Street Outreach Research Articles

A brief tool to assess capacity to consent for medical care among homeless individuals with problematic substance use: study protocol

BackgroundPublic health care increasingly uses outreach models to engage individuals who are marginalized, many of whom misuse substances. Problematic substance use, together with marginalization from the health care system, among homeless adults makes it difficult to assess their capacity to consent to medical care. Tools have been developed to assess capacity to consent; however, these tools are lengthy and unsuitable for outreach settings. The primary objective of this study is to develop, validate, and pilot a brief but sensitive screening instrument which can be used to guide clinicians in assessing capacity to consent in outreach settings. The goal of this paper is to outline the protocol for the development of such a tool.Methods/DesignA brief assessment tool will be developed and compared to the MacArthur Competency Assessment Tool for Treatment (MacCAT-T). As list of 36 possible questions will be created by using qualitative data from clinician interviews, as well as concepts from the literature. This list will be rated by content experts according to the extent that it corresponds to the test objectives. The instrument will be validated with 300 homeless adult volunteers who self-report problematic substance use. Participants will be assessed for capacity using the MacCAT-T and the new instrument. A combination of Classical Test Theory and advanced psychometric methods will be used for the psychometric analysis. Corrected Item-Total correlation will be examined to identify items that discriminate poorly. Guided exploratory factor analysis will be conducted on the final selection of items to confirm the assumptions for a unidimensional polytomous Rasch model. If unidimensionality is confirmed, an unstandardized Cronbach Alpha will be calculated. If multi-dimensionality is detected, a multidimensional Rasch analysis will be conducted. Results from the new instrument will be compared to the total score from the MacCAT-T by using Pearson’s correlation test. The new instrument will then be piloted in real-time by street outreach clinicians to determine the acceptability and usefulness of the new instrument.DiscussionThis research will build on the existing knowledge about assessing capacity to consent and will contribute new knowledge about assessing individuals whose judgment is impaired by substance use.

The Illusions and Juxtapositions of Commercial Sexual Exploitation among Youth:Identifying Effective Street-Outreach Strategies

To explore sexually exploited youths' perspectives of how street outreach workers can effectively provide outreach and connections to services, we conducted qualitative interviews with 13 female participants, ages 14 to 22, in a Midwest U.S. city. Participants reported multiple types of exploitation, most first exploited by age 13, plus substance use and recurrent homelessness. Nearly all had a pimp, and all used the internet as a venue for sexual exploitation. Participants wanted outreach workers to use “soft words” to refer to exploitation. They expressed contradictory images of their “boyfriend” pimps and their exploitation. They wanted outreach workers to “provide resources,” “be nonjudgmental,” “listen,” and “care.” Street outreach can be one way to support sexually exploited youth but should occur in multiple settings.

