Variability in comorbidites and health services use across homeless typologies: multicenter data linkage between healthcare and homeless systems.

BACKGROUND: Homelessness is associated with substantial morbidity. Data linkages between homeless and health systems are important to understand unique needs across homeless populations, identify homeless individuals not registered in homeless databases, quantify the impact of housing services on health-system use, and motivate health systems and payers to contribute to housing solutions. METHODS: We performed a cross-sectional survey including six health systems and two Homeless Management Information Systems (HMIS) in Cook County, Illinois. We performed privacy-preserving record linkage to identify homelessness through HMIS or ICD-10 codes captured in electronic medical records. We measured the prevalence of health conditions and health-services use across the following typologies: housing-service utilizers stratified by service provided (stable, stable plus unstable, unstable) and non-utilizers (i.e., homelessness identified through diagnosis codes-without receipt of housing services). RESULTS: Among 11,447 homeless recipients of healthcare, nearly 1 in 5 were identified by ICD10 code alone without recorded homeless services (n = 2177; 19%). Almost half received homeless services that did not include stable housing (n = 5444; 48%), followed by stable housing (n = 3017; 26%), then receipt of both stable and unstable services (n = 809; 7%). Setting stable housing recipients as the referent group, we found a stepwise increase in behavioral-health conditions from stable housing to those known as homeless solely by health systems. Compared to those in stable housing, prevalence rate ratios (PRR) for those without homeless services were as follows: depression (PRR = 2.2; 95% CI 1.9 to 2.5), anxiety (PRR = 2.5; 95% CI 2.1 to 3.0), schizophrenia (PRR = 3.3; 95% CI 2.7 to 4.0), and alcohol-use disorder (PRR = 4.4; 95% CI 3.6 to 5.3). Homeless individuals who had not received housing services relied on emergency departments for healthcare-nearly 3 of 4 visited at least one and many (24%) visited multiple. CONCLUSIONS: Differences in behavioral-health conditions and health-system use across homeless typologies highlight the particularly high burden among homeless who are disconnected from homeless services. Fragmented and high use of emergency departments for care should motivate health systems and payers to promote housing solutions, especially those that incorporate substance use and mental health treatment.

The Effect of Place of Service on Diabetic Screening Adherence in the Homeless Population.

This study examined the association between place of service and adherence to select diabetes screening measures in a homeless population. At a Midwestern metropolitan federally qualified health center (FQHC), 508 participants with diabetes and also experiencing homelessness were studied throughout calendar year 2018. Diabetes measures included controlled blood pressure, diabetic foot exam and hemoglobin A1C screening. Patients were seen at one of three locations: FQHC only, shelter only and both shelter and FQHC. After controlling for primary insurance, insurance status, homeless status, age group, ethnicity, primary language, race, sex and poverty level, a stepwise binary logistic regression demonstrated significant model improvement in A1c screening (p ≤ 0.001) and controlled blood pressure (p = 0.009) when place of service was added as a predictor. Specifically, results showed significant negative associations in screening adherence for shelter as compared to FQHC for both controlled blood pressure (OR = 0.40; 95% CI = 0.20-0.79; p = 0.009) and A1c screening (OR = 0.06; 95% CI = 0.03-0.16; p ≤ 0.001). Our results support the hypothesis that FQHC care results in higher rates of adherence than shelter only or FQHC and shelter combined care. The study addresses the gap in literature surrounding place of service and patient adherence. Recommendations for future research are included.

Identifying an association between socio-demographic factors and breast cancer screening adherence in a federally qualified health centre sample in the United States. A retrospective, cross-sectional study.

Federally Qualified Health Centres (FQHC) are community-based centres in the United States, intended to fill a gap in care for underserved populations, including Medicaid patients and the homeless. Because of the Affordable Care Act, passed into law in 2010, there was a 29% increase in Medicaid enrolees nationally. One service offered at FQHCs is breast cancer screening. Breast cancer screening has been shown to have the lowest adherence levels among low-income women and homeless women. As they serve patients with socio-economic barriers, FQHCs are a vital resource in ensuring access to such screening. This study aimed to identity an association between socio-demographic factors and breast cancer screening adherence in FQHC patients that included the homeless. This exploratory, cross-sectional, retrospective study looked at encounter level data from a FQHC in a major metropolitan (Chicago, IL) area from January 1st, 2017 through December 31st, 2018. Data were collected in January of 2019. This was a convenience sample. Association was tested through bivariate chi-square tests and multivariate logistic regression analysis, investigating the association between socio-demographic characteristics and compliance (Yes/No) for breast cancer screening. Results showed age (55-59; 65-69) and homeless status (doubling-up, transitional) showed a positive association with breast cancer screening, while insurance status (self-pay) had a negative association. Age, homeless status and insurance type were significantly associated with adherence. Demographic characteristics in the homeless population can be used to identify nonadherence.

Using Peer Navigators to Address the Integrated Health Care Needs of Homeless African Americans With Serious Mental Illness.

OBJECTIVE: The study examined the impact of a peer navigator program (PNP) developed by a community-based participatory research team and used with a group of African Americans with serious mental illness who were homeless. METHODS: Sixty-seven research participants were randomly assigned to receive PNP or treatment as usual (control) for one year. Data on general health and mental health, recovery, and quality of life were collected at baseline and at four, eight, and 12 months. RESULTS: Findings from group × trial analyses of variance of omnibus measures of the four constructs showed significant impact over the year for participants in PNP compared with those in the control group, with analyses showing small to moderate effect sizes: general health status (η2=.24), psychological experience of physical health (η2=.42), recovery (η2=.36), and quality of life (η2=.14). These differences emerged even though both groups showed significant reductions in homelessness and increases in insurance coverage. CONCLUSIONS: Implications for improving in-the-field health care for this population are discussed. Whether these results occurred because navigators were peers per se needs to be examined in future research.