Homelessness Health Research Articles

Optimising the Nursing Scope of Practice in a Homeless Health Service: A Qualitative Descriptive Study.

To explore specialist homeless health professionals' perceptions of gaps in homeless health care and understand whether these might be addressed through existing nursing scopes of practice. Qualitative descriptive study. Semi-structured interviews and focus groups with a purposive sample of 22 staff in nursing (11) and non-nursing (11) roles, engaged with a Homeless Health Service. Data were collected via videoconferencing and recordings transcribed verbatim. An exploratory framework guided deductive and inductive thematic analysis. Service gap themes included the need for integration with mainstream health services, more specialised health professionals, and adaptations to the existing models of care. Addressing these gaps involved enhancements to the broad scope of nursing practice, workforce development by establishing homeless health as a nursing specialty and optimising organisational governance to minimise risk. The most pressing homeless health service delivery gap was lack of health service integration, and it was unclear how this could be resolved through nursing scopes of practice. Other service gaps could be addressed through skilling nurses to practice preventative health care, as well as crisis management. Enhancing nurses' capability in physical and mental health assessment skills including alcohol and other drugs and procedural skills would support wraparound care for people experiencing homelessness. We conclude that a homeless health nursing specialty could be established that formalises the scope of practice of nurses in this field to ensure future post-graduate training aligns with service gaps. This study identifies opportunities to optimise nursing scopes of practice to address Homeless Health Service gaps through reviewing models of care and nursing practice. For example, enhancing nurses' capability to provide preventative and wraparound care. This research may inform a development pathway to enhance education and training for nurses working with vulnerable populations. COREQ 32-item checklist. No patient or public contribution.

Room for Change: Rural Low-Barrier Housing Policy and Program Models for People with Substance Use and Mental Health Comorbidities

Rural North American communities experience disproportionate burdens of housing instability and toxic drug poisonings. These regions face complex intersections of homelessness, substance use, and mental health issues, and innovative strategies are required to effectively address these crises. In British Columbia, Canada, new funding opportunities to address rural homelessness for complex populations have come after a lag in available resources. Complex Care Housing is a model aimed at filling gaps in the current housing and care continuum for people with mental health and substance use challenges. Due to rural-specific social characteristics, new housing models require ongoing evaluation to ensure programs meet the quality and fidelity of gold standard Housing First programs that upload the tenets of harm reduction and person-centeredness.

Food Insecurity Among LGBQ+ Veterans

Food insecurity is associated with numerous adverse health outcomes. Little is known about the prevalence of and risks for food insecurity among veterans identifying as lesbian, gay, bisexual, queer, and similar (LGBQ+), a population facing unique social barriers and medical comorbidities. To examine food insecurity and potential risk factors among LGBQ+ veterans. This retrospective, cross-sectional study used administrative data from all US Veterans Health Administration (VHA) facilities nationally. Participants included veterans screened for food insecurity between March 1, 2021, and August 31, 2023. Positive response to food insecurity screening administered in VHA facilities as part of routine clinical care. Prevalence of and sociodemographic, clinical, and psychosocial factors associated with food insecurity among veterans identifying as LGBQ+ or heterosexual and those with "don't know" responses regarding their sexual orientation. Of 3 580 148 veterans screened, the mean (SD) age was 61.6 (0.4) years; 3 192 507 (89.2%) were assigned male sex at birth. A total of 83 292 veterans (2.3%) identified as LGBQ+, and 10 183 (0.3%) had "don't know" responses. LGBQ+ veterans (5352 [6.4%]) and veterans with "don't know" responses (635 [6.2%]) were more than twice as likely as heterosexual veterans (90 426 [2.6%]) to have positive screen results for food insecurity. While risk factors for food insecurity were similar for veterans across sexual orientation groups, LGBQ+ veterans had higher rates of several risk factors compared with heterosexual veterans, including age younger than 45 years (45.3% vs 19.5%), female sex assigned at birth (44.1% vs 10.0%), being in a minoritized racial or ethnic group (34.7% vs 29.8%), unmarried or unpartnered status (69.1% vs 39.7%), low income (16.4% vs 14.9%), homelessness or housing instability (10.3% vs 5.4%), anxiety (7.7% vs 4.3%), depression (31.1% vs 19.3%), suicidality (3.6% vs 1.4%), posttraumatic stress disorder (42.2% vs 30.2%), substance use disorder (13.1% vs 9.0%), military sexual trauma (24.0% vs 5.4%), and recent intimate partner violence (2.6% vs 1.4%). In this cohort study of veterans screened for food insecurity, LGBQ+ veterans and those with "don't know" responses for sexual orientation experienced food insecurity at nearly 2.5 times the rate of heterosexual veterans. While risk factors for food insecurity were similar across groups, LGBQ+ veterans faced a higher prevalence of particular risks, including homelessness and several mental health and trauma-related comorbidities. Future work should examine targeted screening and interventions tailored to identifying and addressing food insecurity in this population, given their increased vulnerability and burden of food insecurity.

