Funding Health Care for People Experiencing Homelessness: An Examination of Federally Qualified Health Centers' Funding Streams and Homeless Patients Served (2014-2019).

It is estimated that three million people annually experience homelessness, with about a third of the homeless population being served by Federally Qualified Health Centers (FQHCs). Thus, FQHCs, dependent on government funding for financial viability, are vital to the infrastructure addressing the complex issues facing people experiencing homelessness. This study examines the relationship between various government funding streams and the number of homeless patients served by FQHCs. Data for this study come from three publicly available databases: the Uniform Data System (UDS), the IRS Core files, and the Area Resource File. Fixed-effects models employed examine changes across six years from 2014 to 2019. The results suggest that, on average, an additional homeless patient served increases the expenses of FQHCs more than other patients and that federal funding, specifically Health Care for the Homeless (HCH) funding, is a vital revenue source for FQHCs. We found that the number of homeless patients served is negatively associated with contemporaneous state and local funding but positively associated with substance use and anxiety disorders. Our findings have important implications for the effective management of FQHCs in the long term and for broader public policy supporting these vital elements of the social safety net.

What We (Don't) Know about the Infectious Disease Burden Among Youth Experiencing Homelessness in the United States and Canada.

Youth experiencing homelessness (YEH) and sexual and gender minority (SGM) YEH may be at increased risk for infectious diseases due to living arrangements, risk behaviors, and barriers to healthcare access that are dissimilar to those of housed youth and older adults experiencing homelessness. To better understand infectious diseases among YEH populations, we synthesized findings from 12 peer-reviewed articles published between 2012 to 2020 which enumerated YEH or SGM YEH infectious disease burden in locations across the U.S. or Canada. Pathogens presented in the studies were limited to sexually transmitted infections (STIs) and bloodborne infections (BBI). Only three studies enumerated infectious diseases among SGM YEH. There was a dearth of comparison data by housing status (ex., sheltered versus unsheltered youth), SGM identity, or other relevant counterfactual groups in the identified studies. We also introduce three publicly available, national-level surveillance datasets from the U.S. or Canada that quantify certain STIs, BBIs, and tuberculosis among YEH, which may be used for future disease burden assessments. Our review calls for more comprehensive YEH-centered research that includes multimodal data collection and timely disease surveillance to improve estimates of infectious diseases among this vulnerable population.

Drivers of Being Unhoused and the Prevalence of Health Conditions among Unhoused Individuals in Asheville, NC.

Background: During the COVID-19 pandemic, there was an increase in the number of unhoused individuals in Asheville, North Carolina resulting in more tent encampments.Understanding the physical, mental, and socially determined health characteristics associated with being unhoused can help guide stakeholders with policy development, healthcare program planning, and funding decisions to support unhoused individuals. Methods: In this study, we used an observational cross-section methodology. Using a convenience sample approach, we interviewed 101 participants who were receiving services from 2 emergency hotel shelters, a day center, and a resource center. Data were analyzed using descriptive statistics, and open-ended responses were collected and grouped to provide context. Results: Most participants were White (71%) and identified as male (76%). Over 60% reported having a high school education or advanced degree. Of the participants, 76% reported being unhoused for more than 6 months, and their last permanent housing was in Western North Carolina. Dental disease, chronic pain, and hypertension were common physical conditions. PTSD, depression, and anxiety were common mental health conditions. A lack of transportation was the most noted socially determined challenge. Marijuana, methamphetamine, and alcohol were the most often used substances, where methamphetamine was noted to be particularly problematic for the participants. Conclusion: Understanding the physical, mental, and social issues of the complex unhoused population can assist policymakers, healthcare providers, and other stakeholders in addressing challenges and testing improvement strategies.

The global prevalence of mental health disorders among runaway and homeless youth: A meta-analysis.