Technology Use among Emerging Adult Homeless in Two U.S. Cities

Researchers have shown increasing interest in technology use among youths and emerging adults (Bleakley, Merzel, VanDevanter, & Messeri, 2004; Redpath et al., 2006; Valentine & Bemhisel, 2008). However, no research to date examines this issue among emerging adult homeless. As these young people are more difficult to engage in services (Ensign & Bell, 2004; Hudson, Nyamathi, & Sweat, 2008) and have higher rates of mental illness (Merscham, Van Leeuwen, & McGuire, 2009) and substance abuse (Barczyk & Thompson, 2008) than the general population, using technology may provide a novel means to approach them. This exploratory study sought to answer two questions: (1) How often, where, and for what purpose do emerging adult homeless use technology? (2) What risk factors (for example, transience, mental illness, addiction) predict technology use? METHOD Sample and Recruitment Using purposive sampling, we recruited 100 emerging adult homeless from Denver (n = 50) and Los Angeles (n = 50) from shelters, drop-in centers, and street outreach (Bender, Ferguson, Thompson, Komlo, & Pollio, 2010; Ferguson, Bender, Thompson, Xie, & Pollio, 2011; Ferguson, Jun, Bender, Thompson, & Pollio, 2010; Sheehan et al., 1998; Thompson, Jun, Bender, Ferguson, & Pollio, 2010). To meet inclusion criteria, participants needed to be in the age range of 18 to 24 years, have spent at least two weeks away from home in the previous month, and provide written informed consent. Wherever possible, agency case managers made the determination whether a particular individual was eligible for recruitment on the basis of personal knowledge of the individual and the individual's current state of sobriety. In cases of key informant referral, the interviewer made the determination. Data Collection and Measures Research staff administered a 45- to 90-minute retrospective interview with participants, who were compensated $10. Both study design and data collection have been described elsewhere (Bender et al., 2010). Human subjects approval was granted by each researcher's university. Technology use was measured by four items (number of days per week you use e-mail, the Internet, a computer, or MySpace). Because nearly half the sample reported daily use on at least one variable, rather than treating the variable as interval-continuous, two dichotomous variables were created: (1) daily use of any technology (0 = everyday, 1 = less than daily) and (2) weekly use of any technology (0 = 1 to 6 days a week, 1 = no days a week). We created the first variable to explore differences between daily users versus all others; the second to compare between regular users (at least weekly) and those not regularly using computers. Three open--ended questions queried the following: (1) With whom do you communicate online? (2) What is the purpose of your online use? (3) Where do you access technology? Predictors of technology use included age, location (0 = Los Angeles, 1 = Denver), gender (0 = female, 1 = male), race-ethnicity (0 = white, 1 = black, 2=Latino), education (0=high school dropout, 1 = graduate or GED holder), current housing status (0 = in stable housing, 1 = homeless or in shelter), transience status (0 = no moves, 1 = at least one intercity move). Data on self reported criminal behaviors (0 = never arrested, 1 = at least one arrest) and social support (frequency of contact: 0 = almost never or occasionally, 1 = often or a lot) were also collected. Using the Mini International Neuropsychiatric Interview (Sheehan et al., 1998), we assessed symptom criteria for posttraumatic stress disorder, mania, depression, and alcohol and drug abuse or dependence (0 = does not meet criteria, l = meets criteria). Data Analysis Independent samples t tests and chi-square or Fisher's exact tests were used to identify differences in characteristics of daily versus nondaily and at-least-weekly versus less-than-weekly technology users. …

Establishing the Melbourne injecting drug user cohort study (MIX): rationale, methods, and baseline and twelve-month follow-up results

BackgroundCohort studies provide an excellent opportunity to monitor changes in behaviour and disease transmission over time. In Australia, cohort studies of people who inject drugs (PWID) have generally focused on older, in-treatment injectors, with only limited outcome measure data collected. In this study we specifically sought to recruit a sample of younger, largely out-of-treatment PWID, in order to study the trajectories of their drug use over time.MethodsRespondent driven sampling, traditional snowball sampling and street outreach methods were used to recruit heroin and amphetamine injectors from one outer-urban and two inner-urban regions of Melbourne, Australia. Information was collected on participants’ demographic and social characteristics, drug use characteristics, drug market access patterns, health and social functioning, and health service utilisation. Participants are followed-up on an annual basis.Results688 PWID were recruited into the study. At baseline, the median age of participants was 27.6 years (IQR: 24.4 years – 29.6 years) and two-thirds (67%) were male. Participants reported injecting for a median of 10.2 years (range: 1.5 months – 21.2 years), with 11% having injected for three years or less. Limited education, unemployment and previous incarceration were common. The majority of participants (82%) reported recent heroin injection, and one third reported being enrolled in Opioid Substitution Therapy (OST) at recruitment. At 12 months follow-up 458 participants (71% of eligible participants) were retained in the study. There were few differences in demographic and drug-use characteristics of those lost to follow-up compared with those retained in the study, with attrition significantly associated with recruitment at an inner-urban location, male gender, and providing incomplete contact information at baseline.ConclusionsOur efforts to recruit a sample of largely out-of-treatment PWID were limited by drug market characteristics at the time, where fluctuating heroin availability has led to large numbers of PWID accessing low-threshold OST. Nevertheless, this study of Australian injectors will provide valuable data on the natural history of drug use, along with risk and protective factors for adverse health outcomes associated with injecting drug use. Comprehensive follow-up procedures have led to good participant retention and limited attrition bias.

