The Role of Street Medicine and Mobile Clinics for Persons Experiencing Homelessness: A Scoping Review.

INTRODUCTION: An estimated 5800 to 46,500 lives are lost due to homelessness each year. Experiencing homelessness and poor health are cyclically related, with one reinforcing the other. Mobile programs, which include vehicles that travel to deliver care, and street medicine, the act of bringing care to spaces where PEH live, may play a role in alleviating this burden by providing trusted, affordable, and accessible care to this community. METHODS: We conducted a scoping review of peer-reviewed literature on the role of mobile clinics and street medicine in providing care for PEH by searching PubMed, Embase, and Web of Science on 10 August 2023. Articles from 2013 to 2023 specific to programs in the United States were included. The protocol was developed following the PRISMA-ScR guidelines. The primary outcome was the role of mobile programs for persons experiencing homelessness. RESULTS: A total of 15 articles were included in this review. The descriptive findings emphasized that street medicine and mobile clinics provide primary care, behavioral health, and social services. The utilization findings indicate that street medicine programs positively impact the health system through their ability to defer emergency department and hospital visits, providing financial benefits. The comparative findings between mobile programs and office-based programs indicate current successes and areas for improvement. DISCUSSION: Mobile clinics and street medicine programs that serve PEH provide a wide range of services. While more significant structural change is needed to address healthcare costs and housing policies in the United States, mobile clinics and street medicine teams can improve healthcare access and the healthcare system.

Real-time evaluation of a multi-agency TB-screening event for persons experiencing homelessness in a town with a low incidence of TB in England.

Real-time evaluation (RTE) supports populations (e.g., persons experiencing homelessness (PEH) to engage in evaluation of health interventions who may otherwise be overlooked. The aim of this RTE was to explore the understanding of TB amongst PEH, identify barriers/facilitators to attending screening for PEH alongside suggestions for improving TB-screening events targeting PEH, who have high and complex health needs. This RTE composed of free-text structured one-to-one interviews performed immediately after screening at a single tuberculosis (TB) screening event. Handwritten forms were transcribed for thematic analysis, with codes ascribed to answers that were developed into core themes. All RTE participants (n=15) learned about the screening event on the day it was held. Key concerns amongst screening attendees included: stigma around drug use, not understanding the purpose of TB screening, lack of trusted individuals/services present, too many partner organizations involved, and language barriers. Facilitators to screening included a positive welcome to the event, a satisfactory explanation of screening tests, and sharing of results. A need for improved event promotion alongside communication of the purpose of TB screening amongst PEH was also identified. A lack of trust identified by some participants suggests the range of services present should be reconsidered for future screening events.

Cluster of Nontoxigenic Corynebacterium diphtheriae Infective Endocarditis and Rising Background C. diphtheriae Cases-Seattle, Washington, 2020-2023.

BACKGROUND: Nontoxigenic Corynebacterium diphtheriae, often associated with wounds, can rarely cause infective endocarditis (IE). Five patients with C. diphtheriae IE were identified within 12 months at a Seattle-based hospital system. We reviewed prior C. diphtheriae-positive cultures to determine if detections had increased over time and evaluated epidemiologic trends. METHODS: We conducted a formal electronic health record search to identify all patients aged ≥18 years with C. diphtheriae detected in a clinical specimen (ie, wound, blood, sputum) between 1 September 2020 and 1 April 2023. We collected patient demographics, housing status, comorbidities, substance-use history, and level of medical care required at detection. We extracted laboratory data on susceptibilities of C. diphtheriae isolates and on other pathogens detected at the time of C. diphtheriae identification. RESULTS: Between 1 September 2020 and 1 April 2023, 44 patients (median age, 44 years) had a C. diphtheriae-positive clinical culture, with most detections occurring after March 2022. Patients were predominantly male (75%), White (66%), unstably housed (77%), and had a lifetime history of injecting drugs (75%). Most C. diphtheriae-positive cultures were polymicrobial, including wound cultures from 36 (82%) patients and blood cultures from 6 (14%) patients, not mutually exclusive. Thirty-four patients (77%), including all 5 patients with C. diphtheriae IE, required hospital admission for C. diphtheriae or a related condition. Of the 5 patients with IE, 3 died of IE and 1 from COVID-19. CONCLUSIONS: Findings suggest a high-morbidity outbreak disproportionately affecting patients who use substances and are unstably housed.

