Homeless Individuals Research Articles

LeRoy Spaniol, PhD, 1938-2020.

Presents the obituary of LeRoy Spaniol, PhD (1938-2020). LeRoy was a professor at Boston University for 31 years and a cofounder and senior director at the Center for Psychiatric Rehabilitation from 1974 until his retirement. Leroy's dedication to service began early in his life as a seminarian, followed by his work as a therapist helping people heal from divorce and serious mental illness. LeRoy's nationally and internationally cited research and prolific publications focused on the role of the family in psychiatric rehabilitation, effectively serving homeless individuals, competency-based staff training, program evaluation, and coping and recovery from serious mental illnesses. LeRoy's research and authorship of training curricula that emphasized the importance of recovery "as a possibility and even an expectation and key paradigm shift for our field" is a hallmark of his work. To that end, one of LeRoy's proudest accomplishments was founding and teaching in the Recovery Education Center, a rehabilitation program for people with psychiatric disabilities at the Center for Psychiatric Rehabilitation at Boston University. LeRoy participated on many national and regional boards of directors and commissions, and research review committees and was a founding member of the National Alliance on Mental Illness (NAMI) of Massachusetts in 1982. His work with families continued in his retirement, serving as president of NAMI of Cape Cod for 8 years. The awards and distinctions that LeRoy received throughout his career are numerous, and of key importance to him was the LeRoy Spaniol Educator Award established by the Psychiatric Rehabilitation Association (PRA). This award is presented to an individual who has made outstanding contributions toward educating and mentoring a new generation of leaders. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Designing for Growth and Development – A co-designed course for homeless people

Abstract Background In many developed countries, homelessness remains an intractable challenge for intersectoral policies. People who are homeless struggle with a myriad of problems. They frequently experience stigmatisation and social marginalisation. Physical and mental health may be severely compromised, and it could be challenging to retain a sense of personal agency. Objectives. To co-design a personal and organisational development training course, in collaboration with clients and staff of a homeless service provider. To ensure that homeless individuals develop strategies and supports to help them navigate complex life circumstances. 6 three-hour workshops, informed by design-thinking. Each workshop session was co-designed (2 clients of a homeless charity, one staff member of staff, and two academics) in Ireland. Workshops followed the design cycle, starting with empathy exercises, then moved to define specific life challenges related to homelessness. Solution-focused ideation sessions followed. The team proceeded then to build a testable 'prototype'. Results The team jointly developed a high degree of creative confidence and shared responsibility for different sessions. The team developed a 'peer-support programme' as a tangible output. Academic team members gained deep insights into the lived experience of homelessness; client members deployed skills and experiences and gained renewed confidence in their abilities. The homeless charity proceeds with testing the 'peer-support' programme prototype. Conclusions We expect the Access and Life-Long learning programme at the university will offer the programme as a credit-bearing course. Its acceptability and usability will be tested. Key messages Homeless individuals can be meaningfully involved in designing services that empower them to navigate complex systems. Design thinking yields personal and organisational benefits.

Combating homelessness: Insights from a homeless population

There are adequate discussions in literatures to define and discuss homelessness and the homeless. One definition of a homeless is an individual who does not have a permanent dwelling, but live on the streets or at shelters as temporary arrangements. Homelessness is due to several factors, which is also adequately discussed in the literatures. Being homeless, usually gives a negative perception on the wellbeing and social functionality of the homeless individual. This study aims to understand the pertinent issues from the perspective of the homeless. Primary data for this qualitative study were gathered through in-depth interviews of 20 homeless respondents in Penang. The study findings indicate that the underlying causes of homelessness are varied with the main ones being financial and family problems; and alcohol and drug related. Addressing these underlying causes is best way to address the homelessness problem in a more sustainable manner. Some strategies to reduce the number of homeless population based on the study include to better coordinate distribution of free food to reduce overdependence by the homeless, free housing if the case merits it and finally the need for more professional or qualified social workers who can work more closely with the population to empower them to lead a normal life and be less dependent on free handouts. Keywords : homelessness, strategies, social support services

Change in Housing Status among Homeless and Formerly Homeless Individuals in Quebec, Canada: A Profile Study.