The Relationship between Drug User Stigma and Depression among Inner-City Drug Users in Baltimore, MD

There is growing awareness of the role of stigma and discrimination in HIV prevention, testing, and medical care. Yet, few studies have examined the stigma associated with using illicit drugs. In the present study, we examined the relationship between social network characteristics, drug user stigma, and depression. Study participants were comprised of 340 individuals who reported cocaine, crack, and/or heroin use in the prior 6months and were involved in an HIV prevention study. They were recruited through street outreach, referrals, and word of mouth in inner-city Baltimore, MD, USA. The stigma scale was comprised of eight items, such as "how much do you feel ashamed of using drugs?" Depression was assessed with the Center for Epidemiological Studies Depression Scale, using cutoffs of 16 and 20 or greater. In the bivariate analyses, gender, homelessness in the past 6months, drug user stigma, larger size of drug network, and current use of heroin, cocaine, and crack were all significantly associated with high levels of depression, whereas in the multivariate analyses, only drug user stigma remained significantly associated with depression. The results of this study suggest that drug treatment providers and other professionals who provide services to drug users should consider developing trainings to address drug user stigma. These programs should focus on the attitudes and behaviors of health and service providers toward drug users, among drug users themselves, and among family members and others who provide social support to drug users.

P134 Reaching youth with out-of-facility HIV and reproductive health services

BackgroundMany young people, particularly those who are marginalised and most at risk for HIV and reproductive health-related problems, cannot or will not seek traditional facility-based health services. Policies and programs...

Correlates of service utilization among homeless youth.

Though few studies exist on service utilization among homeless youth in the U.S., services are important because without them, many of these young people may resort to delinquent strategies in order to meet their daily survival needs. The current study examines frequency and correlates of service utilization (i.e., shelters, food programs, street outreach, counseling, STI and HIV testing) among a sample of 249 homeless youth ages 14 to 21. Multivariate analysis revealed significant differences in service usage by sex, age, and sexual orientation. Experiencing family physical and/or sexual abuse, being kicked out of the family home, spending more nights per week sleeping on the street, and having ever stayed in a group home facility were significant correlates of homeless youths' service usage.

Reaching Youth With Out-of-Facility HIV and Reproductive Health Services: A Systematic Review

Many young people, particularly those who are marginalized and most at risk for HIV and reproductive health-related problems, cannot or will not seek traditional facility-based health services. Policies and programs are being implemented to provide them with these health services in the community. We sought to review the effectiveness of such approaches in increasing HIV and reproductive health service use. A systematic literature review was undertaken to identify policies promoting or programs delivering HIV or reproductive health services in the community. We reviewed studies that evaluated uptake of services or commodities. Data from studies meeting inclusion criteria were qualitatively analyzed. Twenty studies met inclusion criteria, including 10 containing comparative data (e.g., before and after study or control study design). The studies generally demonstrated positive impact, although results varied across settings and approaches. The most successful approaches included mail-based chlamydia screening in the Netherlands, condom distribution via street outreach in Louisiana, home-based HIV counseling and testing in Malawi, and promotion of over-the-counter access to emergency contraception in various countries. Overall, this review suggests that out-of-facility approaches can be important avenues to reach youth. Continued evaluation is necessary to better understand specific approaches that can successfully deliver health services.

