A Model Pathway to Oral Health Care for Homeless People.

OBJECTIVES: This study aimed at developing a model pathway to use of oral health care by homeless people based on their own perceptions and experiences with oral health care and related services in Vancouver. METHODS: We applied Gelberg-Andresen's behavioural model for vulnerable populations to predict health care use and interviewed 25 homeless adults (18 men and 7 women; age range 25-64 years) to develop a model pathway of care. Data collection and thematic analysis were carried out concurrently and iteratively to construct the pathway, which aimed at mutual decision-making and organization of the care process. RESULTS: Thematic analysis identified 4 main themes: government-sponsored oral health programs, homeless support, oral health outreach initiatives and professional education. CONCLUSIONS: The model pathway helps to explain the factors that enable homeless people to access oral health care. It may also help dental teams foster positive care-seeking behaviour relevant to this vulnerable population so that oral disorders can be managed more sympathetically and effectively.

Housing First improves subjective quality of life among homeless adults with mental illness: 12-month findings from a randomized controlled trial in Vancouver, British Columbia.

PURPOSE: This study used an experimental design to examine longitudinal changes in subjective quality of life (QoL) among homeless adults with mental illness after assignment to different types of supported housing or to treatment as usual (TAU, no housing or supports through the study). We hypothesized that subjective QoL would improve over time among participants assigned to supported housing as compared to TAU, regardless of the type of supported housing received or participants' level of need. METHODS: Participants (n = 497) were stratified by level of need ("high" or "moderate") and randomly assigned to Housing First (HF) in scattered-site apartments, HF in a congregate setting (high needs only), or TAU. Linear mixed-effects regression was used to model the association between study arm and self-reported QoL at baseline and at 6 and 12 months post-baseline by need level. RESULTS: Based on the adjusted overall score on the QoL measure, participants randomized to HF reported significantly greater overall QoL as compared to TAU, regardless of need level or type of supported housing at both 6 and 12 months post-baseline. Scores on the safety and living situation subscales were significantly greater for both high and moderate need participants assigned to supported housing regardless of type at both 6 and 12 months post-baseline as compared to TAU. CONCLUSIONS: Despite multiple health and social challenges faced by homeless individuals with mental illness, HF in both scattered-site and congregate models results in significantly greater perceived QoL as compared to individuals who do not receive HF even after a relatively short period of time.

Emergency department use and hospitalizations among homeless adults with substance dependence and mental disorders.

BACKGROUND: Homelessness, substance use, and mental disorders each have been associated with higher rates of emergency department (ED) use and hospitalization. We sought to understand the correlation between ED use, hospital admission, and substance dependence among homeless individuals with concurrent mental illness who participated in a 'Housing First' (HF) intervention trial. METHODS: The Vancouver At Home study consisted of two randomized controlled trials addressing homeless individuals with mental disorders who have "high" or "moderate" levels of need. Substance dependence was determined at baseline prior to randomization, using the Mini International Neuropsychiatric Interview diagnostic tool, version 6.0. To assess health service use, we reviewed the number of ED visits and the number of hospital admissions based on administrative data for six urban hospitals. Negative binomial regression modeling was used to test the independent association between substance dependence and health service use (ED use and hospitalization), adjusting for HF intervention, age, gender, ethnicity, education, duration of lifetime homelessness, mental disorders, chronic health conditions, and other variables that were selected a priori to be potentially associated with use of ED services and hospital admission. RESULTS: Of the 497 homeless adults with mental disorders who were recruited, we included 381 participants in our analyses who had at least 1 year of follow-up and had a personal health number that could be linked to administrative health data. Of this group, 59% (n = 223) met criteria for substance dependence. We found no independent association between substance dependence and ED visits or hospital admissions [rate ratio (RR) = 0.85; 95% CI 0.62-1.17 and RR = 1.21; 95% CI 0.83-1.77, respectively]. The most responsible diagnoses (defined as the diagnosis that accounts for the length of stay) for hospital admissions were schizo-affective disorder, schizophrenia-related disorder, or bipolar affective disorder; collectively reported in 48% (n = 263) of admissions. Fifteen percent (n = 84) of hospital admissions listed substance dependence as the most responsible diagnosis. CONCLUSIONS: Substance dependence was not independently associated with ED use or hospital admission among homeless adults with mental disorders participating in an HF trial. Hospital admissions among this cohort were primarily associated with severe mental disorders. TRIAL REGISTRATION: ISRCTN57595077 and ISRCTN66721740.