A meta-analysis was performed to identify the pooled prevalence of mental health disorders (MHDs) among runaway and homeless youth (RHY). Relevant studies published between December 1, 1985, and October 1, 2023, were identified in the PubMed, Scopus, Web of Science, and Cochrane Library databases. A preliminary screening of 11,266 papers resulted in the inclusion of 101 studies. The pooled-prevalence estimates were obtained using a random-effects model. The findings showed varying lifetime prevalence rates of MHDs: 47% (conduct disorders and psychological distress), 43% (depression), 34% (major depressive disorders), 33% (post-traumatic stress disorder), 27% (personality disorders), 25% (attention-deficit/hyperactivity disorder), 23% (bipolar disorders), 22% (anxiety), 21% (oppositional defiant disorders), 15% (anorexia), 15% (adjustment disorders), 14% (dysthymia), 11% (schizophrenia), 9% (obsessive-compulsive disorders), and 8% (gambling disorder). The current prevalence rates were: 31% (depression), 23% (major depressive disorder), 23% (anxiety), 21% (post-traumatic stress disorder), 16% (attention-deficit/hyperactivity disorder), 15% (bipolar disorder), 13% (personality disorders), 13% (oppositional defiant disorders), 8% (schizophrenia), and 6% (obsessive-compulsive disorders). Regular screening and the implementation of evidence-based treatments and the promotion of integration and coordination between mental health services for adolescent minors and young adults with other service systems are recommended.

Longitudinal relationships between early-life homelessness and school-aged asthma and wheezing.

BACKGROUND: Homelessness is a disruptive life event with profound impacts on children's health. It remains unclear, however, whether homelessness in early life has an enduring association with asthma and wheezing among school-aged children. OBJECTIVE: To test whether early-life homelessness is prospectively associated with asthma and wheezing during school-aged years. METHODS: We draw on data from 9242 children from the Avon Longitudinal Study of Parents and Children. Children were categorised as 'ever' or 'never' homeless based on maternal reports from the prenatal period through age 5 years. Children were assigned a binary indicator of asthma/wheezing based on maternal reports of asthma and wheezing at ages 6.8, 7.6 and 8.6 years. We used multilevel logistic regression models to test the association of interest in both bivariate analyses and models adjusted for a broad set of potential confounders. We conducted sensitivity analyses using generalised estimating equations and considering asthma and wheezing separately to test the robustness of the results. RESULTS: Between 12.1% and 14.3% of children had asthma or wheezing at ages 6.8, 7.6 and 8.6 years, and these conditions were more common among ever homeless participants. Ever-homeless children displayed higher odds of asthma or wheezing than never-homeless children (OR: 1.59, 95% CI 1.02 to 2.48) after adjustment for child, maternal and household risk factors. Sensitivity analyses yielded similar results. CONCLUSION: Early-life homelessness is prospectively associated with asthma and wheezing among school-aged children and should be prioritised by interventions promoting healthy child development.

Antecedents and Consequences of Violence in Homeless Shelters: Perspectives and Experiences of Service Users and Shelter Staff.

Violence is a critical issue in homeless shelters that affects service users and staff, yet there is limited evidence on how shelter-based violence occurs. The objective of this qualitative study was to investigate the antecedents and consequences of shelter-based violence from the perspectives of service users and staff. Purposive sampling was used to recruit individuals experiencing homelessness and shelter staff in a large metropolitan city in Ontario, Canada. Data from in-depth interviews with 56 individuals experiencing homelessness and 30 shelter staff were analyzed. Findings showed that shelter-based violence toward service users and staff was perceived to manifest in response to three interacting factors: (a) burden of homelessness and shelter living, (b) individual histories and marginalization, and (c) interpersonal conflict. These antecedents had a hierarchical structure in that each subsequent factor exacerbated the risk of previous ones and culminated with the most proximal factor for violence. There were three primary outcomes of shelter-based violence reported by service users and staff: (a) health and environmental harms, (b), procedural enforcement, and (c) avoidant behaviors. Avoidance was often a subsequent impact following health harms, as was procedural enforcement to a lesser extent. Overall, the study findings demonstrate that shelter-based violence is a complex and dynamic problem that is perceived to be the result of interacting structural, environmental, programmatic, interpersonal, and individual factors, with similar consequences for service users and staff. Implications for preventing violence through shelter design and service delivery are discussed.

PROTOCOL: Effectiveness of behavioral interventions for smoking cessation among homeless persons: A systematic review and meta-analysis.

This is the protocol for an updated Campbell systematic review. The objectives are as follows: To evaluate the effect of behavioral interventions on smoking cessation among homeless individuals.

