Housing Status and Acute Care Use After Cancer Diagnosis.

This cohort study examines housing status and acute care use after a cancer diagnosis among individuals treated at a public hospital in San Francisco, California.

Association of Homelessness with Before Medically Advised Discharge After Surgery.

BACKGROUND: Before medically advised (BMA) discharge, which refers to patients leaving the hospital at their own discretion, is associated with higher rates of readmission and death in other settings. It is not known if housing status is associated with this phenomenon after surgery. METHODS: We identified all admitted adults who underwent an operation by one of 11 different surgical services at a single tertiary care hospital between January 2013 and June 2022. Chi-square tests and t-tests were used to compare demographic and clinical features between BMA discharges and standard discharges. Multivariable logistic regression was used to evaluate the association between housing status and BMA discharge, adjusting for demographic and admission characteristics. Documented reasons for BMA discharge were also abstracted from the medical record. RESULTS: Of 111,036 patient admissions, 242 resulted in BMA discharge (0.2%). After adjusting for observable confounders, patients experiencing homelessness had substantially higher odds of BMA discharge after surgery (adjusted odds ratio 4.4, 95% confidence interval 3.0-6.4; p < 0.001) when compared to housed. Patients who underwent emergency surgery, patients with a documented substance use disorder, and those insured by Medicaid also had significantly higher odds of BMA discharge. System- or provider-related reasons (including patient frustration with the hospital environment, challenges in managing substance dependence, and perceived inadequacy of paint control) were documented in 96% of BMA discharges for patients experiencing homelessness (vs. 66% in housed patients). CONCLUSION: BMA discharge is more common in patients experiencing homelessness after surgery even after adjusting for observable confounding characteristics. Deeper understanding of the drivers of BMA discharge in patients experiencing homelessness through qualitative methods are critical to promote more equitable and effective care.

Cluster Analysis of the Highest Users of Medical, Behavioral Health, and Social Services in San Francisco.

BACKGROUND: In the City and County of San Francisco, frequent users of emergent and urgent services across different settings (i.e., medical, mental health (MH), substance use disorder (SUD) services) are referred to as high users of multiple systems (HUMS). While often grouped together, frequent users of the health care system are likely a heterogenous population composed of subgroups with differential management needs. OBJECTIVE: To identify subgroups within this HUMS population using a cluster analysis. DESIGN: Cross-sectional study of HUMS patients for the 2019-2020 fiscal year using the Coordinated Care Management System (CCMS), San Francisco Department of Public Health's integrated data system. PARTICIPANTS: We calculated use scores based on nine types of urgent and emergent medical, MH, and SUD services and identified the top 5% of HUMS patients. Through k-medoids cluster analysis, we identified subgroups of HUMS patients. MAIN MEASURES: Subgroup-specific demographic, comorbidity, and service use profiles. KEY RESULTS: The top 5% of HUMS patients in the study period included 2657 individuals; 69.7% identified as men and 66.5% identified as non-White. We detected 5 subgroups: subgroup 1 (N = 298, 11.2%) who were relatively younger with prevalent MH and SUD comorbidities, and MH services use; subgroup 2 (N = 478, 18.0%), who were experiencing homelessness, with multiple comorbidities, and frequent use of medical services; subgroup 3 (N = 449, 16.9%), who disproportionately self-identified as Black, with prolonged homelessness, multiple comorbidities, and persistent HUMS status; subgroup 4 (N = 690, 26.0%), who were relatively older, disproportionately self-identified as Black, with prior homelessness, multiple comorbidities, and frequent use of medical services; and subgroup 5 (N=742, 27.9%), who disproportionately self-identified as Latinx, were housed, with medical comorbidities and frequent medical service use. CONCLUSIONS: Our study highlights the heterogeneity of HUMS patients. Interventions must be tailored to meet the needs of these diverse patient subgroups.

Analysis of Emergency Department Encounters Among High Users of Health Care and Social Service Systems Before and During the COVID-19 Pandemic.

