residence) compared with persons in the most urban counties (10.3%). As availability of COVID-19 vaccines expands, public health practitioners should continue collaborating with health care providers, pharmacies, employers, faith leaders, and other community partners to identify and address barriers to COVID-19 vaccination in rural areas (2).

The American Medical Association recognizes street homelessness as a significant barrier to the provision of high-quality care.1 Traditional medical training provides inadequate preparation for physicians to manage persons experiencing unsheltered homelessness (PEUH). Street medicine is the direct provision of health care and social support to PEUH,2 who experience high barriers to needed care and tend to use acute hospital-based care at high rates.3We established a street medicine fellowship to enable physicians to acquire the requisite clinical and organizational skills to become leaders in improving outcomes in this vulnerable population.The UPMC Mercy Street Medicine Fellowship is the first of its kind. This one-year, one fellow per year program was initiated in 2019 by UPMC Mercy, Pennsylvania. The fellowship accepts applications from physicians who have completed a residency in internal medicine, family medicine, emergency medicine, or psychiatry, and who seek to develop expertise in caring for PEUH while also participating in multidisciplinary care to enable them to serve as future leaders in this field. At the end of the fellowship training a survey is sent to learners.Fellows are instructed in comprehensive management of PEUH. The program uses the “go-to people” approach to health care as promoted by the Street Medicine Institute. Fellows are challenged to set aside the mindset of the “office approach,” which often does not embrace unique social determinants of health, and round 3 to 4 times per week on the streets, on the riverbanks, and in homeless encampments, including general rounds, targeted case management rounds, and specialty rounds (eg, psychiatric, harm reduction, intimate partner violence, etc). They participate in additional outpatient clinics, 3 half days per week, which have been established for PEUH and for those who have transitioned from street homelessness into housing. Fellows maintain this continuity group of patients throughout the fellowship year. Home visits are also conducted for newly placed patients.Fellows apply the concept of “community united” so that changes initiated in one community are spread to others. They utilize multidisciplinary mentors and engage in productive communication with experts in street medicine. They conduct a formal comparative analysis of 2 communities in which street medicine is practiced to further develop insight into improvement opportunities as well as attend the annual International Street Medicine Symposium as a learning activity and for academic presentation as applicable.Fellows are assessed monthly according to the Accreditation Council for Graduate Medical Education's Core Competencies. Fellows also complete a monthly evaluation of their assigned experience. Lastly, fellows are surveyed at the completion of the year (Figure).Our first fellow now carries a university faculty position in another city. She teaches in the outpatient setting and has integrated clinical street work with community initiatives, a street medicine interest group, and a peer outreach group. Our second fellow is practicing emergency medicine in another city and incorporating her skills to improve care in that setting for PEUH.Although our program is young, our graduates have affirmed that formal fellowship training in street medicine is a viable yet heretofore unexplored avenue toward more effectively addressing society's responsibility toward PEUH.

BackgroundWhooping cough is a communicable disease whose incidence has increased in recent years in some countries with vaccination. Since 1981, in Catalonia (Spain), cases must be reported to the Public Health Department. In 1997, surveillance changed from aggregated counts to individual report and the surveillance system was improved after 2002. Catalan public health is universal with equal coverage geographically. The aim of this study was to determine whether there are differences in whooping cough incidence in rural and urban counties.MethodsCases in 1990–2010 were classified as rural or urban. Incidences and risk ratios (RR) between urban and rural counties and 95% CI were calculated. Associations between rural and urban counties and structural changes during the study period were analysed.ResultsTwelve years of the whole study period showed differences in incidence between rural and urban counties. The incidence was higher in urban counties in seven years and rural counties in five years. There was a positive association of whooping cough incidence in rural and urban counties in four-week periods. Structural changes were detected in the following four-week periods: 4th in 1993, 7th in 1996 and 3rd 2005 in rural counties and 5th 1993, 9th in 1996 and 8th in 2007 in urban counties.ConclusionsDifferences in whooping cough between rural and urban counties were found. In most years, the incidence was higher in urban than in rural counties. Rural and urban counties show similar cyclic behaviour when four-week periods were considered.

Background:Temperature-related mortality risks have mostly been studied in urban areas, with limited evidence for urban–rural differences in the temperature impacts on health outcomes.Objectives:We investigated whether temperature–mortality relationships vary between urban and rural counties in China.Methods:We collected daily data on 1 km gridded temperature and mortality in 89 counties of Zhejiang Province, China, for 2009 and 2015. We first performed a two-stage analysis to estimate the temperature effects on mortality in urban and rural counties. Second, we performed meta-regression to investigate the modifying effect of the urbanization level. Stratified analyses were performed by all-cause, nonaccidental (stratified by age and sex), cardiopulmonary, cardiovascular, and respiratory mortality. We also calculated the fraction of mortality and number of deaths attributable to nonoptimum temperatures associated with both cold and heat components. The potential sources of the urban–rural differences were explored using meta-regression with county-level characteristics.Results:Increased mortality risks were associated with low and high temperatures in both rural and urban areas, but rural counties had higher relative risks (RRs), attributable fractions of mortality, and attributable death counts than urban counties. The urban–rural disparity was apparent for cold (first percentile relative to minimum mortality temperature), with an RR of 1.47 [95% confidence interval (CI): 1.32, 1.62] associated with all-cause mortality for urban counties, and 1.98 (95% CI: 1.87, 2.10) for rural counties. Among the potential sources of the urban–rural disparity are age structure, education, GDP, health care services, air conditioners, and occupation types.Conclusions:Rural residents are more sensitive to both cold and hot temperatures than urban residents in Zhejiang Province, China, particularly the elderly. The findings suggest past studies using exposure–response functions derived from urban areas may underestimate the mortality burden for the population as a whole. The public health agencies aimed at controlling temperature-related mortality should develop area-specific strategies, such as to reduce the urban–rural gaps in access to health care and awareness of risk prevention. Future projections on climate health impacts should consider the urban–rural disparity in mortality risks. https://doi.org/10.1289/EHP3556

This paper deals with the some of the important variable factors relating to health care in Saudi Arabia, with special emphasis on primary health. Other aspects considered are the financial influen...