Involuntary displacement and self-reported health in a cross-sectional survey of people experiencing homelessness in Denver, Colorado, 2018-2019.

BACKGROUND: The number of people experiencing unsheltered homelessness in the U.S. is increasing. Municipalities have responded with punitive responses such as involuntary displacement (i.e., encampment sweeps, move along orders), but little is known about the impact of involuntary displacement on health. The purpose of this study was to investigate the association between broadly defined experiences of involuntary displacement and self-reported health conditions among people experiencing homelessness. METHODS: We used logistic regression models to generate odds ratios using publicly available data from a cross-sectional sample of people experiencing homelessness in Denver, Colorado, during September 2018-February 2019. Hosmer-Lemeshow Goodness of Fit tests were used to assess model fit. RESULTS: Among 397 people experiencing homelessness, involuntary displacement was significantly associated with self-reported infectious diseases (adjusted odds ratio (aOR) 2.09, 95% CI 1.27, 3.41), substance and alcohol use (aOR 2.83; 95% CI 1.70, 4.73), climate-related conditions (aOR 2.27; 95% CI 1.35, 3.83), and worsening mental health (aOR 2.00; 95% CI 1.24, 3.24) after controlling for potential confounders. No statistically significant associations were identified between involuntary displacement and injuries, musculoskeletal issues, chronic conditions, and chronic mental and emotional issues. CONCLUSIONS: This research quantifies the association between involuntary displacement and multiple infectious and non-infectious health outcomes. While city officials attempt to grapple with increasing unsheltered homelessness, it is important to understand what harms are occurring that are associated with current policies. Our research adds to the growing body of literature that involuntary displacement is a harmful response to unsheltered homelessness. Alternative approaches focused on connections to housing and social services should be prioritized.

Pilot trial results of D-HOMES: a behavioral-activation based intervention for diabetes medication adherence and psychological wellness among people who have been homeless.

Introduction: People living with type 2 diabetes who experience homelessness face a myriad of barriers to engaging in diabetes self-care behaviors that lead to premature complications and death. This is exacerbated by high rates of comorbid mental illness, substance use disorder, and other physical health problems. Despite strong evidence to support lay health coach and behavioral activation, little research has effectively engaged people living with type 2 diabetes who had experienced homelessness (DH). Methods: We used community engaged research and incremental behavioral treatment development to design the Diabetes HOmeless MEdication Support (D-HOMES) program, a one-on-one, 3 month, coaching intervention to improve medication adherence and psychological wellness for DH. We present results of our pilot randomized trial (with baseline, 3 mo., 6 mo. assessments) comparing D-HOMES to enhanced usual care (EUC; brief diabetes education session and routine care; NCT05258630). Participants were English-speaking adults with type 2 diabetes, current/recent (<24 mo.) homelessness, and an HbA1c_7.5%. We focused on feasibility (recruitment, retention, engagement) and acceptability (Client Satisfaction Questionnaire, CSQ-8). Our primary clinical outcome was glycemic control (HbA1c) and primary behavioral outcome was medication adherence. Secondary outcomes included psychological wellness and diabetes self-care. Results: Thirty-six eligible participants enrolled, 18 in each arm. Most participants identified as Black males, had high rates of co-morbidities, and lived in subsidized housing. We retained 100% of participants at 3-months, and 94% at 6-months. Participants reported high satisfaction (mean CSQ-8 scores=28.64 [SD 3.94] of 32). HbA1c reduced to clinically significant levels in both groups, but we found no between group differences. Mean blood pressure improved more in D-HOMES than EUC between baseline and 6 mo. with between group mean differences of systolic -19.5 mmHg (p=0.030) and diastolic blood pressure -11.1 mmHg (p=0.049). We found no significant between group differences in other secondary outcomes. Conclusion: We effectively recruited and retained DH over 6 months. Data support that the D-HOMES intervention was acceptable and feasible. We observe preliminary blood pressure improvement favoring D-HOMES that were statistically and clinically significant. D-HOMES warrants testing in a fully powered trial which could inform future high quality behavioral trials to promote health equity. Clinical trial registration: https://clinicaltrials.gov/study/NCT05258630?term=D-HOMES&rank=1, identifier NCT05258630.