Identification of homelessness using health administrative data in Ontario, Canada following a national coding mandate: a validation study.

OBJECTIVES: Conducting longitudinal health research about people experiencing homelessness poses unique challenges. Identification through administrative data permits large, cost-effective studies; however, case validity in Ontario is unknown after a 2018 Canada-wide policy change mandating homelessness coding in hospital databases. We validated case definitions for identifying homelessness using Ontario health administrative databases after introduction of this coding mandate. STUDY DESIGN AND SETTING: We assessed 42 case definitions in a representative sample of people experiencing homelessness in Toronto (n = 640) from whom longitudinal housing history (ranging from 2018 to 2022) was obtained, and a randomly selected sample of presumably housed people (n = 128,000) in Toronto. We evaluated sensitivity, specificity, positive and negative predictive values, and positive likelihood ratios to select an optimal definition, and compared the resulting true positives against false positives and false negatives to identify potential causes of misclassification. RESULTS: The optimal case definition included any homelessness indicator during a hospital-based encounter within 180 days of a period of homelessness (sensitivity = 52.9%; specificity = 99.5%). For periods of homelessness with ≥1 hospital-based healthcare encounter, the optimal case definition had greatly improved sensitivity (75.1%) while retaining excellent specificity (98.5%). Review of false positives suggested that homeless status is sometimes erroneously carried forward in healthcare databases after an individual transitioned out of homelessness. CONCLUSION: Case definitions to identify homelessness using Ontario health administrative data exhibit moderate to good sensitivity and excellent specificity. Sensitivity has more than doubled since the implementation of a national coding mandate. Mandatory collection and reporting of homelessness information within administrative data present invaluable opportunities for advancing research on the health and healthcare needs of people experiencing homelessness.

Disparities in diabetes processes of care among people experiencing homelessness: An opportunity for intervention.

AIMS: To compare processes of diabetes care by homeless status. METHODS: A population-based propensity matched cohort study was conducted in Ontario, Canada. People with diabetes were identified in administrative healthcare data between April 2006 and March 2019. Those with a documented history of homelessness were matched to non-homeless controls. Data on processes of care measures included glucose monitoring tests, screening for microvascular complications, and physician follow-up. Differences in processes of care were compared by homeless status using proportions, risk ratios, and rate ratios. RESULTS: Of the 1,076,437 people with diabetes, 5219 matched pairs were identified. Homelessness was associated with fewer tests for glycated hemoglobin (RR = 0.63; 95 %CI: 0.60-0.67), LDL cholesterol (RR = 0.80; 95 %CI: 0.78-0.82), serum creatinine (RR = 0.94; 95 %CI: 0.92-0.97), urine protein quantification (RR = 0.62; 95 %CI: 0.59-0.66), and eye examinations (RR = 0.74; 95 %CI: 0.71-0.77). People with a history of homelessness were less likely to use primary care for diabetes management (RR = 0.62; 95 %CI: 0.59-0.66) or specialist care (RR = 0.87; 95 %CI: 0.83-0.91) compared to non-homeless controls. CONCLUSIONS: Disparities in diabetes care are evident for people with a history of homelessness and contribute to excess morbidity in this population. These data provide an impetus for investment in tailored interventions to improve healthcare equity and prevent long-term complications.

The Link Between Childhood Abuse Experiences and Homeless People's Quality of Life: A Longitudinal Study.

Studies report a relatively high prevalence of childhood abuse experiences (CAE) among adult homeless people. Within homeless populations, people with CAE appear to be worse off than homeless people without such experiences. This study compares a broad set of factors influencing the quality of the daily lives of Dutch homeless people with and without CAE. It also examines the extent to which CAE are predictive of the rate of change in these factors 2.5 years after entering the social relief system. Data were used from an observational longitudinal multi-site cohort study following Dutch homeless people 2.5 years after entering the social relief system. The 4 constitutional conditions of the Social Quality Approach (living conditions, interpersonal embeddedness, societal embeddedness and self-regulation) were used to cluster the factors included in this study. Participants were interviewed twice, at baseline (N = 513) and at follow up (N = 378), using a quantitative questionnaire. At baseline and follow-up participants with CAE were more disadvantaged in each of the 4 conditions of social quality, except for societal embeddedness at follow-up. After 2.5 years, on average, all participants improved more or less at a similar rate on almost all factors, with a few exceptions: Significant differential changes over time were found regarding employment status, quality of relationships with family members and symptoms of depression and anxiety. Findings corroborate the broad, detrimental and persistent impact of CAE on the quality of daily lives of homeless people and the need for homelessness services to apply trauma-informed care.