Housing stability is a key outcome in studies evaluating housing services for the homeless population. Housing stability has typically been defined dichotomously and based on a fixed duration of maintenance in housing accommodations, which does not fully capture change in housing status among homeless individuals. Moreover, few typologies have examined housing trajectories across different housing types. Cluster analysis was used to develop a typology of housing status change for 270 currently or formerly homeless individuals in Quebec (Canada) residing in shelters and temporary and permanent housing. Participants were interviewed at baseline (T0) and 12 months later (T1). The Gelberg–Andersen Model was used to organize housing-related variables into predisposing, needs and enabling factors. Comparison analyses were conducted to assess group differences. Three groups (Groups 1, 3 and 4) had more favorable and two (Groups 2 and 5) less favorable, housing status at T1. Findings suggest that maintenance or improvement of housing status requires suitable types and frequencies of service use (enabling factors) that are well adapted to the nature and complexity of health problems (needs factors) among homeless individuals. Specific interventions, such as outreach programs and case management, should be prioritized for individuals at higher risk for returning to homelessness.

Exploring the Association of Community Integration in Mental Health among Formerly Homeless Individuals Living in Permanent Supportive Housing.

Supportive housing has been widely used among persons experiencing chronic homelessness and/or mental health conditions. While it has been demonstrated to be effective in addressing homelessness among populations with complex needs, community integration remains a challenge. Community integration is the extent to which individuals live, participate, and socialize in their community and consists of three aspects: physical, social, and psychological. The study utilized data from the Transitions to Housing project that followed formerly homeless individuals (N=383) throughout their first year of residence in permanent supportive housing (PSH). The study set out to examine which aspects of community integration are associated with mental health symptoms in this population. Five nested multivariate linear regression models were conducted and then compared. The model that accounted for demographics, substance use, neighborhood quality, and all three aspects of community integration simultaneously was the best fit and explained the most variance in mental health symptoms (24%). The complete model suggested higher levels of psychological integration were significantly associated with decreased mental health symptoms in this sample. This finding suggests fostering a sense of belonging among PSH residents could improve mental health outcomes. Implications for practice and future research are discussed.

A survey of dermatologic health-related quality of life and resource access in patients experiencing homelessness

A survey of dermatologic health-related quality of life and resource access in patients experiencing homelessness

The development and validation of a marginalization index for inpatient psychiatry.

Marginalization is a multidimensional social construct that influences the mental health status of individuals and their use of psychiatric services. However, its conceptualization and measurement are challenging due to inconsistencies in definitions, and the lack of standard data sources to measure this construct. To create an index for screening marginalization based on an existing comprehensive assessment system used in inpatient psychiatry. Items anticipated to be indicative of marginalization were identified from the Resident Assessment Instrument-Mental Health (RAI-MH) that is used in all inpatient mental health beds in Ontario, Canada. Principal Component Analysis (PCA) and cluster analysis of these items was performed on a sample of 81,232 patients admitted into psychiatric care in Ontario between 1 January 2011 and 31 December 2016 to identify dimensions being measured. Various weights and scoring methods were tested to assess convergent validity on multiple outcomes of marginalization. Receiver Operating Characteristic (ROC) curve analysis was utilized to determine optimal cut-offs for the index by modeling the likelihood of different marginalization outcomes, including homelessness. Fifteen items were identified for the development of the Marginalization Index (MI). PCA and cluster analysis identified that the items measured five dimensions. ROC curve analysis among homeless individuals identified an Area Under the Curve of 0.76 and an optimal cut-off of five on the MI. Frequency analysis of the index by different characteristics identified homeless individuals, frequent mental health service users, persons with a history of violence and police intervention, and persons with addictions issues, as groups with the highest scores, confirming the convergent validity of the index. The MI is a valid measure of marginalization and is strong predictor of risk of homelessness among psychiatric inpatients. MI provides a resource that can be used for social and health policy, decision-support and evaluation.