Disseminating Community-Engaged Research Involving People Experiencing Homelessness and Diabetes Using Participatory Theater.

People experiencing homelessness balance competing priorities resulting in reduced capacity to meet the care demands of chronic conditions, including Type 2 Diabetes Mellitus (T2DM). Arts-based performances present an avenue to expose others to these challenges. This article describes the process of incorporating qualitative research findings in a community-based participatory theater production to expose audiences to the day-to-day realities of living with T2DM while simultaneously experiencing homelessness. We conducted five focus groups and two individual interviews with people living with T2DM who had experienced homelessness with guidance from a community-engaged research team. We then collaborated with a local theater company to present common themes from these focus groups in a co-created play about the experience of managing T2DM while being homeless. We performed a staged reading of the play and assessed audience members' perceived stigma through a pre- and post-survey to determine if audience engagement within our theatrical production could reduce stigma toward individuals living with diabetes and/or people experiencing homelessness. This theatrical production is titled "Life Heist: Stealing Hope While Surviving Diabetes and Homelessness." Our work illustrates the feasibility and effectiveness of using participatory theater to disseminate qualitative research findings.

The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness.

Introduction: Compared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH. Methods: We used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions). Results: In step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing. Discussion: The research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing.

Strengthening Public Health Capacity to Address Infectious Diseases: Lessons From 3 Centers of Excellence in Public Health and Homelessness.

People experiencing homelessness are disproportionately affected by infectious diseases and often face barriers to receiving appropriate medical treatment. Responding to the needs of people experiencing homelessness requires state and local health departments to integrate information sources and coordinate multisector efforts. From 2021 to 2023, the CDC Foundation, in cooperation with the Centers for Disease Control and Prevention, established pilot Centers of Excellence in Public Health and Homelessness in Seattle, Washington; San Francisco, California; and the state of Minnesota. These centers strengthened their capacity to address the needs of people experiencing homelessness by supporting cross-sector partnerships, assessing the interoperability of data systems, prioritizing infectious disease needs, and identifying health disparities. These programs demonstrated that health departments are heterogeneous entities with differing resources and priorities. They also showed the importance of employing dedicated public health staff focused on homelessness, establishing diverse partnerships and the need for support from local leaders to address homelessness.

Bringing Lived Experience to Research on Health and Homelessness: Perspectives of Researchers and Lived Experience Partners.

Improving health and healthcare for people experiencing homelessness (PEH) has become a national research priority. It is critical for research related to homelessness to be guided by input from PEH themselves. We are a group of researchers and individuals who have personally experienced homelessness collaborating on a study focused on homelessness and housing. In this Fresh Focus, we describe our partnership, lessons learned from our work together, what we have gained from our collaboration, and considerations for future homelessness research-lived experience partnerships.

Stories for change protocol: A randomized controlled trial of a digital storytelling intervention for Hispanic/Latino individuals with type 2 diabetes.

BACKGROUND: Hispanic/Latino adults are disproportionately impacted by type 2 diabetes mellitus (T2D). The Stories for Change (S4C) Diabetes digital storytelling intervention promotes T2D self-management among Hispanic/Latino people. We describe the S4C protocol and participant baseline characteristics. METHODS: Study eligibility criteria: Hispanic or Latino, age 18-70 years, ≥1 office visit within a year at a participating clinic, T2D diagnosis for ≥6 months, HbA1c ≥ 8%, and intention to continue care at the recruitment clinic. We used a two-group, parallel randomized controlled trial design and an intervention derived through a community-based participatory research approach. All participants received usual diabetes care and two cards describing how to engage healthcare teams and access diabetes-related resources. At baseline, the intervention group additionally viewed the 12-min, intervention video (four stories about diabetes self-management). To encourage subsequent video viewing, participants received five monthly text messages. The messages prompted them to self-rate their motivation and self-efficacy for T2D management. The control group received no additional intervention. Bilingual (English/Spanish) staff collected data at baseline, six weeks, three months, and six months including biometric measurements and a survey on diabetes self-management outcomes, theory-based measures, and the number of video views. We reviewed the number of diabetes-related appointments attended using electronic medical record data. RESULTS: Participants (n = 451; 70% women, mean age = 53 years) had an average HbA1C ≥9%. Intervention participants reported identifying with the storytellers and engaging with the stories. CONCLUSION: We present a digital storytelling intervention protocol that provides a template for future health promotion interventions prioritizing health disparity populations. CLINICALTRIAL: gov#NCT03766438.