Reconsidering the City of New York Directive on Mental Health Involuntary Removals.

Homelessness is a visible manifestation of large-scale societal challenges, such as lack of affordable housing, poverty, and health inequities. Governments may miss opportunities to address these structural problems by removing people experiencing homelessness from public spaces. On 29 November 2022, after a press conference by Mayor Eric Adams, the city of New York issued a directive entitled Mental Health Involuntary Removals. The program authorized mental health providers and NYPD officers to take any person into custody who appears mentally ill and displays inability to meet basic living needs, even when no dangerous act has been observed. We reviewed the existing literature from 1973 to 2023 for studies, enacted legislation, state and federal policies, and interventions related to homelessness, mental health, and admission of people experiencing homelessness into psychiatric hospitals in the United States. We used academic databases, including PubMed, PsycInfo, and JSTOR for peer-reviewed articles, government reports, and policy analyses. Our search strategy included keyword combinations such as "homelessness and mental health," "policy interventions for homeless populations," and "health care services costs." We applied inclusion criteria focusing on reports and articles that directly address the intersectionality of homelessness, mental health policy, and psychiatric care. Homelessness and mental illness frequently intersect, creating complex challenges that require nuanced solutions. Forced hospitalization of people experiencing homelessness in New York City, while intended to address critical social and health care issues, carries a risk for significant long-term harm. This approach places strain on the mental health care system and may ultimately exacerbate the problems it purports to resolve.

Mitigating Racial Bias in Health Care Algorithms: Improving Fairness in Access to Supportive Housing.

Algorithms for guiding health care decisions have come under increasing scrutiny for being unfair to certain racial and ethnic groups. The authors describe their multistep process, using data from 3,465 individuals, to reduce racial and ethnic bias in an algorithm developed to identify state Medicaid beneficiaries experiencing homelessness and chronic health needs who were eligible for coordinated health care and housing supports. Through an iterative process of adjusting inputs, reviewing outputs with diverse stakeholders, and performing quality assurance, the authors developed an algorithm that achieved racial and ethnic parity in the selection of eligible Medicaid beneficiaries.

Suicide and self-injury-related emergency department visits and homelessness among adults 25–64 years old from 2016 to 2021 in the USA

BackgroundDespite pronounced increases in homelessness and mental health problems in the USA over the past decade, further exacerbated during the pandemic, and the higher prevalence of mental health conditions among...

Association between Homelessness and Temperature-Related Health Emergencies in the United States