Cost-Effectiveness of Housing First With Assertive Community Treatment: Results From the Canadian At Home/Chez Soi Trial.

The At Home/Chez Soi trial for homeless individuals with mental illness showed scattered-site Housing First with Assertive Community Treatment (ACT) to be more effective than treatment as usual. This study evaluated the cost-effectiveness of Housing First with ACT and treatment as usual. Between October 2009 and June 2011, a total of 950 homeless individuals with serious mental illness were recruited in five Canadian cities: Vancouver, Winnipeg, Toronto, Montreal, and Moncton. Participants were randomly assigned to Housing First (N=469) or treatment as usual (N=481) and followed up for up to 24 months. The intervention consisted of scattered-site Housing First, using rent supplements, with ACT. The treatment-as-usual group had access to all other services. The perspective of society was adopted for the cost-effectiveness analysis. Days of stable housing served as the outcome measure. Retrospective questionnaires captured service use data. Most (69%) of the costs of the intervention were offset by savings in other costs, such as emergency shelters, reducing the net annual cost of the intervention to about Can$6,311 per person. The incremental cost-effectiveness ratio was Can$41.73 per day of stable housing (95% confidence interval=Can$1.96-$83.70). At up to Can$60 per day, Housing First had more than an 80% chance of being cost-effective, compared with treatment as usual. Cost-effectiveness did not vary by participant characteristics. Housing First with ACT appeared about as cost-effective as Housing First with intensive case management for people with moderate needs. The optimal mix between the two remains to be determined.

Role-playing in public engagement for housing for vulnerable populations: An experiment exploring its possibilities and limitations

Public consultation and engagement on housing development and neighbourhood change can be so controversial and at times alarmist such that NIMBY (“Not in my back yard”) and even the more extreme BANANA (“Build absolutely nothing anywhere near anyone”) attitudes often prevail. Public engagement as currently conceived and practiced by most governments is faced with high expectations but low satisfaction among many involved. This article reports the findings from a group-based role-playing experiment in Canada involving local residents discussing and evaluating a hypothetical proposal for a new housing development for currently homeless individuals. The results find that those who were randomly assigned a role to play with attitudes different from their own were more likely to report higher satisfaction with the group discussion and recommendation than those who were not assigned a role different from their own identity and attitudes. The study finds no relationship between role-playing and the self-reported sense of one’s influence on the process or how much they learned about the issues. The findings point to new frontiers of public engagement that involve playful role-playing or other “games” as a means to create space for mutual understanding and tolerance for decisions among citizens in these fraught debates.

A classification model of homelessness using integrated administrative data: Implications for targeting interventions to improve the housing status, health and well-being of a highly vulnerable population.

Homelessness is poorly captured in most administrative data sets making it difficult to understand how, when, and where this population can be better served. This study sought to develop and validate a classification model of homelessness. Our sample included 5,050,639 individuals aged 11 years and older who were included in a linked dataset of administrative records from multiple state-maintained databases in Massachusetts for the period from 2011-2015. We used logistic regression to develop a classification model with 94 predictors and subsequently tested its performance. The model had high specificity (95.4%), moderate sensitivity (77.8%) for predicting known cases of homelessness, and excellent classification properties (area under the receiver operating curve 0.94; balanced accuracy 86.4%). To demonstrate the potential opportunity that exists for using such a modeling approach to target interventions to mitigate the risk of an adverse health outcome, we also estimated the association between model predicted homeless status and fatal opioid overdoses, finding that model predicted homeless status was associated with a nearly 23-fold increase in the risk of fatal opioid overdose. This study provides a novel approach for identifying homelessness using integrated administrative data. The strong performance of our model underscores the potential value of linking data from multiple service systems to improve the identification of housing instability and to assist government in developing programs that seek to improve health and other outcomes for homeless individuals.

