Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study.

Background: There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services. Objectives: This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants' use of health care and social care services over 12 months, and costs were calculated. Design and setting: The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model. Participants: People who had been homeless during the previous 12 months were recruited as 'case study participants'; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders. Results: The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services. Limitations: There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model. Conclusions: Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, 'drop-in' services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (HSDR 13/156/03) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 16. See the NIHR Journals Library website for further project information.

Health problems are common among single people who are homeless, but there is little evidence of the best ways to deliver primary health care to them. This study evaluated four types of services (models) that are in existence: (1) health centres primarily for people who are homeless (Dedicated Centres); (2) Mobile Teams that provide health care in hostels and day centres; (3) Specialist GPs that have some services exclusively for patients who are homeless; and (4) Usual Care GPs providing health care to all patients, with no special services for people who are homeless. The study concentrated on single people (not homeless families or couples with dependent children) staying in hostels, other temporary accommodation and on the streets. Overall, 363 patients at these practices who had been homeless in the previous 12 months participated, and information was collected from them over a 12-month period. We examined the extent to which screening for different health conditions was undertaken, and to which treatment and follow-up care were provided for participants with chronic respiratory problems, depression, alcohol problems and drug problems. Information was gathered from their medical records about use of health and social care services over 12 months. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were more favourable. They had staff working specifically with patients who were homeless; provided flexible 'drop-in' services instead of requiring patients to book appointments; and worked closely with mental health, alcohol and drug services, and with hostels, day centres and street outreach teams. Participants were also more satisfied with the health care they received from the specialist models, and were more likely to say that they had confidence and trust in doctors and nurses at these sites. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services.

Quality of life in dementia: a systematically conducted narrative review of dementia-specific measurement scales.

OBJECTIVES: Ascertaining the quality of life (QoL) in people with dementia is important for evaluating service outcomes and cost-effectiveness. This paper identifies QoL measures for people with dementia and assesses their properties. METHOD: A systematic narrative review identified articles using dementia QoL measures. Electronic databases searched were AMED, CINAHL, EMBASE, Index to Theses, IBSS, MEDLINE, PsycINFO, Sociological Abstracts, and Web of Science. All available years and languages (if with an English language abstract) were included. RESULTS: Searches yielded 6806 citations; 3043 were multiple duplicates (759 being true duplicates). Abstracts were read; 182 full papers were selected/obtained, of which 126 were included as relevant. Few measures were based on rigorous conceptual frameworks. Some referenced Lawton's model (Dementia Quality of Life [DQOL] and Quality of Life in Alzheimer's Disease [QOL-AD]), though these tapped part of this only; others claimed relationship to a health-related QoL concept (e.g. DEMQOL), though had less social relevance; others were based on limited domains (e.g. activity, affect) or clinical opinions (Quality of Life in Late-Stage Dementia [QUALID]). Many measures were based on proxy assessments or observations of people with dementia's QoL, rather than their own ratings. The Bath Assessment of Subjective Quality of Life in Dementia (BASQID) was developed involving people with dementia and caregivers, but excluded some of their main themes. All measures were tested on selective samples only (ranging from community to hospital clinics, or subsamples/waves of existing population surveys), in a few sites. Their general applicability remains unknown, and predictive validity remains largely untested. CONCLUSION: The lack of consensus on measuring QoL in dementia suggests a need for a broader, more rigorously tested QoL measure.

Developing homelessness prevention practice: combining research evidence and professional knowledge.

This paper presents recommendations of three kinds for the development of homelessness prevention: for practice changes, for the concerted development of evidence on the effectiveness of different measures, and for a more systematic approach to the identification and dissemination of good practice. The recommendations were developed through consultation with health-care, social service and housing provider staff. They were asked to comment on the results of a study of 131 newly homeless people, which showed that there were five prevalent 'packages of reasons' that created distinctive 'pathways' into homelessness and concluded that some cases were preventable. This article outlines the principles of homelessness prevention and recent British policy initiatives in the field, summarises the research methodology and relevant findings, and describes the consultation. The final section discusses the discrepancy between the high priority that homelessness prevention currently receives and the primitiveness of both the evidence base and the arrangements for good practice dissemination.

The causes of homelessness in later life: findings from a 3-nation study.

OBJECTIVE: This article presents findings from a study of the causes of homelessness among newly homeless older people in selected urban areas of the United States, England, and Australia. METHODS: Interviews were conducted in each country with > or =122 older people who had become homeless during the last 2 years. Information was also collected from the subjects' key workers about the circumstances and problems that contributed to homelessness. RESULT: Two-thirds of the subjects had never been homeless before. Antecedent causes were the accommodation was sold or needed repair, rent arrears, death of a close relative, relationship breakdown, and disputes with other tenants and neighbors. Contributory factors were physical and mental health problems, alcohol abuse, and gambling problems. DISCUSSION: Most subjects became homeless through a combination of personal problems and incapacities, welfare policy gaps, and service delivery deficiencies. Whereas there are nation-specific variations, across the three countries, the principal causes and their interactions are similar.