Abstract Temperature-related illness (TRI) encompasses heat-related illness, such as heat exhaustion and heatstroke, and cold-related illness, such as frostbite and hypothermia. TRI is typically the result of exposure to ambient weather conditions; because of this, unhoused individuals are hypothesized to have higher risk of TRI. However, no national epidemiological studies have been completed to determine this risk. The objective of this study was to determine the association between homelessness and emergency department (ED) diagnosis of TRI in the United States. We conducted a cross-sectional study of adult ED visits in the United States from 2005 through 2020 using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative sample of nonfederal ED patient visits. Housing status (housed versus unhoused) was measured using NHAMCS patient residence category, with blank responses excluded. TRI was defined as ED clinician diagnosis of heat- or cold-related illness using International Classification of Disease, versions 9 and 10 (ICD-9 and ICD-10) codes. Multivariable logistic regression was used to determine adjusted odds of TRI by housing status. There were 323 606 nonpediatric ED visits in the NHAMCS sample. TRI diagnosis was present in 288 (0.09%) visits. 4099 visits (0.9%) were categorized as unhoused. After adjusting for sex, mental health diagnosis, and alcohol or substance use or use disorder, the odds ratio of TRI diagnosis in unhoused individuals was 4.08 (95% CI 2.09, 7.95) compared to housed individuals. We found a higher adjusted odds ratio of TRI diagnosis at an ED visit among unhoused individuals compared with housed individuals. Significance Statement Temperature-related health emergencies, or illnesses caused by exposure to ambient weather conditions, affect numerous Americans each year and are expected to become more common as climate change continues. We wanted to understand whether unhoused individuals are at higher risk of these health emergencies. We used a national sample of emergency department visits in the United States to study this and found out that unhoused individuals are at more than four times the risk of these illnesses than housed individuals. Our work highlights the need for prevention of homelessness, stable housing for housing insecure populations, and heating and cooling centers during weather emergencies.

Can you be a peer if you don’t share the same health or social conditions? A qualitative study on peer integration in a primary care setting

BackgroundPeer support has been extensively studied in specific areas of community-based primary care such as mental health, substance use, HIV, homelessness, and Indigenous health. These programs are often built on the assumption that peers must share similar social identities or lived experiences of disease to be effective. However, it remains unclear how peers can be integrated in general primary care setting that serves people with a diversity of health conditions and social backgrounds.MethodsA participatory qualitative study was conducted between 2020 and 2022 to explore the feasibility, acceptability, and perceived effects of the integration of a peer support worker in a primary care setting in Montreal, Canada. A thematic analysis was performed based on semi-structured interviews (n = 18) with patients, relatives, clinicians, and a peer support worker.FindingsFindings show that peers connect with patients through sharing their own hardships and how they overcame them, rather than sharing similar health or social conditions. Peers provide social support and coaching beyond the care trajectory and link identified needs with available resources in the community, bridging the gap between health and social care. Primary care clinicians benefit from peer support work, as it helps overcome therapeutic impasses and facilitates communication of patient needs. However, integrating a peer into a primary care team can be challenging due to clinicians’ understanding of the nature and limits of peer support work, financial compensation, and the absence of a formal status within healthcare system.ConclusionOur results show that to establish a relationship of trust, a peer does not need to share similar health or social conditions. Instead, they leverage their experiential knowledge, strengths, and abilities to create meaningful relationships and reliable connections that bridge the gap between health and social care. This, in turn, instills patients with hope for a better life, empowers them to take an active role in their own care, and helps them achieve life goals beyond healthcare. Finally, integrating peers in primary care contributes in overcoming obstacles to prevention and care, reduce distrust of institutions, prioritize needs, and help patients navigate the complexities of healthcare services.

Role of homelessness and psychiatric disorders in suicide deaths among veterans: A four-way decomposition analysis

Homelessness and suicide are top priorities in the U.S. Department of Veterans Affairs (VA). This study examined the various pathways involving homelessness, substance use, and mental health disorders in relation to suicide deaths among veterans in the VA healthcare system. A retrospective cohort study was conducted among 6,128,921 veterans—399,125 homeless and 5,729,796 non-homeless—followed-up between 2017 and 2021 using VA/Department of Defense linked databases. Multivariable Cox regression was applied for homelessness and psychiatric disorders as predictor of suicide deaths, sequentially controlling for demographic, clinical, substance use, and mental health characteristics. Four-way decomposition analysis was used to calculate proportions of suicide deaths mediated and/or moderated by homelessness, substance use, and mental health disorders. The relationship between homelessness and suicide-specific mortality risk was reduced from 40 % greater risk in unadjusted to 9 % greater risk in fully-adjusted models. Nearly 26 % of the total effect of homelessness on suicide-specific mortality risk was mediated by substance use disorders, whereas 49 % was mediated and 36 % was moderated by mental health disorders. In conclusion, excess suicide-specific mortality risk in homeless veterans is partly explained by substance use and mental health disorders, highlighting the importance of wrap-around health and social services for homeless veterans in mitigating suicide risk.