Multidrug-Resistant Shigella sonnei Bacteremia among Persons Experiencing Homelessness, Vancouver, British Columbia, Canada.

Increased invasive bloodstream infections caused by multidrug resistant Shigella sonnei were noted in Vancouver, British Columbia, Canada, during 2021-2023. Whole-genome sequencing revealed clonal transmission of genotype 3.6.1.1.2 (CipR.MSM5) among persons experiencing homelessness. Improvements in identifying Shigella species, expanding treatment options for multidrug resistant infections, and developing public health partnerships are needed.

Exploratory assessment: Nurse-led community health worker delivered HCV intervention for people experiencing homelessness.

BACKGROUND: Getting and maintaining Hepatitis C Virus (HCV) cure is challenging among people experiencing homelessness (PEH) as a result of critical social determinants of health such as unstable housing, mental health disorders, and drug and alcohol use. OBJECTIVES: The purpose of this exploratory pilot study was to compare a registered nurse/community health worker (RN/CHW)-led HCV intervention tailored for PEH, "I am HCV Free," with a clinic-based standard of care (cbSOC) for treating HCV. Efficacy was measured by sustained virological response at 12 weeks after stopping antivirals (SVR12), and improvement in mental health, drug and alcohol use, and access to healthcare. METHODS: An exploratory randomized controlled trial design was used to assign PEH recruited from partner sites in the Skid Row Area of Los Angeles, California, to the RN/CHW or cbSOC programs. All received direct-acting antivirals. The RN/CHW group received directly observed therapy in community-based settings, incentives for taking HCV medications, and wrap-around services, including connection to additional healthcare services, housing support, and referral to other community services. For all PEH, drug and alcohol use and mental health symptoms were measured at month 2 or 3 and 5 or 6 follow-up, depending on HCV medication type, while SVR12 was measured at month 5 or 6 follow-up. RESULTS: Among PEH in the RN/CHW group, 75% (3 of 4) completed SVR12 and all three attained undetectable viral load. This was compared with 66.7% (n = 4 of 6) of the cbSOC group who completed SVR12; all four attained undetectable viral load. The RN/CHW group, as compared to the cbSOC, also showed greater improvements in mental health, and significant improvement in drug use, and access to healthcare services. DISCUSSION: While this study shows significant improvements in drug use and health service access among the RN/-CHW group, the sample size of the study limits the validity and generalizability of the results. Further studies using larger sample sizes are necessitated.

Building Emergency Response Capacity: Multi-Career-Stage Social Workers' Engagement with Homeless Sector during the First Two Waves of COVID-19 in Halifax, Nova Scotia, Canada.

The dramatic increase of global extreme events (e.g., natural, technological, and willful hazards) propels social workers to be equipped with emergency response capacity, supporting affected individuals, families, and communities to prepare, respond, and recover from disasters. Although social workers have historically been engaged in emergency response, social work curriculum and professional training remain slow to adapt, jeopardizing their capacity to support the vulnerable and marginalized populations, who have always been disproportionately affected by extreme events. In response to this deficit, this article utilizes a critical reflection approach to examine three social workers' (a senior faculty, a junior faculty, and a social work student) interventions and challenges in their emergency response to persons experiencing homelessness (PEHs) during the first two waves of COVID-19 in Halifax, Nova Scotia, Canada (March 2020 to March 2021). The cross-career-stage reflections and analyses exhibit these three social workers' COVID-19-specific emergency response efforts: a top-down advocacy effort for social development and policy, a bottom-up cognitive effort to comprehend the community's dynamics, and a disaster-driven self-care effort. These three types of effort demonstrate a greater need for social work education and professional training, to develop more disaster-specific components to contribute to building the emergency response capacity of the next generation of social workers through in-classroom pedagogical enhancement and on-site field education training, better supporting PEHs and other vulnerable and marginalized groups living in the diverse context of extreme events in Canada and internationally.

Missed appointments during COVID-19: The impact of telehealth for persons experiencing homelessness with substance use disorders.

We examined the impact of telehealth on appointment retention among individuals with substance use disorder (SUD) by housing status. We evaluated appointment status using multivariate logistic regression with primary predictor variables of visit modality, patient's housing status and interaction between these two variables. Between March 1 and September 30, 2020, there were 18,206 encounters among 1,626 clients with SUD. For telehealth encounters, the probability of an appointment no-show was significantly higher for persons experiencing homelessness compared to stably housed (37% versus 25%, p < 0.001). Housing status influences the effectiveness of telehealth as a modality of healthcare delivery for individuals with SUD.