Importance: Although the general US population had fewer emergency department (ED) visits during the COVID-19 pandemic, patterns of use among high users are unknown. Objectives: To examine natural trends in ED visits among high users of health and social services during an extended period and assess whether these trends differed during COVID-19. Design, Setting, and Participants: This retrospective cohort study combined data from 9 unique cohorts, 1 for each fiscal year (July 1 to June 30) from 2012 to 2021, and used mixed-effects, negative binomial regression to model ED visits over time and assess ED use among the top 5% of high users of multiple systems during COVID-19. Data were obtained from the Coordinated Care Management System, a San Francisco Department of Public Health platform that integrates medical and social information with service use. Exposures: Fiscal year 2020 was defined as the COVID-19 year. Main Outcomes and Measures: Measured variables were age, gender, language, race and ethnicity, homelessness, insurance status, jail health encounters, mental health and substance use diagnoses, and mortality. The main outcome was annual mean ED visit counts. Incidence rate ratios (IRRs) were used to describe changes in ED visit rates both over time and in COVID-19 vs non-COVID-19 years. Results: Of the 8967 participants, 3289 (36.7%) identified as White, 3005 (33.5%) as Black, and 1513 (16.9%) as Latinx; and 7932 (88.5%) preferred English. The mean (SD) age was 46.7 (14.2) years, 6071 (67.7%) identified as men, and 7042 (78.5%) had experienced homelessness. A statistically significant decrease was found in annual mean ED visits among high users for every year of follow-up until year 8, with the largest decrease occurring in the first year of follow-up (IRR, 0.41; 95% CI, 0.40-0.43). However, during the pandemic, ED visits decreased 25% beyond the mean reduction seen in prepandemic years (IRR, 0.75; 95% CI, 0.72-0.79). Conclusions and Relevance: In this study, multiple cohorts of the top 5% of high users of multiple health care systems in San Francisco had sustained annual decreases in ED visits from 2012 to 2021, with significantly greater decreases during COVID-19. Further research is needed to elucidate pandemic-specific factors associated with these findings and understand how this change in use was associated with health outcomes.

Association of Shelter-in-Place Hotels With Health Services Use Among People Experiencing Homelessness During the COVID-19 Pandemic.

Importance: Some jurisdictions used hotels to provide emergency noncongregate shelter and support services to reduce the risk of COVID-19 infection among people experiencing homelessness (PEH). A subset of these shelter-in-place (SIP) hotel guests were high users of acute health services, and the association of hotel placement with their service use remains unknown. Objective: To evaluate the association of SIP hotel placements with health services use among a subset of PEH with prior high acute health service use. Design, Setting, and Participants: This study used a matched retrospective cohort design comparing health services use between PEH with prior high service use who did and did not receive a SIP hotel placement, from April 2020 to April 2021. The setting was 25 SIP hotels in San Francisco, California, with a daily capacity of 2500 people. Participants included PEH who were among the top 10% high users of acute medical, mental health, and substance use services and who had 3 or more emergency department (ED) visits in the 9 months before the implementation of the SIP hotel program. Data analysis for this study was performed from February 2021 to May 2022. Exposures: SIP hotel placement with on-site supportive services. Main Outcomes and Measures: The primary outcomes were ED visits, hospitalizations and bed days, psychiatric emergency visits, psychiatric hospitalizations, outpatient mental health and substance use visits, and outpatient medical visits. Results: Of 2524 SIP guests with a minimum of 90-day stays, 343 (13.6%) met criteria for high service use. Of 686 participants with high service use (343 SIP group; 343 control), the median (IQR) age was 54 (43-61) years, 485 (70.7%) were male, 283 (41.3%) were Black, and 337 (49.1%) were homeless for more than 10 years. The mean number of ED visits decreased significantly in the high-user SIP group (1.84 visits [95% CI, 1.52-2.17 visits] in the 90 days before SIP placement to 0.82 visits [95% CI, 0.66-0.99 visits] in the 90 days after SIP placement) compared with high-user controls (decrease from 1.33 visits [95% CI, 1.39-1.58 visits] to 1.00 visits [95% CI, 0.80-1.20 visits]) (incidence rate ratio [IRR], 0.60; 95% CI, 0.47-0.75; P < .001). The mean number of hospitalizations decreased significantly from 0.41 (95% CI, 0.30-0.51) to 0.14 (95% CI, 0.09-0.19) for SIP guests vs 0.27 (95% CI, 0.19-0.34) to 0.22 (95% CI, 0.15-0.29) for controls (IRR, 0.41; 95% CI, 0.27-063; P < .001). Inpatient hospital days decreased significantly from a mean of 4.00 (95% CI, 2.44-5.56) to 0.81 (95% CI, 0.40-1.23) for SIP guests vs 2.27 (95% CI, 1.27-3.27) to 1.85 (95% CI, 1.06-2.65) for controls (IRR, 0.25; 95% CI, 0.12-0.54; P < .001), as did psychiatric emergency visits, from a mean of 0.03 (95% CI, 0.01-0.05) to 0.01 (95% CI, 0.00-0.01) visits for SIP guests vs no change in the control group (IRR, 0.25; 95% CI, 0.11-0.51; P < .001). Conclusions and Relevance: These findings suggest that in a population of PEH with high use of acute health services, SIP hotel placement was associated with significantly reduced acute care use compared with high users without a placement.