Traumatic Brain Injury and Its Risk Factors in a Homeless Population

ObjectiveTo characterize the traumatic brain injury (TBI) profile and its associated risk factors in homeless individuals in Santa Clara County, CA. DesignObservational cohort study. SettingTwo homeless shelter health clinics in Santa Clara County, CA. ParticipantsCurrently or recently homeless individuals seeking health care at 2 homeless shelter health clinics between August 2013 and May 2014. InterventionsNot applicable. Main Outcome MeasuresDemographics, TBI incidence and characteristics. ResultsThe findings indicate that TBI history in the homeless population was higher (79.7%) than in the general population (12%). Almost half of the population (49.2%) reported that their TBI occurred before the age of 18. Of the participants, 68.2% reported sustaining a TBI with loss of consciousness. TBI caused by violence (60%) was lower in this cohort than other homeless cohorts but was the main cause of injury regardless of age. Alcoholism was a risk factor for having more TBIs. No differences in TBI profile were found between sexes. ConclusionsOur findings underscore the need for more research on the lifetime risk factors associated with TBI to prevent and reduce the number of brain injuries in homeless populations.

Outpatient-Based Opioid Treatment Engagement and Attendance: A Prospective Cohort Study of Homeless-Experienced Adults.

The opioid overdose epidemic disproportionately impacts people experiencing homelessness. Outpatient-based opioid treatment (OBOT) programs have been established in homeless health care settings across the USA, but little is known about the success of these programs in engaging and retaining this highly marginalized patient population in addiction care. To evaluate predictors of initial engagement and subsequent attendance in a homeless-tailored OBOT program. Prospective cohort study with 4months of follow-up. A total of 148 homeless-experienced adults (≥18years) who newly enrolled in the Boston Healthcare for the Homeless Program (BHCHP) OBOT program over a 1-year period (1/6/2022-1/5/2023). The primary outcomes were (1) initial OBOT program engagement, defined as having ≥2 additional OBOT visits within 1month of OBOT enrollment, and (2) subsequent OBOT program attendance, measured monthly from months 2 to 4 of follow-up. The average age was 41.7years (SD 10.2); 23.6% were female, 35.8% were Hispanic, 12.8% were non-Hispanic Black, and 43.9% were non-Hispanic White. Over one-half (57.4%) were initially engaged. OBOT program attendances during months 2, 3, and 4 were 60.8%, 50.0%, and 41.2%, respectively. One-quarter (24.3%) were initially engaged and then attended the OBOT program every month during the follow-up period. Participants in housing or residential treatment programs (vs. unhoused; adjusted odds ratios (aORs) = 2.52; 95% CI = 1.17-5.44) and those who were already on or initiated a medication for opioid use disorder (OUD) (aOR = 6.53; 95% CI = 1.62-26.25) at the time of OBOT enrollment had higher odds of engagement. Older age (aOR = 1.74 per 10-year increment; 95% CI = 1.28-2.38) and initial engagement (aOR = 3.50; 95% CI = 1.86-6.59) conferred higher odds of attendance. In this study, over half initially engaged with the OBOT program, with initial engagement emerging as a strong predictor of subsequent OBOT program attendance. Interventions aimed at enhancing initial OBOT program engagement, including those focused on housing and buprenorphine initiation, may improve longer-term outcomes in this marginalized population.

Housing, Homelessness, and Mental Health

Homelessness is one of the most significant humanitarian, policy, and public health issues in the United States. People experiencing homelessness are at a heightened risk of various health issues, including severe mental illness, and face a life expectancy up to 30 years shorter than those with stable housing. The US Department of Housing and Urban Development (HUD) defines homelessness as lack of a fixed, regular, and adequate nighttime residence and reports that there has been a steady rise in the number of individuals with mental illness lacking stable housing, far outpacing the capacity of available services. Despite the importance of housing for mental health, psychiatrists are often ill-equipped to intervene on this key social determinant of health. This article reviews underlying factors contributing to homelessness for individuals with mental illness, details clinical ramifications of homelessness, and outlines evidence-based interventions for supporting people experiencing homelessness and psychiatric illness. [ Psychiatr Ann. 2024;54(7):e202–e208.]