A critical scoping review about the impact of music in the lives of young adults who use drugs.

Music is among the most frequently used medium to promote young adults' well-being. To that aim, the efficiency of music is explained by its capacity to modulate emotions through its effect on the brain's reward pathways. Hence, music could help individuals suffering from dysregulations in these pathways, whose experience of positive emotions is often inhibited. Such dysregulations are particularly present in individuals with problematic psychoactive substance (PAS) use, who are overrepresented in the context of homelessness. While few of them initiate treatment, they successfully rely on their own resources to promote their well-being, including music, though its impact in this context remains under-studied. This scoping review describes the impact of music on the well-being, PAS use and addictive trajectory of young housed and homeless individuals with problematic PAS use. Eleven French and English databases were screened for peer-reviewed articles using concepts and keywords related to music, PAS and well-being. From the 3697 results, 39 were reviewed. Results were organised according to the observed impact of music and analysed critically. Literature shows that PAS users value the impact of music in meeting emotional, psychological and social needs, especially when they experience homelessness. Yet, research has been highly limited to the harmful consequences of music, limiting our knowledge of its potential benefits. To deepen our understanding about the impact of music, future research should endorse a broader perspective and consider the personal and contextual experiences accompanying the involvement in music, factors that were traditionally overlooked.

Sick Enough? Mental Illness and Service Eligibility for Homeless Individuals at the Border

This paper measures mental illness among individuals experiencing homelessness in a border city and compares it to the general housed population. We use original data from a homeless survey conducted in El Paso, Texas. Respondents self-reported any possible mental illness or related symptoms. We find that mental illness is not disproportionally common among the homeless, yet this is something that is often claimed by laypersons, some social service workers, and some researchers that limit sampling to institutionalized settings where formal mental illness is often among the prerequisites for admission. We find that “severe mental illness” among homeless persons is 6.2% (only around 2–3% higher than the general population), and “any mental illness” is 20.8% (only 1–3% higher than in the general population). Our results are consistent with other research focusing on street samples.

“When you're homeless, they look down on you”: A qualitative, community-based study of homeless individuals with heart failure

BackgroundOutpatient heart failure (HF) care involves intensive self-management (SM). Effective HF SM is associated with improved outcomes. Homelessness poses challenges to successful SM. ObjectivesTo identify the ways in which homelessness may impede successful SM of HF and engagement with the healthcare system. MethodsWe conducted open-ended, semi-structured interviews with homeless adults with HF. Data were analyzed by a multidisciplinary team using a grounded theory approach. ResultsWe interviewed 19 participants, 11 (58%) of whom were homeless at the time of interview. Interviews revealed a combination of influences on HF SM. Major themes included instability and lack of routine, tradeoffs between basic necessities and HF SM, and stigmatization by healthcare providers. ConclusionsAnticipatory guidance aimed at the unique challenges faced by homeless individuals with HF may aid successful SM. HF providers should simlpify medication regimes and engage in non-stigmatizing discourse. Larger-scale interventions include the creation of medical respite programs.

Disaster psychiatry and homelessness: creating a mental health COVID-19 response

Homeless individuals across the globe live in a constant state of crisis Yet, during times of societal crisis such as COVID-19 that affect all populations, disaster planning has rarely included this high-risk group The high burden of co-occurring physical, mental, and substance use disorders, absence of reliable shelter, scant access to health information, and scarcity of financial, transportation, and nutritional resources all create unique vulnerabilities for this population These factors restrict the ability of people experiencing homelessness to respond and adapt to public health recommendations before and during a disaster In particular, the mental health needs of people who are homeless during disasters have received minimal attention (PsycInfo Database Record (c) 2021 APA, all rights reserved)

Emergency Department Use and Barriers to Health Care Among Homeless and Uninsured Patients at a Student-Run Free Clinic

