Housing Boston's Chronically Homeless Unsheltered Population: 14 Years Later.

OBJECTIVE: The long-term outcomes of permanent supportive housing for chronically unsheltered individuals, or rough sleepers, are largely unknown. We therefore assessed housing outcomes for a group of unsheltered individuals who were housed directly from the streets after living outside for decades. METHODS: Using an open-cohort design, 73 chronically unsheltered individuals were enrolled and housed in permanent supportive housing directly from the streets of Boston from 2005 to 2019. Through descriptive, regression, and survival analysis, we assessed housing retention, housing stability, and predictors of survival. RESULTS: Housing retention at ≥1 year was 82% yet fell to 36% at ≥5 years; corresponding Kaplan-Meier estimates for retention were 72% at ≥1, 42.5% at ≥5, and 37.5% at ≥10 years. Nearly half of the cohort (45%) died while housed. The co-occurrence of medical, psychiatric, and substance use disorder, or "trimorbidity," was common. Moves to a new apartment were also common; 38% were moved 45 times to avoid an eviction. Each subsequent housing relocation increased the risk of a tenant returning to homelessness. Three or more housing relocations substantially increased the risk of death. CONCLUSIONS: Long-term outcomes for this permanent supportive housing program for chronically unsheltered individuals showed low housing retention and poor survival. Housing stability for this vulnerable population likely requires more robust and flexible and long-term medical and social supports.

Substance consumption and intoxication patterns in a medically supervised overdose prevention program for people experiencing homelessness.

Background: Opioid overdose is a leading cause of death among homeless individuals. Combining psychoactive substances with opioids increases overdose risk. This study aimed to describe intoxication patterns at a drop-in space offering medical monitoring and harm reduction services to individuals who arrive intoxicated and at risk of overdose. Methods: We examined data from visits to the Supportive Place for Observation and Treatment at Boston Health Care for the Homeless Program between January 1, 2017 and December 31, 2017. We used k-means cluster analysis to characterize intoxication patterns based on clinically assessed sedation levels and vital sign parameters. Multinomial logistic regression analysis assessed demographic and substance consumption predictors of cluster membership. Linear and logistic regression models examined associations between cluster membership and care outcomes. Results: Across 305 care episodes involving 156 unique patients, cluster analysis revealed 3 distinct intoxication patterns. Cluster A (26.6%) had mild sedation and normal vital signs. Cluster B (44.5%) featured greater sedation with bradycardia and/or hypotension. Cluster C (28.9%) was comparable to cluster B but with the addition of hypoxia. Self-reported consumption of non-opioid sedatives prior to arrival was common (63.3% of episodes) and predicted membership in cluster B (aOR 2.75, 95% CI 1.40, 5.40) and cluster C (aOR 3.38, 95% CI 1.48, 7.70). In comparison to cluster A episodes, cluster C episodes were longer (mean 4.8 vs. 2.3 hours, p < 0.001) and more likely to require supplemental oxygen (27.3% vs. 2.5%, p < 0.001). Few episodes required hospital transfer (4.7%) or naloxone (1.0%). No deaths occurred. Conclusions: In a medically supervised overdose monitoring program, reported use of non-opioid sedatives strongly predicted more complex clinical courses and should be factored into overdose prevention efforts. Low-threshold medical monitoring in an ambulatory setting was sufficient for most episodes, suggesting a role for such programs in reducing harm and averting costly emergency services.

Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston.