With Liberty and Justice for ALL: The Case for Decriminalizing Homelessness and Mental Health in America

With Liberty and Justice for ALL: The Case for Decriminalizing Homelessness and Mental Health in America

Beyond Brick and Mortar: The Rise of Street Medicine.

In 2023, approximately 650,000 people experienced homelessness (PEH) nightly in the United States, the highest number recorded in the country's history. This alarming statistic has made homelessness a key issue in the 2024 elections, especially with the White House's goal to reduce homelessness by 25% by 2025. Despite efforts and investments, homelessness remains a persistent public health challenge. The recent inclusion of street medicine services in Center for Medicare and Medicaid Services (CMS) billing codes represents a significant step forward. Street medicine, defined by CMS as healthcare provided in non-permanent locations to unsheltered individuals, now qualifies for Medicare reimbursement. This policy change, alongside state-level initiatives, aims to improve healthcare access for the unhoused, particularly older adults. However, challenges remain in establishing adequate fee schedules and integrating care management. Despite these obstacles, the integration of healthcare and housing services is crucial for addressing homelessness effectively, promoting stability, and improving health outcomes for PEH. This manuscript explores the history, practical guidance, and potential impacts of these developments on homelessness and public health.

Implementing a Reproducible Foot and Vaccine Clinic Model to Address Healthcare Needs of People Experiencing Homelessness

Background: Homeless Health, Education, Awareness and Leadership in Street Medicine (HEALS) is a nonprofit, medical student-run organization. The mission of HEALS is to address the medical and psychosocial needs of people experiencing homelessness (PEH). Through street medicine outreach initiatives, HEALS works to improve health outcomes associated with unstable housing and limited access to healthcare. The HEALS Foot and Vaccine Clinic was developed to screen for and treat vascular insufficiency, chronic and acute wounds, and foot-related pathologies, and provide vaccinations to prevent infectious illnesses. This clinic also aimed to prevent exposure-related injuries by providing proper footwear and direct access to care. Aim: Our objective is to create a reproducible foot and vaccine clinic model for student-run clinics to address the needs of PEH through interprofessional collaboration and service learning. Methods: The event was funded through a crowdfunding campaign and donations and was hosted at a local shelter. Medical students and physicians employed by the medical school partnered with five community outreach programs to provide medical care. The Department of Health (DoH) administered vaccinations against common viral diseases. Results: Through crowdfunding campaigns, $6,646.00 was raised to contribute to the cost of boots, hygiene kits for attendees, and cleaning supplies, budgeted at $5,198.00. Forty-seven individuals experiencing homelessness were provided with foot care and twenty-six vaccines were administered. The DoH administered twelve hepatitis A, five coronavirus disease 2019 (COVID-19), and nine influenza vaccinations at this event. Successive members of HEALS have since replicated this model to replicate foot and vaccine clinics and expand outreach to the neighboring county, yielding increased event attendance and funding. Using this model, student-run free clinics may implement similar initiatives within their own communities to address the complex needs of PEH.

The Role of Street Medicine and Mobile Clinics for Persons Experiencing Homelessness: A Scoping Review.

An estimated 5800 to 46,500 lives are lost due to homelessness each year. Experiencing homelessness and poor health are cyclically related, with one reinforcing the other. Mobile programs, which include vehicles that travel to deliver care, and street medicine, the act of bringing care to spaces where PEH live, may play a role in alleviating this burden by providing trusted, affordable, and accessible care to this community. We conducted a scoping review of peer-reviewed literature on the role of mobile clinics and street medicine in providing care for PEH by searching PubMed, Embase, and Web of Science on 10 August 2023. Articles from 2013 to 2023 specific to programs in the United States were included. The protocol was developed following the PRISMA-ScR guidelines. The primary outcome was the role of mobile programs for persons experiencing homelessness. A total of 15 articles were included in this review. The descriptive findings emphasized that street medicine and mobile clinics provide primary care, behavioral health, and social services. The utilization findings indicate that street medicine programs positively impact the health system through their ability to defer emergency department and hospital visits, providing financial benefits. The comparative findings between mobile programs and office-based programs indicate current successes and areas for improvement. Mobile clinics and street medicine programs that serve PEH provide a wide range of services. While more significant structural change is needed to address healthcare costs and housing policies in the United States, mobile clinics and street medicine teams can improve healthcare access and the healthcare system.