Background: Free clinics often provide healthcare to homeless individuals who face barriers to accessing primary care and other healthcare services. This study aimed to assess: (1) barriers to healthcare experienced by uninsured and homeless patients at a student-run free clinic; (2) patient perceptions of helpfulness of social service resources; and (3) relationships between barriers and emergency department (ED) use and health status.
 Methods: In 2017, patient interviews were conducted at a student-run free clinic in central Texas. A structured questionnaire was used to collect demographics, perceived health status, ED usage, and ratings of barriers to healthcare and helpfulness of social service resources. Data analysis included descriptive and bivariate analyses, used to examine the relationship between barriers to healthcare services and ED use, and between barriers to healthcare services and health status.
 Results: In total, 48 patients participated. The highest-rated barrier to receiving medical care was cost of healthcare, followed by lack of transportation and lack of insurance. Of the top 5 most utilized resources, Medicaid was rated as most helpful, followed by a medical assistance program and caseworkers. Reported ED use was significantly associated with higher ratings of lack of transportation as a barrier (p=0.03), use of a local mental health services program (p=0.01), and having insurance coverage through a local medical assistance program, Medicaid, or Medicare (p=0.01). No significant relationship was found between any healthcare barrier and health status.
 Conclusions: This study found that the highest barrier to medical care was cost of healthcare and that lack of transportation was significantly related to ED usage. In the future, this clinic might consider introducing a resource that addresses the barrier of transportation for its patients.

Formerly Homeless and Other Stakeholder Perspectives of a Permanent Supportive Housing Program in Los Angeles County

In 2012, the Department of Health Services in Los Angeles County created the Housing for Health (HFH) initiative, which provides permanent supportive housing (PSH) and rental subsidies to homeless individuals who are among the highest utilizers of acute care overall and particularly under Medicaid. In addition to housing and rental subsidies, HFH provides intensive case management services and connects clients to a broad range of health, social, and income support services in the community. HFH is a partner of Los Angeles County Whole Person Care Pilot (WPC‐LA), a program implemented under California’s Section 1115 Medicaid Waiver focused on providing care coordination and housing support services to enrollees with complex care needs.We used data from a mixed‐methods evaluation of HFH between 2016 and 2018 that was designed to gauge HFH’s effectiveness and its impact on health service utilization and outcomes in other public service sectors, such as social services, mental health services, and public health. We examined the perspectives of a broad range of PSH stakeholders from interviews on the impact of HFH.Data were collected through semi‐structured in‐depth interviews with 14 key informants, and nine focus groups in which 42 formerly homeless tenants and 29 providers of PSH programs participated. Verbatim transcripts were independently coded by at least two research team members. Emerging patterns and themes were identified using a process of constant comparison analysis across and within distinct data sources.Study participants included current PSH tenants, direct service providers, housing and homeless services program administrators, and multisectoral agency leaders in both public and private sectors.Stakeholders indicated positive impacts of HFH as it has expanded the reach and intensity of PSH. They commented on HFH’s capacity to address housing needs including outreach, intake, engagement, placement, and stabilization. Stakeholders said that HFH’s multisectoral and collaborative approach and use of intensive case management services have enhanced continuity of care with positive effects on tenant outcomes. Reported challenges to HFH implementation were related to the context of extremely limited housing inventory and a workforce not yet sufficient to meet increasing demand with frequent turnover. Systems‐level facilitators, including enhanced communication and accountability practices, were cited as essential to support ongoing implementation and to ensure fidelity of the HFH approach.Stakeholders perceived that HFH was a catalyst for positive change in the administration and delivery of PSH programs and services in Los Angeles.Our findings from senior administrator perspectives point to the importance of cross‐sectoral leadership, and the need to reconcile disparate organizational cultures through enhanced communication and inter‐organizational accountability. Formerly homeless tenant and direct service provider perspectives support the value of adopting person‐centered approaches in the planning and delivery of services across sectors. Finally, the model of partnership provided by HFH and WPC‐LA builds on long‐standing and trusted community providers to support the sustainability of these efforts.The Robert Wood Johnson Foundation.

