Health-Related Quality of Life Among Homeless Smokers: Risk and Protective Factors of Latent Class Membership.

Health-related quality of life (HRQoL) is a multidimensional assessment of well-being and health status. Most work in this area assumes that HRQoL is a homogenous construct; however, it is possible HRQoL subgroups may exist. The purpose of the study was to characterize common classes of HRQoL among adult, homeless smokers, a particularly vulnerable group of the larger population, and to evaluate risk and protective factors of HRQoL class membership. Homeless smokers (N = 456; 65.1% male; Mage = 43.19 years [SD = 11.77]) completed self-report measures of sociodemographics, smoking characteristics, anxiety sensitivity, stress, social support, and the Center for Disease Control (CDC) four-item HRQoL measure. A latent class analysis was conducted for HRQoL. Multinomial regression models were used to simultaneously test correlates of class membership. A three-class solution, consisting of poor HRQoL, moderate HRQoL, and excellent HRQoL, demonstrated superior fit. Correlates of class membership included sex, age, lifetime months of being homeless, smoking characteristics, anxiety sensitivity, stress, and social support. The current findings provide novel evidence for three distinct classes of HRQoL among homeless smokers. Results suggest that older smokers with greater emotional distress, as evidenced by greater anxiety sensitivity, greater stress, and less social support, may be particularly vulnerable to poorer HRQoL.

The prevalence and characteristics of homelessness in the NSW substance treatment population: implications for practice.

This study examines the prevalence and characteristics of homelessness episodes in Australian substance misuse treatment. A dataset containing all closed substance treatment episodes in NSW, Australia from July 2006 to June 2011 was used. Statistical analysis was used to determine any relationships between demographic and treatment variables and homelessness. Of the 213, 129 treatment episodes in the dataset 12.8% have some form of homelessness. Non-government and residential services have the highest prevalence of homelessness. Sex, age, and drug type have weak relationships with homelessness. Leaving against the advice of the treatment provider is more common in episodes where homelessness is a factor. Homelessness is a problem experienced by a significant proportion of the substance treatment population and treatment providers have an opportunity and an obligation to address it in their treatment delivery.

Rethinking research on forming typologies of homelessness.

In homelessness research and policymaking, it seems to be axiomatic that single adults experience 3 temporally based types of homelessness: chronic, episodic, and transitional. We discuss problems with the theorization of this typology and with the research design, data analysis, and time-aggregated conceptualization and measurement of temporality in the empirical work supporting the typology. To address the latter, we suggest a time-patterned approach to temporality and report a 10-group typology that differs significantly from the more familiar 3-group typology. We argue that which approach is used-and how typologies are developed more generally-should be based on theory and the uses to which typologies are put rather than on claims to being more true.

Homeless population: characterization and contextualization by census research.

OBJECTIVES: to analyze characteristics of homeless people and factors associated with living on the streets. METHODS: a census-type sectional survey carried out between 2015 and 2018, in the municipality of Maringá-Paraná. A total of 701 homeless answered a structured questionnaire with sociodemographic data, living conditions, and drug use. We used Pearson's correlation test for the association analysis of the variables at a 95% confidence level. RESULTS: men (90.7%) the average age of 37.7 years had been homeless for an average of 5.39 years. Most had little education (54.2%), and homelessness was due to drug use (47.2%) and family disagreements (38.9%). CONCLUSIONS: drug use and family disagreements were the main reasons for homelessness. Time on the street, gender, and drugs were associated with a negative correlation to be homeless; and age, mean daily income, the number of daily meals, having been in prison, and having an income source were associated with positive correlation.

A classification model of homelessness using integrated administrative data: Implications for targeting interventions to improve the housing status, health and well-being of a highly vulnerable population.