Immunity against measles, mumps, rubella, and varicella among homeless individuals in Germany - A nationwide multi-center cross-sectional study.

Introduction: Homeless individuals suffer a high burden of vaccine-preventable infectious diseases. Moreover, they are particularly susceptible to adverse infection outcomes with limited access to the health care system. Data on the seroprevalence of measles, mumps, rubella, and varicella within this cohort are missing. Methods: The seroprevalence of measles, mumps, rubella, and varicella was determined within the homeless population in Germany. Predictors of lacking immune protection were determined using multivariable logistic regression analysis. Results: Homeless individuals in Germany (n = 611) showed a seroprevalence of 88.5% (95% CI: 85.8-91.0) for measles, 83.8% (95% CI: 80.6-86.6) for mumps, 86.1% (95% CI: 83.1-88.7) for rubella, and 95.7% (95% CI 93.8-97.2) for varicella. Measles seroprevalences declined from individuals born in 1965 to individuals born in 1993, with seroprevalences not compatible with a 95% threshold in individuals born after 1980. For mumps, seroprevalences declined from individuals born in 1950 to individuals born in 1984. Here, seroprevalences were not compatible with a 92% threshold for individuals born after 1975. Seronegativity for measles, mumps and rubella was associated with age but not with gender or country of origin. Discussion: Herd immunity for measles and mumps is not achieved in this homeless cohort, while there was sufficient immune protection for rubella and varicella. Declining immune protection rates in younger individuals warrant immunization campaigns also targeting marginalized groups such as homeless individuals. Given that herd immunity thresholds are not reached for individuals born after 1980 for measles, and after 1975 for mumps, vaccination campaigns should prioritize individuals within these age groups.

Excess mortality among people in homelessness with substance use disorders: a Swedish cohort study.

BACKGROUND: People in homelessness have an increased risk of substance use disorders (SUDs) and poor health outcomes. This cohort study aimed to investigate the association between homelessness and mortality in people with SUDs, adjusting for age, sex, narcotic use, intravenous drug use and inpatient care for SUDs. METHODS: Data from the Swedish National Addiction Care Quality Register in the Stockholm region were used to analyse mortality risk in people with SUDs (n=8397), including 637 in homelessness, 1135 in precarious housing and 6625 in stable housing, at baseline. HRs and CIs were calculated using Cox regression. RESULTS: Mortality was increased for people in homelessness (HR 2.30; 95% CI 1.70 to 3.12) and precarious housing (HR 1.23; 95% CI 0.86 to 1.75) compared with those in stable housing. The association between homelessness and mortality decreased (HR 1.27; 95% CI 0.91 to 1.78) after adjusting for narcotic use (HR 1.28; 95% CI 1.00 to 1.63), intravenous drug use (HR 1.98; 95% CI 1.52 to 2.58) and inpatient care for SUDs (HR 1.96; 95% CI 1.57 to 2.45). Standardised mortality ratios (SMRs) showed that mortality among people in homelessness with SUDs was 13.6 times higher than the general population (SMR=13.6; 95% CI 10.2 to 17.9), and 3.7 times higher in people in stable housing with SUDs (SMR=3.7; 95% CI 3.2 to 4.1). CONCLUSION: Homelessness increased mortality, but the risk decreased after adjusting for narcotic use, intravenous drug use and inpatient care for SUDs. Interventions are needed to reduce excess mortality among people in homelessness with SUDs.

Developing oral health services for people experiencing severe and multiple disadvantage: a case study from Southwest England.