Typology of Currently or Formerly Homeless Individuals Based on Their Use of Health and Social Services.

This study identified profiles among 455 currently or formerly homeless individuals in Quebec (Canada), based on health and social service use. Using latent class analysis, four profiles were identified that grouped individuals with: (1) few health problems, and using few case managers and family doctors, but with high frequency of psychiatric consultations, emergency department (ED) visits and hospitalizations; (2) chronic physical illnesses, having case managers and family doctors, but low frequency of ED visits and hospitalizations; (3) moderate health problems and little service use; and (4) multiple and complex health problems and high frequency of service use. These profiles suggest the following recommendations to more adequately meet patient needs: regarding Class 1, improved outreach services, more ED liaison nurses and peer navigation; Class 2: more family doctors and case managers; Class 3: higher family doctors; and Class 4: more assertive or intensive case management, harm reduction and permanent housing resources.

Soup kitchens: The stigma of being poor and the construction of social identity

This project involved an ethnographic study that documented how homeless individuals who frequent local soup kitchens view themselves and how they manage the stigma that can be associated with this population. Qualitative techniques of observation and brief conversations over a 3-year period with more than 100 soup kitchen participants constituted the data. Findings of this project confirm the earlier work of Goffman and more recent work where clear stigma responses and identities were observed in homeless and low-income adults.

Cardiovascular disease in homeless versus housed individuals: a systematic review of observational and interventional studies

ObjectivesTo identify: (i) risk of cardiovascular disease (CVD) in homeless versus housed individuals and (ii) interventions for CVD in homeless populations.MethodsWe conducted a systematic literature review in EMBASE until December...

Hospital Readmission and Emergency Department Revisits of Homeless Patients Treated at Homeless-Serving Hospitals in the USA: Observational Study.

As the U.S. homeless population grows, so has the challenge of providing effective care to homeless individuals. Understanding hospitals that achieve better outcomes after hospital discharge for homeless patients has important implications for making our health system more sustainable and equitable. To determine whether homeless patients experience higher rates of readmissions and emergency department (ED) visits after hospital discharge than non-homeless patients, and whether the homeless patients exhibit lower rates of readmissions and ED visits after hospital discharge when they were admitted to hospitals experienced with the treatment of the homeless patients ("homeless-serving" hospitals-defined as hospitals in the top decile of the proportion of homeless patients). A population-based longitudinal study, using the data including all hospital admissions and ED visits in FL, MA, MD, and NY in 2014. Participants were 3,527,383 patients (median age [IQR]: 63 [49-77] years; 1,876,466 [53%] women; 134,755 [4%] homeless patients) discharged from 474 hospitals. Risk-adjusted rates of 30-day all-cause readmissions and ED visits after hospital discharge. After adjusting for potential confounders, homeless patients had higher rates of readmissions (adjusted rate, 27.3% vs. 17.5%; adjusted odds ratio [aOR], 1.93; 95% CI, 1.69-2.21; p < 0.001) and ED visits after hospital discharge (37.1% vs. 23.6%; aOR, 1.98; 95% CI, 1.74-2.25; p < 0.001) compared with non-homeless patients. Homeless patients treated at homeless-serving hospitals exhibited lower rates of readmissions (23.9% vs. 33.4%; p < 0.001) and ED visits (31.4% vs. 45.4%; p < 0.001) after hospital discharge than homeless patients treated at non-homeless-serving hospitals. Homeless patients were more likely to be readmitted or return to ED within 30 days after hospital discharge, especially when they were treated at hospitals that treat a small proportion of homeless patients. These findings suggest that homeless patients may receive better discharge planning and care coordination when treated at hospitals experienced with caring for homeless people.