Homelessness is poorly captured in most administrative data sets making it difficult to understand how, when, and where this population can be better served. This study sought to develop and validate a classification model of homelessness. Our sample included 5,050,639 individuals aged 11 years and older who were included in a linked dataset of administrative records from multiple state-maintained databases in Massachusetts for the period from 2011-2015. We used logistic regression to develop a classification model with 94 predictors and subsequently tested its performance. The model had high specificity (95.4%), moderate sensitivity (77.8%) for predicting known cases of homelessness, and excellent classification properties (area under the receiver operating curve 0.94; balanced accuracy 86.4%). To demonstrate the potential opportunity that exists for using such a modeling approach to target interventions to mitigate the risk of an adverse health outcome, we also estimated the association between model predicted homeless status and fatal opioid overdoses, finding that model predicted homeless status was associated with a nearly 23-fold increase in the risk of fatal opioid overdose. This study provides a novel approach for identifying homelessness using integrated administrative data. The strong performance of our model underscores the potential value of linking data from multiple service systems to improve the identification of housing instability and to assist government in developing programs that seek to improve health and other outcomes for homeless individuals.

Homeless people in León (Nicaragua): Conceptualizing and measuring homelessness in a developing country.

Homelessness is a global phenomenon that affects groups in situations of poverty and social exclusion, in both developed and developing nations. However, the scientific literature on homeless people in developing countries is scant. This work shows the difficulties defining homelessness and examines the necessary criteria for who will be deemed a homeless person in a developing country. Furthermore, the results of the Point-In-Time (PIT) count of homeless people-a measure of the number of homeless people on a specific day-done in the city of León, Nicaragua (population: 185,000). Throughout the PIT count, 82 unduplicated people living in homelessness were tallied (76% male, 23% female), of which 47 answered a questionnaire. Most of the homeless people in León are male, mestizo, of Nicaraguan nationality, with a primary level education or less, and in a situation of chronic homelessness. Results showed a mean age of 47 years for these individuals. Most of the homeless people showed a bad physical appearance, had poor personal hygiene, and wore dirty clothing. Around half of the homeless observed seemed to have problems related to mental health, alcohol, and/or drugs. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Taxonomy of medical comorbidity for veterans who are homeless.

Homeless veterans have numerous medical and behavioral health problems. Grouping homeless people based on comorbidity patterns may assist in determining severity of illness and triaging health care more effectively. We sought to determine if a finite number of profiles could be identified related to demographic characteristics, living situation, length of homelessness, and referral areas using interview data from 2,733 veterans who were presently or recently homeless. We considered 12 disorders: eye problems, hypertension, cardiovascular problems, COPD/emphysema, tuberculosis, gastrointestinal problems, hepatic disease, neurologic disorders, orthopedic problems, skin problems, and trauma. Ratings were evaluated using cluster analysis. Comparison statistics were used to compare intercluster differences in demographics, homeless situation, and referral recommendations. A four-cluster solution is proposed: generalized illness, hepatic disease, lung disease, and neurologic disorder. Medical health problems are common and heterogeneous in homeless individuals. Classifications of these problems may be useful in planning treatment and predicting outcome.

Homelessness, health status, and health care use.

OBJECTIVES: Little is known about the health status of those who are newly homeless. We sought to describe the health status and health care use of new clients of homeless shelters and observe changes in these health indicators over the study period. METHODS: We conducted a longitudinal study of 445 individuals from their entry into the homeless shelter system through the subsequent 18 months. RESULTS: Disease was prevalent in the newly homeless. This population accessed health care services at high rates in the year before becoming homeless. Significant improvements in health status were seen over the study period as well as a significant increase in the number who were insured. CONCLUSION: Newly homeless persons struggle under the combined burdens of residential instability and significant levels of physical disease and mental illness, but many experience some improvements in their health status and access to care during their time in the homeless shelter system.

Expert knowledge, cognitive polyphasia and health: a study on social representations of homelessness among professionals working in the voluntary sector in London.

This article develops a social representational approach to understanding expert knowledge and its relation to health. Research with homelessness professionals (HPs) working in the UK voluntary sector shows that expert definitions of homelessness can either undermine or enhance the health of the homeless. Guided by the concepts of social representations and cognitive polyphasia, the analysis reveals a contradictory field of knowledge, which reflects the struggle of professionals to sustain a humanizing approach and resist the pressures of statutory agendas. We conclude pointing to the need of recognizing the impact of professional's knowledge on the health and care policies for the homeless.

Planning services for the homeless in the San Francisco peninsula.