Skin and needle hygiene intervention for injection drug users: Results from a randomized, controlled Stage I pilot trial

A new skin and needle hygiene intervention, designed to reduce high-risk injection practices associated with bacterial and viral infections, was tested in a pilot, randomized controlled trial. Participants included 48 active heroin injectors recruited through street outreach and randomized to either a 2-session intervention or an assessment-only condition (AO) and followed up for 6 months. The primary outcome was skin- and needle-cleaning behavioral skills measured by videotaped demonstration. Secondary outcomes were high-risk injection practices, intramuscular injection, and bacterial infections. Intervention participants had greater improvements on the skin (d = 1.00) and needle-cleaning demonstrations (d = .52) and larger reductions in high-risk injection practices (d = .32) and intramuscular injection (d = .29), with a lower incidence rate of bacterial infections (hazard ratio = .80), at 6 months compared with AO. The new intervention appears feasible and promising as a brief intervention to reduce bacterial and viral risks associated with drug injection.

A cluster analysis of service utilization and incarceration among homeless youth

Our paper examines service usage (e.g., shelter) as well as a typology of individuals who are most likely to use groupings of services among 249 homeless youth. Our results revealed that the majority of homeless young people have used food programs (66%) and street outreach (65%) on at least one occasion within the past year. Cluster analysis of services revealed four distinct groups: (1) basic survival service use, characterized by above average shelter, food, and outreach service use, but below average on counseling, substance abuse/mental health services, and incarceration; (2) multiple service use, which included above average use of all six services; (3) incarceration experience, characterized by above average incarceration experience, but below average use of all other five services; and (4) minimal service use, which included slightly above average use of counseling, but below average use of all other services. These findings have the potential to provide important information that may assist with targeting services to homeless youth.

The Feasibility of Interventions to Reduce HIV Risk and Drug Use among Heterosexual Methamphetamine Users

This paper reports on a feasibility study that examined contingency management among out-of-treatment, heterosexual methamphetamine users and the reduction of drug use and HIV risk. Fifty-eight meth users were recruited through street outreach in Denver from November 2006 through March 2007. The low sample size reflects that this was a pilot study to see if CM is feasible in an out-of-treatment, street-recruited population of meth users. Secondary aims were to examine if reductions and drug use and risk behavior could be found. Subjects were randomly assigned to contingency management (CM) or CM plus strengths-based case management (CM/SBCM), with follow-up at 4 and 8 months. Participants were primarily White (90%), 52% male and averaged 38 years old. Eighty-three percent attended at least one CM session, with 29% attending at least fifteen. All participants reduced meth use significantly at follow-up. Those who attended more sessions submitted more stimulant-free urines than those who attended fewer sessions. Participants assigned to CM/SBCM attended more sessions and earned more vouchers than clients in CM. Similarly, participants reported reduced needle-sharing and sex risk. Findings demonstrate that CM and SBCM may help meth users reduce drug use and HIV risk.

Street-outreach Improves Detection but not Referral for Drug Users with Latent Tuberculosis, New York City

Street outreach in two New York City communities, Harlem and the South Bronx, between May 2001 and March 2003, provided tuberculin skin test (TST) screening to illicit drug users outside the traditional health care system. Persons who used heroin, cocaine, and/or crack were offered a TST, incentives to return for TST reading, and further evaluation if TST was positive. Of 809 participants, 530 (66%) accepted a TST and 81% (429/530) returned for TST reading. Of 429 participants, 40 (9%) were TST positive. Participants found TST positive did not differ from those found TST negative in previous drug user treatment or drug use practices including snorting heroin, sniffing cocaine, smoking crack, and injecting drugs of any kind. Of the 40 participants found TST positive, the 21 who tested TST positive for the first time were more likely to be male (p = .03) and noninjectors (p = .02), than the 19 who had tested TST positive in the past. Only two newly identified persons pursued follow-up care. Street recruitment expanded testing. Better follow-up strategies are needed. The study's limitations are noted.

Experiencing violence as a predictor of drug use relapse among former drug users in Baltimore, Maryland.