OBJECTIVES: We quantified tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities among homeless adults. METHODS: We ascertained causes of death among 28 033 adults seen at the Boston Health Care for the Homeless Program in 2003 to 2008. We calculated population-attributable fractions to estimate the proportion of deaths attributable to tobacco, alcohol, or drug use. We compared attributable mortality rates with those for Massachusetts adults using rate ratios and differences. RESULTS: Of 1302 deaths, 236 were tobacco-attributable, 215 were alcohol-attributable, and 286 were drug-attributable. Fifty-two percent of deaths were attributable to any of these substances. In comparison with Massachusetts adults, tobacco-attributable mortality rates were 3 to 5 times higher, alcohol-attributable mortality rates were 6 to 10 times higher, and drug-attributable mortality rates were 8 to 17 times higher. Disparities in substance-attributable deaths accounted for 57% of the all-cause mortality gap between the homeless cohort and Massachusetts adults. CONCLUSIONS: In this clinic-based cohort of homeless adults, over half of all deaths were substance-attributable, but this did not fully explain the mortality disparity with the general population. Interventions should address both addiction and non-addiction sources of excess mortality.

Comparing homeless persons' care experiences in tailored versus nontailored primary care programs.

OBJECTIVES: We compared homeless patients' experiences of care in health care organizations that differed in their degree of primary care design service tailoring. METHODS: We surveyed homeless-experienced patients (either recently or currently homeless) at 3 Veterans Affairs (VA) mainstream primary care settings in Pennsylvania and Alabama, a homeless-tailored VA clinic in California, and a highly tailored non-VA Health Care for the Homeless Program in Massachusetts (January 2011-March 2012). We developed a survey, the "Primary Care Quality-Homeless Survey," to reflect the concerns and aspirations of homeless patients. RESULTS: Mean scores at the tailored non-VA site were superior to those from the 3 mainstream VA sites (P < .001). Adjusting for patient characteristics, these differences remained significant for subscales assessing the patient-clinician relationship (P < .001) and perceptions of cooperation among providers (P = .004). There were 1.5- to 3-fold increased odds of an unfavorable experience in the domains of the patient-clinician relationship, cooperation, and access or coordination for the mainstream VA sites compared with the tailored non-VA site; the tailored VA site attained intermediate results. CONCLUSIONS: Tailored primary care service design was associated with a superior service experience for patients who experienced homelessness.

Establishing Academic Homes for Homelessness: A Call to Action.

Although homelessness ranks as one of society's most pressing and visible health equity challenges, the academic community has not actively addressed its health impacts, root causes, and potential solutions. Few schools and programs of public health even offer a basic course for students. In the COVID-19 pandemic era, academia must demonstrate urgency to address homelessness and educate learners, motivate fledgling researchers, inform policy makers, offer community-engaged and evidence-based studies, and join in the growing national debate about best approaches. At a minimum, every public health student should understand the interdisciplinary challenges of homelessness, its implications for health equity, and opportunities to address the crisis. We call for academia, particularly schools and programs of public health, to engage more fully in national partnerships to care for members of society who are most marginalized, in terms of health and behavioral health outcomes, quality of life, and connectedness.

The hunger-obesity paradox: obesity in the homeless.

Despite stereotypes of the homeless population as underweight, the literature lacks a rigorous analysis of weight status in homeless adults. The purpose of this study is to present the body mass index (BMI) distribution in a large adult homeless population and to compare this distribution to the non-homeless population in the United States. Demographic, BMI, and socioeconomic variables from patients seen in 2007-2008 were collected from the Boston Health Care for the Homeless Program (BHCHP). This population was compared to non-homeless adults from the National Health and Nutrition Examination Survey (NHANES). Among 5,632 homeless adults, the mean BMI was 28.4 kg/m(2) and the prevalence of obesity was 32.3 %. Only 1.6 % of homeless adults were underweight. Compared to mean BMI in NHANES (28.6 kg/m(2)), the difference was not significant in unadjusted analysis (p = 0.14). Adjusted analyses predicting BMI or likelihood of obesity also showed that the homeless had a weight distribution not statistically different from the general population. Although underweight has been traditionally associated with homelessness, this study suggests that obesity may be the new malnutrition of the homeless in the United States.

Food insufficiency and health services utilization in a national sample of homeless adults.