A survey of clients seeking homeless services at agencies in the SF Peninsula, indicates that a disproportionate percentage are minority group members (African American and Hispanic) and veterans, and points to the need for integrated housing, social services, and health care for this vulnerable population.

BRIEF REPORT: the aging of the homeless population: fourteen-year trends in San Francisco.

BACKGROUND: Homelessness is associated with high rates of health and substance use problems. OBJECTIVE: To examine trends in the age, housing, health status, health service utilization, and drug use of the homeless population over a 14-year period. DESIGN: Serial cross-sectional. PARTICIPANTS: We studied 3,534 literally homeless adults recruited at service providers in San Francisco in 4 waves: 1990-1994, 1996-1998, 1999-2000, and 2003. MEASUREMENTS: Age, time homeless, self-reported chronic conditions, hospital and emergency department utilization, and drug and alcohol use. RESULTS: The median age of the homeless increased from 37 to 46 over the study waves, at a rate of 0.66 years per calendar year (P<.01). The median total time homeless increased from 12 to 39.5 months (P<.01). Emergency department visits, hospital admissions, and chronic health conditions increased. CONCLUSIONS: The homeless population is aging by about two thirds of a year every calendar year, consistent with trends in several other cities. It is likely that the homeless are static, aging population cohort. The aging trends suggest that chronic conditions will become increasingly prominent for homeless health services. This will present challenges to traditional approaches to screening, prevention, and treatment of chronic diseases in an aging homeless population.

Identifying homelessness at an urban public hospital: a moving target?

Hospitals do not routinely collect data about homelessness. The objectives of the present study were to (1) describe rate of patient reports of homelessness among inpatients at a public hospital, (2) assess the agreement between patient report of housing status on a study questionnaire with clinical and administrative data about homelessness, and (3) assess changes in housing status during hospitalization. We conducted a cross-sectional survey of inpatients at an urban public hospital to assess housing status; we then examined subjects' medical charts to assess agreement with the questionnaire on housing status. Of inpatients, 25.6% were homeless at discharge. An additional 19.4% were marginally housed. One third of homeless persons had their housing status change during their hospitalization. Administrative data identified 25.6% and physicians' notes identified 22.5% as homeless. Clinical, administrative, and survey data did not agree. Homelessness and changes in housing status are common among inpatients at an urban public hospital. Poor agreement on who is homeless limits the usefulness of data.

Identifying Homelessness among Veterans Using VA Administrative Data: Opportunities to Expand Detection Criteria.

Researchers at the U.S. Department of Veterans Affairs (VA) have used administrative criteria to identify homelessness among U.S. Veterans. Our objective was to explore the use of these codes in VA health care facilities. We examined VA health records (2002-2012) of Veterans recently separated from the military and identified as homeless using VA conventional identification criteria (ICD-9-CM code V60.0, VA specific codes for homeless services), plus closely allied V60 codes indicating housing instability. Logistic regression analyses examined differences between Veterans who received these codes. Health care services and co-morbidities were analyzed in the 90 days post-identification of homelessness. VA conventional criteria identified 21,021 homeless Veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (rate 2.5%). Adding allied V60 codes increased that to 31,260 (rate 3.3%). While certain demographic differences were noted, Veterans identified as homeless using conventional or allied codes were similar with regards to utilization of homeless, mental health, and substance abuse services, as well as co-morbidities. Differences were noted in the pattern of usage of homelessness-related diagnostic codes in VA facilities nation-wide. Creating an official VA case definition for homelessness, which would include additional ICD-9-CM and other administrative codes for VA homeless services, would likely allow improved identification of homeless and at-risk Veterans. This also presents an opportunity for encouraging uniformity in applying these codes in VA facilities nationwide as well as in other large health care organizations.

Dimensions of homelessness.