Upsurge of Conjugate Vaccine Serotype 4 Invasive Pneumococcal Disease Clusters Among Adults Experiencing Homelessness in California, Colorado, and New Mexico.

After 7-valent pneumococcal conjugate vaccine introduction in the United States in 2000, invasive pneumococcal disease (IPD) due to serotype 4 greatly decreased in children and adults. Starting in 2013, serotype 4 IPD incidence increased among adults within 3 of 10 Active Bacterial Core surveillance sites. Of 325 serotype 4 cases among adults in 2010-2018, 36% were persons experiencing homelessness (PEH); incidence of serotype 4 IPD among PEH was 100-300 times higher than in the general population within these 3 areas. Genome sequencing for isolates recovered 2015-2018 (n = 246), revealed that increases in serotype 4 IPD were driven by lineages ST10172, ST244, and ST695. Within each lineage, clusters of near-identical isolates indicated close temporal relatedness. Increases in serotype 4 IPD were limited to Colorado, California, and New Mexico, with highest increases among PEH, who were at increased risk for exposure to and infections caused by these strains.

Use of a Standardized Dalbavancin Approach to Facilitate Earlier Hospital Discharge for Vulnerable Patients Receiving Prolonged Inpatient Antibiotic Therapy.

Twenty-seven patients receiving prolonged inpatient antibiotic therapy for a serious bacterial infection received a single dose of dalbavancin 7-10 days before the planned end date to facilitate earlier hospital discharge. Eighty-one percent met criteria for clinical success, 7% experienced a potential adverse event, and 182 hospital days were averted.

Public Health Response to Tuberculosis Outbreak among Persons Experiencing Homelessness, Minneapolis, Minnesota, USA, 2017-2018.

Tuberculosis (TB) is a greater risk for populations experiencing homelessness. When a TB exposure occurs in a homeless shelter, evaluation of contacts is both urgent and challenging. In 2017, local public health workers initiated a response to a TB outbreak in homeless shelters in Minneapolis, Minnesota, USA. In this contact investigation, we incorporated multiple techniques to identify, evaluate, and manage patients, including the concentric-circle method to characterize amount of contact, identifying the most frequent sites of sporadic medical care, using electronic medical records, and engaging with medical providers treating this population. Of 298 contacts evaluated, 41 (14%) had latent TB infection and 2 had active TB disease. Our analysis indicated a significant relationship between duration of exposure and positive TB test result (p = 0.001). We encourage local public health departments to expand beyond traditional contact tracing techniques by leveraging partnerships and existing systems to reach contacts exposed in shelters.

Identifying occupation-based needs and services for individuals experiencing homelessness using interviews and photovoice.

BACKGROUND: Homelessness can impact society and individuals in many ways. OBJECTIVE: The purpose of this project was to examine the current occupation-based needs and services among persons experiencing homelessness (PEH) in a major city. METHODS: Researchers conducted semi-structured interviews with eight PEH residing in a homeless shelter. Three questions were asked of each participant: What daily personal activities have been most impacted since undergoing homelessness? Which services have been most helpful to you in overcoming homelessness? What other services might you find helpful to individuals experiencing housing insecurity? Researchers also gathered qualitative data utilizing a Photovoice component in which twelve PEH had the opportunity to photograph one object and provide a quote associated with the meaningful object. RESULTS: Under-addressed areas of occupation, services received, and services requested were identified. Findings suggest that areas of occupation most impacted by homelessness include instrumental activities of daily living (IADLs), activities of daily living (ADLs), leisure, social participation, and rest and sleep. Services received included case management and often met basic self-care needs of PEH. Services requested included group therapy, restructuring of the shelter to support individualization, and staff training. CONCLUSIONS: Occupational therapy practitioners have the skill set to assess needed services among PEH. Meaningful objects captured by the clients via Photovoice may relate to past, present and future satisfaction despite being homeless.

Homeless shelter context and tuberculosis illness experiences during a large outbreak in Atlanta, Georgia.