The purpose of this study was to examine experiencing violence as a predictor of subsequent drug relapse among a sample of former crack, cocaine, and heroin users in Baltimore, MD, USA. The sample consists of 228 former drug users in Baltimore who were recruited through street outreach. Mixed-effects models were used to examine experiencing violence as a predictor of drug relapse at follow-up after adjusting for clustering of responses among participants living in the same census block. Using longitudinal data, we found that experiencing violence in the past year predicted drug relapse at 2-year follow-up among former drug users. Results indicate experiencing violence is a determinant of drug use relapse and highlight the importance of addressing the fundamental issues of violence experienced in inner-city communities. Addressing the extent of recent violence among drug treatment participants, providing coping skills, and reducing community violence are strategies that may address the link between violence and drug relapse.

The association between parental risk behaviors during childhood and having high risk networks in adulthood

BackgroundPrior research suggests that both social networks and parent drug use influence individual drug use among adolescents and that peers continue to influence drug use among adults. This analysis aims to determine whether parent drug use during childhood is associated with having drug-using networks in adulthood after adjusting for individual adult drug use. Methods650 young adult drug users were recruited through targeted street outreach and respondent-driven sampling in New York City (2006–2009). Baseline surveys ascertained demographics, network characteristics, drug use behaviors, and parental drug use during childhood. Negative binomial regression was used to evaluate this association. ResultsThe median age was 33 years, 22% injected, 49% were Black, and during childhood 26% of mothers, 32% of fathers, and 13% of primary caregivers used drugs. After adjustment, having >1 parent who used drugs was associated with having a greater proportion of drug using (Adjusted Prevalence Ratio [APR]=1.18; 95%CI: 1.01–1.38) and specifically crack-smoking networks (APR=1.71; 95%CI: 1.21–2.43) in adulthood. Females’ networks consisted of more drug users (APR=1.18; 95%CI: 1.01–1.38), injectors (APR=1.44; 95%CI: 1.09–1.90), crack smokers (APR=1.48; 95%CI: 1.18–1.87) and heroin users (APR=1.43; 95%CI: 1.13–1.81); blacks had a greater proportion of crack smoking (APR=1.41; 95%CI: 1.09–1.82), but a smaller proportion of injecting (APR=0.64; 95%CI: 0.43–0.94) and heroin smoking (APR=0.60; 95%CI: 0.47–0.77) networks as adults. ConclusionsThese data suggest that parental drug use is independently associated with having drug-using networks in adulthood. Interventions that target parents and caregivers and that promote drug cessation could impede risky network formation in both adolescents and adults.

HIV prevalence and sexual risk behaviour among non-injection drug users in Tijuana, Mexico

Prior studies estimate HIV prevalence of 4% among injection drug users (IDUs), compared with 0.8% in the general population of Tijuana, Mexico. However, data on HIV prevalence and correlates among non-injecting drug users (NIDUs) are sparse. Individuals were recruited through street outreach for HIV testing and behavioural risk assessment interviews to estimate HIV prevalence and identify associated sexual risk behaviours among NIDUs in Tijuana. Descriptive statistics were used to characterise ‘low-risk’ NIDUs (drug users who were not commercial sex workers or men who have sex with men). Results showed that HIV prevalence was 3.7% among low-risk NIDUs. During the prior six months, 52% of NIDUs reported having >1 casual partner; 35% reported always using condoms with a casual partner; and 13% and 15%, respectively, reported giving or receiving something in exchange for sex. Women were significantly more likely than men to have unprotected sex with an IDU (p<0.01). Conclusions: The finding that HIV prevalence among NIDUs was similar to that of IDUs suggests that HIV transmission has occurred outside of traditional core groups in Tijuana. Broad interventions including HIV testing, condom promotion and sexual risk reduction should be offered to all drug users in Tijuana.

Does Respondent Driven Sampling Alter the Social Network Composition and Health-Seeking Behaviors of Illicit Drug Users Followed Prospectively?