COVID-19 Vaccination Of People Experiencing Homelessness And Incarceration In Minnesota.

We used data from a statewide public health-health system collaboration to describe trends in COVID-19 vaccination rates by racial and ethnic groups among people experiencing homelessness or incarceration in Minnesota. Vaccination completion rates among the general population and people incarcerated in state prisons were substantially higher than those among people experiencing homelessness or jail incarceration.

Clinic- and Community-Based SARS-CoV-2 Testing Among People Experiencing Homelessness in the United States, March-November 2020.

OBJECTIVE: SARS-CoV-2 testing is a critical component of preventing the spread of COVID-19. In the United States, people experiencing homelessness (PEH) have accessed testing at health clinics, such as those provided through Health Care for the Homeless (HCH) clinics or through community-based testing events at homeless service sites or encampments. We describe data on SARS-CoV-2 testing among PEH in US clinic- and community-based settings from March through November 2020. METHODS: We conducted a descriptive analysis of data from HCH clinics and community testing events. We used a standardized survey to request data from HCH clinics. We developed and made publicly available an online data entry portal to collect data from community-based organizations that provided testing for PEH. We assessed positivity rates across clinics and community service sites serving PEH and used generalized linear mixed models to account for clustering. RESULTS: Thirty-seven HCH clinics reported providing 280 410 tests; 3.2% (n = 8880) had positive results (range, 1.6%-4.9%). By race, positivity rates were highest among people who identified as >1 race (11.6%; P < .001). During the reporting period, 22 states reported 287 community testing events and 14 116 tests; 7.1% (n = 1004) had positive results. Among facility types, day shelters (380 of 2697; 14.1%) and inpatient drug/alcohol rehabilitation facilities (32 of 251; 12.7%) reported the highest positivity rates. CONCLUSIONS: While HCH clinic data provided results for a larger number of patients, community-based testing data showed higher positivity rates. Clinic data demonstrated racial disparities in positivity. Community-based testing data provided information about SARS-CoV-2 transmission settings. Although these data provide information about testing, standard surveillance systems are needed to better understand the incidence of disease among PEH.

The development and pilot testing of a behavioral activation-based treatment for depressed mood and multiple health behavior change in patients with recent acute coronary syndrome.

BACKGROUND: Patients with acute coronary syndrome (ACS) with depressed mood demonstrate poor cardiovascular behavioral risk profiles and elevated risk for recurrent ACS and mortality. Behavioral Activation (BA) offers an intervention framework for an integrated treatment targeting both depression and critical health behaviors post-ACS. Behavioral Activation for Health and Depression (BA-HD) was developed and pilot tested in a multiphase iterative process. METHODS: First, an initial treatment manual was conceptualized based on the team's prior work, as well as the extant literature. Second, qualitative interviews were conducted with target patients and target providers on the proposed BA-HD treatment rationale, content, and structure. Framework matrix analyses were used to summarize and aggregate responses. Third, an expert panel was convened to elicit additional manual refinements. Finally, patients with post-ACS depression and health behavior non-adherence were recruited to complete an open pilot trial to evaluate acceptability (Client Satisfaction Questionnaire [CSQ], exit interview) and treatment engagement (number of sessions attended; treatment completion was considered completion of 8 out of 10 possible sessions). RESULTS: The initial BA-HD treatment manual expanded an existing treatment manual for post-ACS BA-based mood management and smoking cessation to target four health behaviors relevant to post-ACS patients (e.g., smoking cessation, medication adherence, physical activity, and diet). After the initial conceptualization, ten post-ACS patients and eight cardiac rehabilitation professionals completed qualitative interviews. Patients endorsed bi-directional interactions between mood and health behaviors post-ACS. Both patients and providers expressed general support of the proposed treatment rationale and values-guided, collaborative goal-setting approach. Patients, providers, and experts provided feedback that shaped the iterative manual development. After the BA-HD manual was finalized, eight participants were enrolled in a single-arm pilot trial. The mean CSQ score was 30.57 ± 2.23, indicating high satisfaction. Seven out of eight (88%) completed treatment. Pre- to post treatment improvements in depressed mood and health behaviors were promising. CONCLUSIONS: BA-HD treatment is an acceptable approach to target both mood and health behaviors in post-ACS patients with depression. A future larger, controlled trial is needed to evaluate the efficacy of the BA-HD treatment. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04158219.