Setting: Persons experiencing homelessness (PEH) represent a population at high risk for tuberculosis (TB). While quantitative studies have characterized some important features of this key group, less has been captured directly from PEH about how they experience TB illness itself and the prevention and control measures implemented in response to an outbreak. This qualitative study aimed to explore PEH's TB disease experiences in the context of a large TB outbreak involving homeless shelters in Atlanta, Georgia, USA. Design: This was a qualitative cross-sectional study involving in-depth interviews with 10 PEH with active TB disease. Key themes were identified through coded data analysis. Results: The central theme to emerge was that stressful social environments of homeless shelters shape illness experiences and health care seeking behaviors, and limit the influence of shelter-based prevention and control measures implemented in response to a TB outbreak. Despite availability, shelter-based latent tuberculous infection (LTBI) testing and education services were minimally engaged. Furthermore, hardships inherent to homelessness were interrelated with disease normalization and symptom minimization. Conclusions: Homeless shelter-related stress may have important implications for the prevention and control of TB outbreaks in this setting. This stress may hinder case finding; a model of supplemental TB education and testing for LTBI at proximal community venues is necessary.

Contexte: Les personnes sans domicile fixe (SDF) représentent une population à haut risque de tuberculose (TB). Si les études quantitatives ont caractérisé certains traits importants de ce groupe clé, moins d'informations ont été obtenues directement des SDF sur la façon dont ces personnes expérimentent la TB maladie elle-même et les mesures de prévention et de lutte mises en œuvre en réponse à l'épidémie. Cette étude qualitative visait à explorer l'expérience des SDF en matière de TB maladie dans le contexte d'une vaste flambée épidémique impliquant des centres d'hébergement de SDF à Atlanta, Georgie.Schéma : Une étude qualitative transversale impliquant des entretiens approfondis avec dix SDF atteints de TB active. Les thèmes clés ont été identifiés grâce à une analyse des données codées.Résultats : Le thème central qui a émergé est que l'environnement social stressant des centres d'hébergement façonne les expériences de la maladie et les comportements de recherche de soins et limite l'influence des mesures de prévention et de lutte basées dans ces centres et mises en œuvre en réponse à une flambée de TB. En dépit de leur disponibilité dans les centres d'hébergement, le dépistage de l'infection tuberculeuse latent (ITL) et les services d'éducation ont été très peu engagés. Plus encore, les difficultés inhérentes à l'absence de domicile fixe ont été indissociables de la normalisation de la maladie et de la minimisation des symptômes.Conclusions: Le stress lié à l'hébergement dans un refuge pour SDF peut avoir des implications majeures dans la prévention et la lutte contre les flambées de TB dans ce contexte. Ce stress peut entraver la découverte des cas et soutenir un modèle d'éducation supplémentaire à la TB et une recherche de l'ITL dans les lieux communautaires proches.

Marco de referencia: Las personas que carecen de vivienda constituyen una población con alto riesgo de contraer la tuberculosis (TB). Los estudios cuantitativos han caracterizado algunos aspectos importantes de este grupo poblacional, pero poco se ha captado directamente de su forma de vivenciar la enfermedad tuberculosa y las medidas de prevención y de control que se instauran en respuesta a un brote epidémico. El presente estudio cualitativo tuvo por objeto analizar las vivencias de la enfermedad tuberculosa por parte de las personas que carecen de vivienda, en el contexto de un amplio brote epidémico de TB que ocurrió en los albergues para personas sin techo en Atlanta, Georgia.Método: Fue este un estudio cualitativo transversal, que comportó entrevistas exhaustivas a 10 personas sin vivienda, con enfermedad tuberculosa activa. Se reconocieron los principales temas mediante un análisis temático con datos codificados.Resultados: El principal tema que surgió en el análisis fue que los entornos sociales estresantes de los albergues determinan las experiencias de la enfermedad y el comportamiento de búsqueda de atención y limitan la repercusión de las medidas de prevención y control que se aplican en los albergues en respuesta a un brote epidémico de TB. Pese a su disponibilidad, las pruebas diagnósticas de la infección tuberculosa latente y los servicios educativos prestados en los albergues se utilizaban poco. Además, las adversidades inherentes a la falta de vivienda se correlacionaron con una normalización de la enfermedad y la minimización de los síntomas.Conclusión: El estrés generado en los albergues destinados a las personas sin vivienda puede tener repercusiones importantes en la prevención y el control de los brotes de TB en estos entornos. Este estrés puede obstaculizar la búsqueda de casos y su demostración respalda la aplicación de un modelo de educación complementaria en materia de TB y de pruebas diagnósticas de la infección latente en los centros comunitarios próximos.