People experiencing severe and multiple disadvantage (SMD) have disproportionately high levels of dental disease and tooth loss but have limited access to dental care. This paper presents an evidence-based case study of co-designing, implementing, evaluating and refining a community dental clinic for people experiencing SMD in the Southwest of England. It shares challenges, lessons, and solutions. Tailored interventions that coordinate flexible and responsive care are important for facilitating dental access for individuals experiencing SMD. Participatory approaches can deliver a range of impacts both on research and service development. No single fixed model of co-design can be applied in service development, and the choice will vary depending on local context, available resources and joint decision making. Through co-design, vulnerable populations such as those with SMD can shape dental services that are more acceptable, appropriate and responsive to their needs. This approach can also ensure long-term sustainability by bridging treatment pathway development and commissioning.

Homeless people: a review of personality disorders.

Personality disorders in homeless people pose a challenge to the medical community and society, requiring specialized approaches for these super-difficult patients. The prevalence of personality disorders is higher in homeless populations than in the general population. However, there is a knowledge gap regarding personality disorders among people experiencing homelessness, and the implications of this lack of recognition are substantial. This paper provides a brief narrative review of personality disorders among homeless individuals. The primary importance and specificity of these disorders in this population remain unexplored. We searched PubMed and Web of Science databases in February and November 2023 using the keywords 'homeless' and 'personality disorder', and selected fifty-eight studies to be included in this literature review. The main themes of the results were personality disorders in homeless individuals and comorbid psychiatric disorders; risk factors and other psychological and behavioral data; clinical and intervention outcomes; and challenges linked to assessment, treatment, and intervention. The homeless population experiences significant diagnostic variability and the diagnosis of personality disorders is still evolving, contributing to difficulties in diagnosis, assessment, and treatment. A future challenge is to raise clinical awareness and optimize research knowledge, assessment, and intervention in personality disorders among homeless individuals with comorbid psychiatric disorders.

Prevalence and Characteristics of Tuberculosis in the Korean Homeless Population Based on Nationwide Tuberculosis Screening.

Background: The government of Korea implemented a strategy of prevention and early diagnosis in high-risk groups to reduce the tuberculosis (TB) burden. This study aims to investigate the TB epidemiology and gap in understanding of TB prevalence among homeless individuals by analyzing active TB chest X-ray (CXR) screening results in Korea. Methods: The Korean National Tuberculosis Association conducted active TB screening with CXR for homeless groups from January 1 to December 31, 2021. Sputum acid fast bacilli smear and culture were performed for the subjects suggestive of TB on CXR. We performed a cross-sectional analysis of the data in comparison with the national health screening results from the general population. Results: Among 17,713 homeless persons, 40 (0.23%), 3,077 (17.37%), and 79 (0.45%) were categorized as suggested TB, inactive TB, and observation required, respectively. Prevalence of suggested TB in the homeless was significantly higher (3-5 fold) than in the national general health screening based on age category (p < 0.005). Twenty-nine cases were confirmed as TB, yielding a prevalence of 164 cases per 100,000 individuals; 19 of these 29 cases showed inactive TB on CXR. Body mass index (p = 0.0478) and CXR result (p < 0.001) significantly correlated with confirmed TB based on multivariable analysis. Conclusion: Nutrition status and CXR results, especially that of inactive TB, should be considered in active TB screening of the homeless population, where TB prevalence is higher than the general population.

Backgrounds and perspectives of San Antonio street sleepers.

Background: The question of what brings someone to homelessness and keeps them there has many varied and complex answers. The authors believe the answers lie within the persons experiencing homelessness (PEH). Methods: This is an interpretive approach study based on convenience sampling of the San Antonio, TX, unsheltered population, utilizing semi-structured interviews from January 2022 through November 2022. Results: The six most common themes that emerged from the subjects' backgrounds were 1) jail or prison time or other personally significant legal issues; 2) personal substance abuse or addiction struggles; 3) physical and mental health challenges as an adult; 4) disdain of shelters and preference for rough sleeping; 5) a problematic childhood; 6) did not enjoy school as a child or young adult. Conclusion: To gain more insight into a situation as complex as the state of homelessness, researchers should meet with those on the frontline of this epidemic and hear first-hand their personal histories, challenges, successes, and suggestions. Though not a novel approach, the researchers found limited previous literature in regard to approach, scope and in relation of causation related to homelessness, especially about the U.S. unsheltered population. The ultimate goal is for such research to help guide outreach services and legislation related to PEH.

"Access to healthcare is a human right": a constructivist study exploring the impact and potential of a hospital-community partnered COVID-19 community response team for Toronto homeless services and congregate living settings.