Respondent driven sampling (RDS) was originally developed to sample and provide peer education to injection drug users at risk for HIV. Based on the premise that drug users' social networks were maintained through sharing rituals, this peer-driven approach to disseminate educational information and reduce risk behaviors capitalizes and expands upon the norms that sustain these relationships. Compared with traditional outreach interventions, peer-driven interventions produce greater reductions in HIV risk behaviors and adoption of safer behaviors over time, however, control and intervention groups are not similarly recruited. As peer-recruitment may alter risk networks and individual risk behaviors over time, such comparison studies are unable to isolate the effect of a peer-delivered intervention. This analysis examines whether RDS recruitment (without an intervention) is associated with changes in health-seeking behaviors and network composition over 6 months. New York City drug users (N = 618) were recruited using targeted street outreach (TSO) and RDS (2006–2009). 329 non-injectors (RDS = 237; TSO = 92) completed baseline and 6-month surveys ascertaining demographic, drug use, and network characteristics. Chi-square and t-tests compared RDS- and TSO-recruited participants on changes in HIV testing and drug treatment utilization and in the proportion of drug using, sex, incarcerated and social support networks over the follow-up period. The sample was 66% male, 24% Hispanic, 69% black, 62% homeless, and the median age was 35. At baseline, the median network size was 3, 86% used crack, 70% used cocaine, 40% used heroin, and in the past 6 months 72% were tested for HIV and 46% were enrolled in drug treatment. There were no significant differences by recruitment strategy with respect to changes in health-seeking behaviors or network composition over 6 months. These findings suggest no association between RDS recruitment and changes in network composition or HIV risk, which supports prior findings from prospective HIV behavioral surveillance and intervention studies.

Social Support, Exposure to Violence and Transphobia, and Correlates of Depression Among Male-to-Female Transgender Women With a History of Sex Work

We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW). A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire. More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression. For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.

GB virus C infection among young, HIV‐negative injection drug users with and without hepatitis C virus infection

Our study examined the association between GB virus C (GBV-C) and (i) hepatitis C virus (HCV) infection status, (ii) biomedical indicators of liver disease (alanine and aspartate aminotransferases) and (iii) HCV RNA level among young injection drug users (IDUs) recruited using street outreach and respondent-driven methods. Cross-sectional and longitudinal analyses were completed. GBV-C (active or resolved) infection was significantly (P < 0.05) more prevalent among HCV antibody-positive (anti-HCV+) (65.1%) than antibody-negative (anti-HCV-) (32.3%) (OR = 3.9, 95% CI: 2.3-6.9) IDUs. The prevalence of resolved GBV-C infection was highest among those with chronic HCV infection (41.9%), followed by those with resolved HCV infection (34.4%) and significantly lower (P < 0.05) among anti-HCV participants (16.9%). Although not statistically significant (P = 0.13), a similar pattern was observed for active GBV-C infection. No association between GBV-C infection status and biomedical indicators of liver disease or HCV RNA level over time was observed. In conclusion, GBV-C infection prevalence was higher among anti-HCV+ compared to anti-HCV- young IDUs, similar to prior studies among older populations. In particular, chronically HCV-infected young IDUs had an increased rate of GBV-C clearance.

Subpopulations of Illicit Drug Users Reached by Targeted Street Outreach and Respondent-Driven Sampling Strategies: Implications for Research and Public Health Practice

To determine whether illicit drug users recruited through respondent-driven sampling (RDS) and targeted street outreach (TSO) differ by comparing two samples recruited concurrently with respect to sample selection and potential recruitment biases. Two hundred seventeen (217) heroin, crack, and cocaine users aged 18-40 years were recruited through TSO in New York City (2006-2009). Forty-six RDS seeds were recruited similarly and concurrently, yielding a maximum of 14 recruitment waves and 357 peer recruits. Baseline questionnaires ascertained sociodemographic, drug use, and drug network characteristics. Descriptive statistics and log-binomial regression were used to compare RDS and TSO samples. RDS recruits were more likely to be male (prevalence ratio [PR]:1.28), Hispanic (PR:1.45), black (PR: 1.58), older (PR: 1.02), homeless (PR: 1.19), and crack users (PR: 1.37). RDS recruited fewer injectors (PR:0.35) and heroin users (PR:0.74). Among injectors, RDS recruits injected less frequently (PR:0.77) and were less likely to use Needle Exchange Programs (PR:0.35). These data suggest that RDS and TSO strategies reach different subgroups of drug users. Understanding the differing capabilities of each recruitment strategy will enable researchers and public health practitioners to select an appropriate recruitment tool for future research and public health practice.