Investigations of homelessness have been hampered by the lack of operational definitions sensitive enough to achieve subgroup differentiation and simple enough to permit replication. As a consequence, programming and policy development have often proceeded based on varying assessments of the composition, size, and needs of the homeless population. This paper describes the empirical use of duration of homelessness and dwelling place as elements of an operational definition of homelessness. The approach reflects a conceptualization of homelessness as a continuous variable that can be described by coordinates of time and place. A screening instrument that quantified the homeless experience was developed and evaluated in conjunction with a federally funded demonstration project for homeless substance-abusing men and women. Eight hundred and thirty-nine men and women from six public detoxification centers were screened over a two-year period that began in August 1988. Respondents were asked eight questions to assess duration (time) and location (place) of homelessness before they entered the detoxification center. A simple index was constructed retrospectively and found to differentiate the sample into homeless and near-homeless subgroups. Between-group differences were statistically significant in demographics, presenting problems, and probability for successful intervention. These data paralleled previously reported differences between homeless subgroups and support the concurrent validity of the index. Cronbach's alpha (.72) showed the index to be moderately reliable. Differentiation of homeless persons into meaningful subgroups appears possible and programmatically recommended. Homelessness is not a unitary phenomenon, and it is unlikely to respond to therapeutic interventions that fail to consider individual differences.

ASAM Patient Placement Criteria treatment levels: do they correspond to care actually received by homeless substance abusing adults?

We report findings from a community-based two-city survey of homeless adults comparing the level of substance abuse treatment assigned to them using the ASAM Patient Placement Criteria with care actually received during the previous 12 months. Overall 531 adults were surveyed with 382 meeting DSM-IIIR criteria of being in need of treatment or having a demand for treatment. Of those with a treatment need, 1.5% met criteria for outpatient care, 40.3% intensive outpatient/partial hospitalization care, 29.8% medically monitored care and 28.8% managed care levels. In contrast, of those receiving treatment (50.5%, 162 persons), almost all care received by this cohort was either inpatient or residential based (83.6%). Unsheltered homeless persons and those without insurance were significantly more likely to report not receiving needed treatment. Lack of treatment availability or capacity, expense, and changing one's mind while on a wait list were the most commonly cited reasons for no treatment.

Health care utilization among homeless adults prior to death.

This study characterizes health care utilization prior to death in a group of 558 homeless adults in Boston. In the year before death, 27 percent of decedents had no outpatient visits, emergency department visits, or hospitalizations except those during which death occurred. However, 21 percent of homeless decedents had a health care contact within one month of death, and 21 percent had six or more outpatient visits in the year before death. Injection drug users and persons with HIV infection were more likely to have had contact with the health care system. This study concludes that homeless persons may be underusing health care services even when they are at high risk of death. Because a subset of homeless persons had extensive health care contacts prior to death, opportunities to prevent deaths may have been missed, and some deaths may not have been preventable through medical intervention.

A comparison of taxonomic systems for classifying homeless men.

The present study compared the relative merits of two taxonomic systems for classifying homeless men. One system classified homeless men based on their past history of psychiatric disability. The other system classified individuals on the basis of their current psychiatric impairment. Both classification systems displayed significant discriminating power using a set of predictor variables that included demographic variables, childhood happiness, current life satisfaction, social support, stressful life events, and history of homelessness. Based on the percentage of correct classifications the system based on current impairment was superior to the system based on past history.

Detecting earlier indicators of homelessness in the free text of medical records.

Early warning indicators to identify US Veterans at risk of homelessness are currently only inferred from administrative data. References to indicators of risk or instances of homelessness in the free text of medical notes written by Department of Veterans Affairs (VA) providers may precede formal identification of Veterans as being homeless. This represents a potentially untapped resource for early identification. Using natural language processing (NLP), we investigated the idea that concepts related to homelessness written in the free text of the medical record precede the identification of homelessness by administrative data. We found that homeless Veterans were much higher utilizers of VA resources producing approximately 12 times as many documents as non-homeless Veterans. NLP detected mentions of either direct or indirect evidence of homelessness in a significant portion of Veterans earlier than structured data.

Development of a frailty framework among vulnerable populations.

Frailty is a public health issue that is experienced by homeless and other vulnerable populations; to date, a frailty framework has not been proposed to guide researchers who study hard-to-reach populations. The Frailty Framework among Vulnerable Populations has been developed from empirical research and consultation with frailty experts in an effort to characterize antecedents, that is, situational, health-related, behavioral, resource, biological, and environmental factors that contribute to physical, psychological, and social frailty domains and impact adverse outcomes. As vulnerable populations continue to age, a greater understanding of frailty will enable the development of nursing interventions.