Implementation of rapid and frequent SARS-CoV2 antigen testing and response in congregate homeless shelters.

BACKGROUND: People experiencing homelessness who live in congregate shelters are at high risk of SARS-CoV2 transmission and severe COVID-19. Current screening and response protocols using rRT-PCR in homeless shelters are expensive, require specialized staff and have delays in returning results and implementing responses. METHODS: We piloted a program to offer frequent, rapid antigen-based tests (BinaxNOW) to residents and staff of congregate-living shelters in San Francisco, California, from January 15th to February 19th, 2021. We used the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework to evaluate the implementation. RESULTS: Reach: We offered testing at ten of twelve eligible shelters. Shelter residents and staff had variable participation across shelters; approximately half of eligible individuals tested at least once; few tested consistently during the study. Effectiveness: 2.2% of participants tested positive. We identified three outbreaks, but none exceeded 5 cases. All BinaxNOW-positive participants were isolated or left the shelters. Adoption: We offered testing to all eligible participants within weeks of the project's initiation. Implementation: Adaptations made to increase reach and improve consistency were promptly implemented. Maintenance: San Francisco Department of Public Health expanded and maintained testing with minimal support after the end of the pilot. CONCLUSION: Rapid and frequent antigen testing for SARS-CoV2 in homeless shelters is a viable alternative to rRT-PCR testing that can lead to immediate isolation of infectious individuals. Using the RE-AIM framework, we evaluated and adapted interventions to enable the expansion and maintenance of protocols.

Assessment of a Hotel-Based COVID-19 Isolation and Quarantine Strategy for Persons Experiencing Homelessness.