BACKGROUND: Homeless people have high rates of hospitalization and emergency department (ED) use. Obtaining adequate food is a common concern among homeless people and may influence health care utilization. OBJECTIVE: We tested the hypothesis that food insufficiency is related to higher rates of hospitalization and ED use in a national sample of homeless adults. DESIGN: We analyzed data from the 2003 Health Care for the Homeless (HCH) User Survey. PARTICIPANTS: Participants were 966 adults surveyed at 79 HCH clinic sites throughout the US. The study sample was representative of over 436,000 HCH clinic users nationally. MEASURES: We determined the prevalence and characteristics of food insufficiency among respondents. Using multivariable logistic regression, we examined the association between food insufficiency and four past-year acute health services utilization outcomes: (1) hospitalization for any reason, (2) psychiatric hospitalization, (3) any ED use, and (4) high ED use (≥ 4 visits). RESULTS: Overall, 25% of respondents reported food insufficiency. Among them, 68% went a whole day without eating in the past month. Chronically homeless (p = 0.01) and traumatically victimized (p = 0.001) respondents were more likely to be food insufficient. In multivariable analyses, food insufficiency was associated with significantly greater odds of hospitalization for any reason (AOR 1.59, 95% CI 1.07, 2.36), psychiatric hospitalization (AOR 3.12, 95% CI 1.73, 5.62), and high ED utilization (AOR 2.83, 95% CI 1.32, 6.08). CONCLUSIONS: One-fourth of homeless adults in this national survey were food insufficient, and this was associated with increased odds of acute health services utilization. Addressing the adverse health services utilization patterns of homeless adults will require attention to the social circumstances that may contribute to this issue.

Training Clinicians to Care for Patients Where They Are.

Homelessness remains a pervasive, long-standing problem in the United States and is poised to increase as a result of the COVID-19 pandemic. Individuals experiencing homelessness bear a higher burden of complex medical and mental health illnesses and often struggle to obtain quality and timely health care. The United States desperately needs to train a workforce to confront this large and growing crisis, but few health professional schools currently devote curricula to the clinical needs of people experiencing homelessness. This article discusses educational and curricular strategies for health professional students. Understanding the health needs of-and the social influences on the lives of-people experiencing homelessness is crucial for addressing this health equity challenge.

The unmet health care needs of homeless adults: a national study.

OBJECTIVES: We assessed the prevalence and predictors of past-year unmet needs for 5 types of health care services in a national sample of homeless adults. METHODS: We analyzed data from 966 adult respondents to the 2003 Health Care for the Homeless User Survey, a sample representing more than 436,000 individuals nationally. Using multivariable logistic regression, we determined the independent predictors of each type of unmet need. RESULTS: Seventy-three percent of the respondents reported at least one unmet health need, including an inability to obtain needed medical or surgical care (32%), prescription medications (36%), mental health care (21%), eyeglasses (41%), and dental care (41%). In multivariable analyses, significant predictors of unmet needs included food insufficiency, out-of-home placement as a minor, vision impairment, and lack of health insurance. Individuals who had been employed in the past year were more likely than those who had not to be uninsured and to have unmet needs for medical care and prescription medications. CONCLUSIONS: This national sample of homeless adults reported substantial unmet needs for multiple types of health care. Expansion of health insurance may improve health care access for homeless adults, but addressing the unique challenges inherent to homelessness will also be required.

The Boston Health Care for the Homeless Program: a public health framework.

During the past 25 years, the Boston Health Care for the Homeless Program has evolved into a service model embodying the core functions and essential services of public health. Each year the program provides integrated medical, behavioral, and oral health care, as well as preventive services, to more than 11 000 homeless people. Services are delivered in clinics located in 2 teaching hospitals, 80 shelters and soup kitchens, and an innovative 104-bed medical respite unit. We explain the program's principles of care, describe the public health framework that undergirds the program, and offer lessons for the elimination of health disparities suffered by this vulnerable population.

The Use of High-Risk Criteria to Assess Mortality Risk among Unsheltered Homeless Persons.