How Should Autonomy of Persons Experiencing Homelessness Be Balanced With Public Health During a Pandemic?

The COVID-19 pandemic underscores long-standing challenges to the health of persons experiencing homelessness. This case commentary considers primary care clinicians' response to a patient who declines COVID-19 testing and isolation. This article also considers other outbreaks in the United States in which the autonomy of persons with low income or persons of color was neglected and calls for community engagement, policies that center interests of marginalized groups, and economic relief, including supportive housing.

Electronic cigarette use patterns and chronic health conditions among people experiencing homelessness in MN: a statewide survey.

BACKGROUND: Adults experiencing homelessness have higher rates of disease and premature morbidity compared to the general population. Tobacco use is a primary contributing factor to these disparities; however, less is known regarding e-cigarette use patterns among adults experiencing homelessness and whether e-cigarettes are used in a manner that is narrowing or widening health disparities. This study aimed to describe the 1) prevalence and trends in e-cigarette use, 2) correlates of e-cigarettes use, and 3) rates of chronic health conditions by product use pattern in a community-based sample of adults experiencing homelessness. METHODS: Adults experiencing homelessness in Minnesota were surveyed by self-report in 2015 (n = 3672) and 2018 (n = 4181) regarding e-cigarette and combustible cigarette use, potential correlates of e-cigarette use, and self-reported chronic health conditions (i.e., asthma, hypertension, diabetes, and cancer). RESULTS: Frequency of use increased from 2015 to 2018 for combustible cigarettes (66.9% vs. 72.3%), e-cigarettes (11.4% vs. 14.5%), and dual combustible/e-cigarette use (10.2% vs. 12.9%). The strongest bivariate correlates of past 30-day e-cigarette use were younger age, non-binary gender identification, non-heterosexual orientation, identification as White/Caucasian, greater frequency of lifetime homelessness, substance use, lack of regular place for medical care, mental health diagnosis, criminal justice involvement, and combustible cigarette smoking. Dual users had significantly higher rates of asthma and cancer than both those using combustible cigarettes and those using neither combustible nor e-cigarettes. CONCLUSIONS: During a time when cigarette smoking, e-cigarette use, and dual use were decreasing in the general population in Minnesota, rates increased in the homeless population. We observed that the rates of dual use were more than five times greater among homeless adults compared to the general population in 2018. Correlates of e-cigarette use were identified and should be used to identify subpopulations for intervention targeting. Mechanisms of the relationship between dual use and increased risks of health conditions deserve further study.

Health system resource use among populations with complex social and behavioral needs in an urban, safety-net health system.

BACKGROUND: Costs incurred by health systems when caring for populations with social or behavioral complexity are poorly understood. We compared the frequency and costs of unreimbursed care among individuals with complexity factors (homelessness, a history of county jail incarceration, and/or substance use disorder or mental illness [SUD/MI]). METHODS: We conducted a cross-sectional analysis using electronic health record data for adults aged 18 and older between January 1, 2016 and December 31, 2017 from a Midwestern safety-net health system. Zero-inflated negative binomial regression models were used to assess risk-adjusted associations between complexity factors and care coordination encounters, missed appointments, and excess inpatient days. RESULTS: Our sample included 154,719 unique patients; 6.8% were identified as homeless, 7.8% had a history of county jail incarceration, and 20.6% had SUD/MI. Individuals with complexity factors were more likely to be African-American, Native American, or covered by Medicaid. In adjusted models, homelessness and SUD/MI were significantly associated with care coordination encounters (RR 1.8 [95% CI,1.7-2.0]; RR 1.9 [95% CI,1.8-2.0]), missed appointments (RR 1.5 [95% CI,1.4-1.6]; RR 1.7 [95% CI,1.7-1.8]), and excess inpatient days (RR 1.5 [95% CI,1.3-1.8]; RR 2.8 [95% CI,2.5-3.1]). County jail incarceration was associated with a significant increase in missed appointments. In 2017, SUD/MI accounted for 81.8% ($7,773,000/$9,502,000) of excess costs among those with social or behavioral complexity. CONCLUSIONS: Social and behavioral complexity are independently associated with high levels of unreimbursed health system resource use. IMPLICATIONS: Future payment models should account for the health system resources required to care for populations with complex social and behavioral needs. LEVEL OF EVIDENCE: IV.