Addressing the Healthcare Needs of Transgender Youth in the Emergency Department.

Transgender is a term that refers to individuals who identify with a gender that is different from the sex assigned to them at birth. In addition to gender dysphoria, many transgender youth experience a number of challenges including homelessness, violence, and mental health problems such as suicidality. Although transgender people represent a growing subset of the population, most providers receive very little training specific to the unique healthcare needs of transgender patients. In this CME review article, we define relevant terminology then discuss best practices for clinical encounters involving transgender youth in the emergency department. Finally, we review gender-affirming care including behavioral modifications, hormones, and surgeries for transfeminine and transmasculine individuals.

Home Is Where the Health Is: Developing Medical Students’ Understanding of Homeless Health

Home Is Where the Health Is: Developing Medical Students’ Understanding of Homeless Health

Barriers to Escape: How Homelessness and Drug Addiction Prevent Women from Escaping Sex Trafficking and Commercial Sex

Victims of sex trafficking and women purportedly involved in prostitution volun-tarily face a complex web of interconnected challenges when attempting to escape their current circumstances. By analyzing the shared and distinct challenges faced by these women, the paper aims to inform policymakers and service providers, offering recommendations to empower women seeking to escape exploitation through multi-disciplinary and interconnected networks of providers. This study surveyed 74 wom-en in Detroit, Michigan, using nonprobability convenience sampling over a 10-month period in 2020. It compared three groups of women who self-reported as victims of sex trafficking, women who voluntarily engaged in some form of commercial sex, and women currently not in the sex industry. The study examined five outcome dimen-sions: substance use, housing stability, violence, interactions with law enforcement, and healthcare barriers. Among surveyed women, 45 reported sex trafficking experi-ences, 20 engaged in prostitution voluntarily, and nine were currently neither traf-ficked nor in prostitution. While some experiences were shared, like drug use and child presence, unique challenges emerged for sex trafficking victims. Victims of sex traffick-ing reported higher rates of homelessness, violence, lower education, and poorer health compared to others. However, those who were trafficked and those who report-ed being voluntarily involved in the sex trade had many similar problems. The survey highlights the interconnected barriers faced by women in sex trafficking or prostitu-tion: substance abuse, homelessness, and health problems. All three groups of women reported having children, which underscores the great need for support systems for families of trafficking survivors or those in the sex industry. Educating professionals and raising awareness can enhance responses and interventions, enabling more women to design exit strategies and begin the path to recovery.

Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless.

To evaluate universal suicide risk screening and evaluation processes among newly homeless Veterans. Not applicable. Examination of Veterans Health Administration (VHA) using newly homeless patients' health record data in Calendar Year 2021. Not applicable. Health record data. Most patients received suicide risk screening and/or evaluation in the year prior to and/or following homeless identification (n = 49,505; 87.4%). Smaller percentages of patients were screened and/or evaluated in close proximity to identification (n = 7358; 16.0%), 1-30 days prior to identification (n = 12,840; 39.6%), or 1-30 days following identification (n = 14,263; 34.3%). Common settings for screening included primary care, emergency and urgent care, and mental health services. Of positive screens (i.e., potentially elevated risk for suicide), 72.6% had a Comprehensive Suicide Risk Evaluation (CSRE) completed in a timely manner (i.e., same day or within 24 h). Age, race, and sex were largely unrelated to screening and/or evaluation. Although many newly identified homeless patients were screened and/or evaluated for suicide risk, approximately 13% were not screened; and 27% of positive screens did not receive a timely CSRE. Continued efforts are warranted to facilitate suicide risk identification to ensure homeless patients have access to evidence-based interventions.