Homeless Admissions Research Articles

Homelessness and Gender: Differences in Characteristics and Comorbidity of Substance Use Disorders at Admission to Services

Background: Substance use disorders and homelessness are two closely related behavioral health issues. This study examines associations between homelessness and severity of substance use disorder (SUD) characteristics (inclusive of alcohol and other legal and illegal drugs) and presence of mental health comorbidity among individuals entering treatment for SUD. We also examine differences in SUD and mental health comorbidity by gender within a sample of clients experiencing homelessness upon admission to treatment. Methods: Using the 2017 Treatment Episodes Data Set, we used logistic regression models to examine the association between homelessness and indicators of severity (e.g., frequency of use, route of transmission) and the presence of mental health conditions, and to examine the association between gender and these dependent variables among only individuals experiencing homelessness at treatment admission. Results: After controlling for covariates, homelessness is significantly associated with increased odds of cocaine and methamphetamine use compared to all other substances, higher frequency of use, younger age of first use, use of more substances, injection drug use, and co-occurring mental health conditions. Female gender is inversely associated with younger age at first use and highly associated with co-occurring mental health conditions among those experiencing homelessness at admission to treatment. Conclusions: Individuals experiencing homelessness enter substance use services with different characteristics of substance use disorders, different patterns of use, and with higher rates of mental health comorbidity. Within homeless admissions, women have significant differences in substance use and higher likelihood of mental health comorbidity than men. Future research should focus on the specific treatment needs of individuals experiencing homelessness, and how the combination of homelessness and gender affects barriers and challenges to treatment.

Re-defining the point of need? Exploring the impact of physiotherapy on individuals within the Homeless Admissions Leeds Pathway (HALP)

Purpose: ‘Tri-morbidity’ (physical and mental health problems and substance abuse) characterises long-term homelessness, often resulting in revolving door admissions into hospital for homeless people. Due to complexity of their lives, homeless people's potential recovery is limited. Pathway teams nationally aim to improve hospital discharge for service-users. Locally, a HALP team working with a local homeless charity aims to improve hospital discharge for service-users, however little data exists in regard to experiences of discharge from hospital and physiotherapy for individuals within the HALP.

The Development of an Inclusion Health Integrated Care Programme for Homeless Adults in Dublin, Ireland

Introduction: Since 2013, the number of homeless adults in Dublin has doubled. Homeless people have higher morbidity and mortality, use a disproportionate amount of healthcare resources and generate a large volume of potentially preventable healthcare and other costs compared to more privileged individuals. Homeless people frequently need the input of multiple health and social care providers. We sought to develop and pilot a person-centred, multi-disciplinary approach to care delivery through an Inclusion Health Integrated Care Programme for homeless people attending St James’s Hospital. Methods: Action research approach: a programme was developed, and iteratively used and evaluated by the team at a weekly quality-improvement QI team meeting. Routinely collected administrative data was utilised to capture hospital presentations and length of stay for homeless individuals and the number of homeless people in the hospital catchment area. A survey was carried out to determine the views of hospital staff on the programme. Results: The Inclusion Health team, based in St James’s Hospital SJH, Dublin, was piloted from August 2016- August 2017. The team consisted of a part-time consultant physician and a full- time nurse manager funded by the National Nursing and Midwifery Planning and Development Unit. Patients were referred to the team by community-based health and social care providers or by hospital staff. The team reviewed patient cases during their inpatient admission, and continued to be involved in care co-ordination after discharge through a weekly inter-agency integrated care meeting. The team provided input to 360 homeless admissions during the one-year pilot. The approach was feasible and acceptable, with on-going engagement and attendance at weekly meetings by hospital and NGO staff. Feedback from community-based agencies and hospital staff was that the Programme delivered “a more coordinated approach to patient care, improved discharge planning with homeless services and streamlined admissions all of which have resulted in more positive patient outcomes.” During the pilot period, the number of homeless admissions to SJH fell from 0.03 to 0.017 per capita of homeless adults in Dublin per quarter. The mean length of stay for homeless adults in SJH fell from 16 days S.D 7 days to 7 days S.D. 2.5 days. The estimated bed days saving over the one-year pilot was 3,668. Limitations: A randomised controlled trial of integrated care versus no integrated care would enable more thorough assessment of intervention causality. A RCT design suitable for assessment of a complex intervention e.g. stepped wedge may be required. Conclusion: An Inclusion Health Integrated Care Programme is feasible and acceptable and offers benefits to patients and health care providers, with evidence of reduced need for costly unscheduled healthcare during the pilot programme.

Homeless Patients in the ICU: An Observational Propensity-Matched Cohort Study.

To describe epidemiology and outcome of critically ill homeless patients, as compared with those of nonhomeless patients. Homeless and nonhomeless admissions were matched on the basis of a 1:4 ratio, using a propensity score-based procedure involving age, sex, date, and main diagnosis at ICU admission. A 18-bed closed medical ICU of a French tertiary care university hospital. All consecutive admissions from July 2000 to December 2012. None. There were 421 homeless and 9,353 nonhomeless admissions. Considering homeless admissions, 50% patients had no health insurance, 56% had no financial resource, 91% were socially isolated, and 69% lived in street. In a multivariable analysis of homeless admissions including age, sex, and Simplified Acute Physiology Score II, living in street was significantly associated with hospital mortality (odds ratio=2.94; 95% CI, 1.30-7.10; p=0.012). As compared with nonhomeless, homeless admissions more frequently concerned men (89% vs 57%; p<0.0001) and younger patients (49 yr [43-57] vs 62 yr [46-76]; p<0.0001), whereas Simplified Acute Physiology Score II (37 [24-50] vs 37 [25-52]; p=0.99) and distribution of the number of organ supports (p=0.49) were similar. ICU mortality concerned 19.1% and 18% of matched homeless and nonhomeless admissions, respectively. The corresponding figures for hospital mortality were 20.8% and 20.6%. In multivariable analysis, homeless status was associated with neither ICU (odds ratio=1.27 [0.92-1.73]; p=0.14) nor hospital mortality (odds ratio=1.07 [0.77-1.49]; p=0.68), while it was independently associated with longer ICU (means ratio=1.16 [1.01-1.34]; p=0.035) and hospital (means ratio=1.30 [1.12-1.49]; p=0.0002) stay of survivors. Critically ill homeless patients benefit from the same level of care and have globally the same prognosis than housed patients but experience longer lengths of stay. Most precarious patients living in street have a higher mortality rate. The study perspective is not ICU centered but also concerns the global organization of healthcare since homeless patients are referred by numerous sources and discharged to different wards.

Profiling the medical admissions of the homeless

Aim: to describe the characteristics and outcomes of homeless people admitted to our Internal Medicine service in St. James’s Hospital, Dublin (Ireland), between 2002 and 2011. Methods: we interrogated an anonymized in-patient database. Results: there were 1,460 homeless admissions (623 unique patients; 39% admitted more than once). Most patients were young, male, and had low comorbidity levels. Thirty-seven percent of the admissions were alcohol-related and 27% substance abuse-related. Thirteen percent had an active psychiatric illness. Their in-patient mortality rate was 5%. Seventy two percent were discharged without the residential arrangement being explicitly documented, 15% self-discharged or absconded, and 8% were discharged to a residential facility. Conclusion: results are novel in our context and will be relevant for local policy and practice.

Homeless Admissions and Immigration in a State Mental Hospital

Homeless Admissions and Immigration in a State Mental Hospital