Experiences with Work and Participation in Public Programs by Low-Income Medicaid Enrollees Using Qualitative Interviews.

BACKGROUND: Centers for Medicare & Medicaid Services (CMS) began encouraging governors to implement work requirements for Medicaid enrollees using section 1115 waivers in 2018. Significant controversy surrounds such attempts, but we know little about the perceptions and experiences of enrollees. OBJECTIVE: To characterize experiences of work and its relationship to participation in Medicaid and other public programs among potential targets of Medicaid work requirements. DESIGN: In-depth, semi-structured, one-time qualitative interviews. PARTICIPANTS: 35 very low-income, non-disabled Medicaid expansion enrollees participating in a county-sponsored Medicaid managed care plan as a part of a larger study. APPROACH: We used a biographical narrative interpretive method during interviews including questions about the use of employment and income support and other public programs including from state and federal disability programs. Our team iteratively coded verbatim transcripts allowing for emergent themes. KEY RESULTS: Interview data revealed high motivation for, and broad participation in, formal and informal paid work. Eight themes emerged: (1) critical poverty (for example, "I'm not content, but what choices do I have?"); (2) behavioral and physical health barriers to work; (3) social barriers: unstable housing, low education, criminal justice involvement; (4) work, pride, and shame; (5) inflexible, unstable work (for example, "Can I have a job that will accommodate my doctor appointments?…Will my therapy have to suffer? You know? So it's a double edged sword."); (6) Medicaid supports the ability to work; (7) lack of transparency and misalignment of program eligibility (for example, "It's not like I don't want to work because I would like to work. It's just that I don't want to be homeless again, right?"); and (8) barriers, confusion, and contradictions about federal disability. CONCLUSIONS: We conclude that bipartisan solutions prioritizing the availability of well-paying jobs and planful transitions off of public programs would best serve very low-income, work-capable Medicaid enrollees.

Development and Implementation of an Interdisciplinary Intensive Primary Care Clinic for High-Need High-Cost Patients in a Safety Net Hospital.

In 2010, payment for some of Hennepin County Medical Center's highest need patients changed from fee for service to a per capita formula. This financial stress led the institution to employ a population health lens that revealed a significant concentration of spending on a small segment of the population. Finding high rates of potentially avoidable inpatient and emergency care, an organizational effort was initiated to attempt to manage this high-need, high-cost population more effectively. A freestanding interdisciplinary intensive primary care clinic was developed. Nurses led a risk stratification process to identify eligible patients for co-located medical, care coordination, and social services from multidisciplinary care teams. Workflows to engage the population were designed to reduce readmissions and inappropriate use of emergency services. Soon after opening, the clinic added mental health and substance use professionals. For people entering the clinic between January 2010 and July 2017, utilization and financial data were collected for the year before (pre) and after (post) enrollment (n = 487). Bivariate statistics and outlier analyses facilitated comparisons between pre/post enrollment. Patients visited the new clinic twice per month on average and outpatient costs almost doubled. Overall costs were 16% lower, with the largest decrease seen in inpatient costs. This experience has led to ongoing investment, replication, and expansion of the model. An interdisciplinary intensive primary care clinic for high-utilizing, underserved patients is a promising intervention. Multidisciplinary teams and ongoing institutional support are critical to program success. Payment reform is essential to the development of such programs.