Importance: Several jurisdictions in the United States have secured hotels to temporarily house people experiencing homelessness who require isolation or quarantine for confirmed or suspected coronavirus disease 2019 (COVID-19). To our knowledge, little is known about how these programs serve this vulnerable population outside the hospital setting. Objective: To assess the safety of a hotel-based isolation and quarantine (I/Q) care system and its association with inpatient hospital capacity. Design, Setting, and Participants: This retrospective cohort study of a hotel-based I/Q care system for homeless and unstably housed individuals in San Francisco, California, was conducted from March 19 to May 31, 2020. Individuals unable to safely isolate or quarantine at home with mild to moderate COVID-19, persons under investigation, or close contacts were referred from hospitals, outpatient settings, and public health surveillance to 5 I/Q hotels. Of 1009 I/Q hotel guests, 346 were transferred from a large county public hospital serving patients experiencing homelessness. Exposure: A physician-supervised team of nurses and health workers provided around-the-clock support, including symptom monitoring, wellness checks, meals, harm-reduction services, and medications for opioid use disorder. Main Outcomes and Measures: Characteristics of I/Q hotel guests, program retention, county hospital readmissions, and mean length of stay. Results: Overall, the 1009 I/Q hotel guests had a median age of 44 years (interquartile range, 33-55 years), 756 (75%) were men, 454 (45%) were Latinx, and 501 (50%) were persons experiencing sheltered (n = 295) or unsheltered (n = 206) homelessness. Overall, 463 (46%) received a diagnosis of COVID-19; 303 of 907 (33%) had comorbid medical disorders, 225 of 907 (25%) had comorbid mental health disorders, and 236 of 907 (26%) had comorbid substance use disorders. A total of 776 of 955 guests (81%) completed their I/Q hotel stay; factors most strongly associated with premature discontinuation were unsheltered homelessness (adjusted odds ratio, 4.5; 95% CI, 2.3-8.6; P < .001) and quarantine status (adjusted odds ratio, 2.6; 95% CI, 1.5-4.6; P = .001). In total, 346 of 549 patients (63%) were transferred from the county hospital; of 113 ineligible referrals, 48 patients (42%) had behavioral health needs exceeding I/Q hotel capabilities. Thirteen of the 346 patients transferred from the county hospital (4%) were readmitted for worsening COVID-19. Overall, direct transfers to I/Q hotels from emergency and outpatient departments were associated with averting many hospital admissions. There was a nonsignificant decrease in the mean hospital length of stay for inpatients with confirmed or suspected COVID-19 from 5.5 to 2.7 days from March to May 2020 (P = .11). Conclusions and Relevance: To support persons experiencing homelessness during the COVID-19 pandemic, San Francisco rapidly and safely scaled a hotel-based model of I/Q that was associated with reduced strain on inpatient capacity. Strategies to improve guest retention and address behavioral health needs not met in hotel settings are intervention priorities.

Large repayments of premium subsidies may be owed to the IRS if family income changes are not promptly reported.

Subsidies for health insurance premiums under the Affordable Care Act are refundable tax credits. They can be taken when taxes are filed or in advance, as reductions in monthly premiums that must be reconciled at tax filing. Recipients who take subsidies in advance will receive tax refunds if their subsidies were too small but will have to make repayments if their subsidies were too high. We analyzed predicted repayments and refunds for people receiving subsidies, using California as a case study. We found that many families could owe large repayments to the Internal Revenue Service at their next tax filing. If income changes were reported and credits adjusted in a timely manner throughout the tax year, the number of filers owing repayments would be reduced by 7-41 percent and the median size of repayments reduced by as much as 61 percent (depending on the level of changes reported and the method used to adjust the subsidy amounts). We recommend that the health insurance exchanges mandated by the Affordable Care Act educate consumers about how the subsidies work and the need to promptly report income changes. We also recommend that they provide tools and assistance to determine the amount of subsidies that enrollees should take in advance.

Proposed regulations could limit access to affordable health coverage for workers' children and family members.

Key Findings. The Patient Protection and Affordable Care Act (ACA) is designed to offer premium subsidies to help eligible individuals and their families purchase insurance coverage when affordable job-based coverage is not available. However, the law is unclear on how this affordability protection is applied in those instances where self-only coverage offered by an employer is affordable but family coverage is not. Regulations recently proposed by the Department of the Treasury would make family members ineligible for subsidized coverage in the exchange if an employee is offered affordable self-only coverage by an employer, even if family coverage is unaffordable. This could have significant financial consequences for low- and moderate-income families that fall in this gap. Using an alternative interpretation of the law could allow the entire family to enter the exchange when family coverage is unaffordable, which would broaden access to coverage. However, this option has been cited as cost prohibitive. In this brief we consider a middle ground alternative that would base eligibility for the individual worker on the cost of self-only coverage, but would use the additional cost to the employee for family coverage as the basis for determining affordability and eligibility for subsidies for the remaining family members. We find that: Under the middle ground alternative scenario an additional 144,000 Californians would qualify for and use premium subsidies in the California Health Benefit Exchange, half of whom are children. Less than 1 percent of those with employer-based coverage would move to subsidized coverage in the California Health Benefit Exchange as a result of having unaffordable coverage on the job.