Double Jeopardy: Homeless and Elderly in New York City

In 2010, 6 years after the city of New York launched its 5-year plan to end homelessness, there were more homeless people in the city than ever before. An increasing number of these homeless people were older adults. Peter's Place, a drop-in center dedicated to serving homeless older adults, was closed, and its population scattered among the remaining drop-in centers and shelters. Faced with severe budget cuts, the city terminated its contracts to provide medical services in shelters. shelter population has suffered disproportionately from austerity measures. Homeless older adults are faced with the same problems as their younger counterparts, but their travails are compounded by physical frailties and vulnerability to predators. Housing options are limited, and their expectations for the future bleak. There is a movement in the United States to keep older adults in their homes rather than placing them in nursing homes. However, what would people do if they have no homes? Four case studies are presented about homeless older adults in New York City to illustrate the complexity of their situations. Names and details have been changed to protect the identities of those involved. CASE A: DENNIS I met Dennis in 2006, while working as a nurse practitioner at a clinic in the shelter where he was brought by the street Outreach team. He had spent 10 years on the steps of a church in midtown Manhattan. All previous attempts to locate him in a shelter had failed. He is now in a small shelter, dedicated to serving people with persistent mental illness. He had numerous medical problems, which were addressed in the shelter's clinic. shelter also provided a psychiatrist a few days a week and and a nurse on call for 16 hours a day. Within a week, Dennis was medically stable, taking medication, and settling down in the shelter. I was born in New York City in 1924 to an affectionate family. My father played the violin beautifully. He came from Russia in 1917 during the revolution. On weekends, he would play at a Russian place on 2nd Avenue. He was 32 when he died. He punctured his finger and within 5 days, he was dead of poisoning. I was 5. We moved in with grandma for 9 years. She loved everyone, and everyone loved her. My mother was 23 when my father died. I had a sister, Rosie, a year and a half older than me. She died in 1987. We were like twins. We moved up to Washington Heights. Nothing lasts for long. Then we moved to Manhattan. When I was 4 years old, I won a national contest for beauty and talent. In the finals, they lined up about 20 of us. I'll never forget those lights; boy, they were hot. You couldn't see a thing. And the noise, with people clapping and cheering-it scared the heck out of me. I took a bow; my head almost touched the stage. Real dramatic. I was in The Old Gang Comedy for about a year. Later it was called The Little Rascals. I was the original Weezer. It was done in a studio in New Jersey. In 1929, it moved to Hollywood. We didn't go along. I was drafted into the army at 18. I went to summer camp when I was a little boy so the whole army routine was not unusual; nor difficult to be away from home. First, I was a quartermaster, up till that time they were drafting people 21-42 years old. In 1943, they started drafting from 18-38. D-day came. We got orders to ship overseas. Three days after my 20th birthday, we set sail from Staten Island. There was a submarine out there. I landed in Scotland and came to Stonehenge in South England, then set sail for France- from Utah Beach to the gates of Berlin. By that time, I was a tank gunner. I wasn't stationed anywhere, just moving around. After the war, I went to school, became an architect. I never took the licensing exam so I worked as a draftsman for 30 years in New York, Westchester County, and New Hampshire. That's where I met my last wife. I was invited to do the city hall for the town of Laconia. After the birth of my son Steven, she took off with him and my other son, Jeffrey. …