We assessed the ability of high-risk criteria developed by Boston Health Care for the Homeless Program to identify increased mortality during a 10-year cohort study (January 2000-December 2009) of 445 unsheltered adults. To qualify as high-risk for mortality, an individual slept unsheltered for six consecutive months or longer plus had one or more of the following characteristics: tri-morbidity, defined as co-occurring medical, psychiatric, and addiction diagnoses; one or more inpatient or respite admissions; three or more emergency department visits; 60 years old or older; HIV/AIDS; cirrhosis; renal failure; frostbite, hypothermia, or immersion foot. A total of 119 (26.7%) individuals met the high-risk criteria. The remaining 326 individuals in the cohort were considered lowerrisk. During the study, 134 deaths occurred; 52 (38.8%) were among high-risk individuals. Compared with sheltered individuals, the age-standardized mortality ratio for the high-risk group was 4.0 (95% confidence interval 3.0, 5.2) times higher and for the lower-risk group was 2.2 (1.8, 2.8) times higher. The hazard ratio, a measure of survival, for the high-risk group was 1.7 (1.2, 2.4) times that of the lower-risk group. High-risk criteria predicted an increased likelihood of mortality among unsheltered individuals. The lower-risk group also had high mortality rates compared with sheltered individuals.

Addressing COVID-19 Among People Experiencing Homelessness: Description, Adaptation, and Early Findings of a Multiagency Response in Boston.

People experiencing homelessness are at high risk for coronavirus disease 2019 (COVID-19). In March 2020, Boston Health Care for the Homeless Program, in partnership with city and state public health agencies, municipal leaders, and homeless service providers, developed and implemented a citywide COVID-19 care model for this vulnerable population. Components included symptom screening at shelter front doors, expedited testing at pop-up sites, isolation and management venues for symptomatic people under investigation and for people with confirmed disease, quarantine venues for asymptomatic exposed people, and contact investigation and tracing. Real-time disease surveillance efforts in a large shelter outbreak of COVID-19 during the third week of operations illustrated the need for several adaptations to the care model to better respond to the local epidemiology of illness among people experiencing homelessness. Symptom screening was de-emphasized given the high number of asymptomatic or minimally symptomatic infections discovered during mass testing; contact tracing and quarantining were phased out under the assumption of universal exposure among the sheltered population; and isolation and management venues were rapidly expanded to accommodate a surge in people with newly diagnosed COVID-19. During the first 6 weeks of operation, 429 of 1297 (33.1%) tested people were positive for COVID-19; of these, 395 people were experiencing homelessness at the time of testing, representing about 10% of the homeless adult population in Boston. Universal testing, as resources permit, is a focal point of ongoing efforts to mitigate the effect of COVID-19 on this vulnerable group of people.

Health Care Spending And Use Among People Experiencing Unstable Housing In The Era Of Accountable Care Organizations.

Provider organizations are increasingly held accountable for health care spending in vulnerable populations. Longitudinal data on health care spending and use among people experiencing episodes of homelessness could inform the design of alternative payment models. We used Medicaid claims data to analyze spending and use among 402 people who were continuously enrolled in the Boston Health Care for the Homeless Program (BHCHP) from 2013 through 2015, compared to spending and use among 18,638 people who were continuously enrolled in Massachusetts Medicaid with no evidence of experiencing homelessness. The BHCHP population averaged $18,764 per person per year in spending-2.5 times more than spending among the comparison Medicaid population ($7,561). In unadjusted analyses this difference was explained by greater spending in the BHCHP population on outpatient care, including emergency department care, as well as on inpatient care and prescription drugs. After adjustment for covariates and multiple hypothesis testing, the difference was largely driven by outpatient spending. Differences were sensitive to adjustments for risk score, which suggests that housing instability and health risk are meaningfully correlated. This longitudinal analysis improves understanding of health care use and resource needs among people who are homeless or have unstable housing, and it could inform the design of alternative payment models for vulnerable populations.