BACKGROUND: Individuals experiencing homelessness face unique physical and mental health challenges, increased morbidity, and premature mortality. COVID -19 creates a significant heightened risk for those living in congregate sheltering spaces. In March 2020, the COVID-19 Community Response Team formed at Women's College Hospital, to support Toronto shelters and congregate living sites to manage and prevent outbreaks of SARS-CoV-2 using a collaborative model of onsite mobile testing and infection prevention. From this, the Women's College COVID-19 vaccine program emerged, where 14 shelters were identified to co-design and support the administration of vaccine clinics within each shelter. This research seeks to evaluate the impact of this partnership model and its future potential in community-centered integrated care through three areas of inquiry: (1) vaccine program evaluation and lessons learned; (2) perceptions on hospital/community partnership; (3) opportunities to advance hospital-community partnerships. METHODS: Constructivist grounded theory was used to explore perceptions and experiences of this partnership from the voices of shelter administrators. Semi-structured interviews were conducted with administrators from 10 shelters using maximum variation purposive sampling. A constructivist-interpretive paradigm was used to determine coding and formation of themes: initial, focused, and theoretical. RESULTS: Data analysis revealed five main categories, 16 subcategories, and one core category. The core category "access to healthcare is a human right; understand our communities" emphasizes access to healthcare is a consistent barrier for the homeless population. The main categories revealed during a time of confusion, the hospital was seen as credible and trustworthy. However, the primary focus of many shelters lies in housing, and attention is often not placed on health resourcing, solidifying partnerships, accountability, and governance structures therein. Health advocacy, information sharing tables, formalized partnerships and educating health professionals were identified by shelter administrators as avenues to advance intersectoral relationship building. CONCLUSION: Hospital-community programs can alleviate some of the ongoing health concerns faced by shelters - during a time of COVID-19 or not. In preparation for future pandemics, access to care and cohesion within the health system requires the continuous engagement in relationship-building between hospitals and communities to support co-creation of innovative models of care, to promote health for all.

A scoping review examining patient experience and what matters to people experiencing homelessness when seeking healthcare.

BACKGROUND: Homelessness is associated with significant health disparities. Conventional health services often fail to address the unique needs and lived experience of homeless individuals and fail to include participatory design when planning health services. This scoping review aimed to examine areas of patient experience that are most frequently reported by people experiencing homelessness when seeking and receiving healthcare, and to identify existing surveys used to measure patient experience for this cohort. METHODS: A scoping review was undertaken reported according to the PRISMA-ScR 2020 Statement. Databases were searched on 1 December 2022: MEDLINE, EMBASE, APA PsychINFO and CINAHL. Included studies focused on people experiencing homelessness, healthcare services and patient experience, primary research, published in English from 2010. Qualitative papers and findings were extracted and synthesized against a modified framework based on the National Institute for Health and Care Excellence guidelines for care for people experiencing homelessness, the Institute of Medicine Framework and Lachman's multidimensional quality model. People with lived experience of homelessness were employed as part of the research team. RESULTS: Thirty-two studies were included. Of these, 22 were qualitative, seven quantitative and three mixed methods, from the United States of America (n = 17), United Kingdom (n = 5), Australia (n = 5) and Canada (n = 4). Health services ranged from primary healthcare to outpatient management, acute care, emergency care and hospital based healthcare. In qualitative papers, the domains of 'accessible and timely', 'person-centred', and values of 'dignity and respect' and 'kindness with compassion' were most prevalent. Among the three patient experience surveys identified, 'accessible and timely' and 'person-centred' were the most frequent domains. The least frequently highlighted domains and values were 'equitable' and 'holistic'. No questions addressed the 'safety' domain. CONCLUSIONS: The Primary Care Quality-Homeless questionnaire best reflected the priorities for healthcare provision that were highlighted in the qualitative studies of people experiencing homelessness. The most frequently cited domains and values that people experiencing homelessness expressed as important when seeking healthcare were reflected in each of the three survey tools to varying degrees. Findings suggest that the principles of 'Kindness and compassion' require further emphasis when seeking feedback on healthcare experiences and the domains of 'safety', 'equitable', and 'efficiency' are not adequately represented in existing patient experience surveys.