Electronic medical record implementation for a healthcare system caring for homeless people.

OBJECTIVE: Electronic medical record (EMR) implementation at centers caring for homeless people is constrained by limited resources and the increased disease burden of the patient population. Few informatics articles address this issue. This report describes Boston Health Care for the Homeless Program's migration to new EMR software without loss of unique care elements and processes. MATERIALS AND METHODS: Workflows for clinical and operational functions were analyzed and modeled, focusing particularly on resource constraints and comorbidities. Workflows were optimized, standardized, and validated before go-live by user groups who provided design input. Software tools were configured to support optimized workflows. Customization was minimal. Training used the optimized configuration in a live training environment allowing users to learn and use the software before go-live. RESULTS: Implementation was rapidly accomplished over 6 months. Productivity was reduced at most minimally over the initial 3 months. During the first full year, quality indicator levels were maintained. Keys to success were completing before go-live workflow analysis, workflow mapping, building of documentation templates, creation of screen shot guides, role-based phased training, and standardization of processes. Change management strategies were valuable. The early availability of a configured training environment was essential. With this methodology, the software tools were chosen and workflows optimized that addressed the challenges unique to caring for homeless people. CONCLUSIONS: Successful implementation of an EMR to care for homeless people was achieved through detailed workflow analysis, optimizing and standardizing workflows, configuring software, and initiating training all well before go-live. This approach was particularly suitable for a homeless population.

Mortality Among Unsheltered Homeless Adults in Boston, Massachusetts, 2000-2009.

Importance: Previous studies have shown high mortality rates among homeless people in general, but little is known about the patterns of mortality among "rough sleepers," the subgroup of unsheltered urban homeless people who avoid emergency shelters and primarily sleep outside. Objectives: To assess the mortality rates and causes of death for a cohort of unsheltered homeless adults from Boston, Massachusetts. Design, Setting, and Participants: A 10-year prospective cohort study (2000-2009) of 445 unsheltered homeless adults in Boston, Massachusetts, who were seen during daytime street and overnight van clinical visits performed by the Boston Health Care for the Homeless Program's Street Team during 2000. Data used to describe the unsheltered homeless cohort and to document causes of death were gathered from clinical encounters, medical records, the National Death Index, and the Massachusetts Department of Public Health death occurrence files. The study data set was linked to the death occurrence files by using a probabilistic record linkage program to confirm the deaths. Data analysis was performed from May 1, 2015, to September 6, 2016. Exposure: Being unsheltered in an urban setting. Main Outcomes and Measures: Age-standardized all-cause and cause-specific mortality rates and age-stratified incident rate ratios that were calculated for the unsheltered adult cohort using 2 comparison groups: the nonhomeless Massachusetts adult population and an adult homeless cohort from Boston who slept primarily in shelters. Results: Of 445 unsheltered adults in the study cohort, the mean (SD) age at enrollment was 44 (11.4) years, 299 participants (67.2%) were non-Hispanic white, and 72.4% were men. Among the 134 individuals who died, the mean (SD) age at death was 53 (11.4) years. The all-cause mortality rate for the unsheltered cohort was almost 10 times higher than that of the Massachusetts population (standardized mortality rate, 9.8; 95% CI, 8.2-11.5) and nearly 3 times higher than that of the adult homeless cohort (standardized mortality rate, 2.7; 95% CI, 2.3-3.2). Non-Hispanic black individuals had more than half the rate of death compared with non-Hispanic white individuals, with a rate ratio of 0.4 (95% CI, 0.2-0.7; P < .001). The most common causes of death were noncommunicable diseases (eg, cancer and heart disease), alcohol use disorder, and chronic liver disease. Conclusions and Relevance: Mortality rates for unsheltered homeless adults in this study were higher than those for the Massachusetts adult population and a sheltered adult homeless cohort with equivalent services. This study suggests that this distinct subpopulation of homeless people merits special attention to meet their unique clinical and psychosocial needs.