Complex care needs of patients with late-stage HIV disease: a retrospective study.

This retrospective chart review provides a profile of an emerging population of vulnerable HIV patients with complex comorbidities. Data were abstracted from all 83 patients admitted in 2008 to Casey House, a community-based hospital dedicated to supportive and palliative care for persons with HIV in Toronto, Canada. We describe patient characteristics, including medical and psychiatric conditions, and use a Venn diagram and case study to illustrate the frequency and reality of co-occurring conditions that contribute to the complexity of patients' health and health care needs. The mean age at admission was 49.2 years (SD10.5). Sixty-seven patients (80.7%) were male. Patients experienced a mean of 5.9 medical comorbidities (SD2.3) and 1.9 psychiatric disorders (lifetime Axis I diagnoses). Forty patients (48.2%) experienced cognitive impairment including HIV-associated dementia. Patients were on a mean of 11.5 (SD5.3) medications at admission; 74.7% were on antiretroviral medications with 55.0% reporting full adherence. Current alcohol and drug use was common with 50.6% reporting active use at admission. Our Venn diagram illustrates the breadth of complexity in the clients with 8.4% of clients living in unstable housing with three or more medical comorbidities and two or more psychiatric diagnoses. Comprehensive HIV program planning should include interventions that can flexibly adapt to meet the multidimensional and complex needs of this segment of patients. Researchers, policy-makers, and clinicians need to have greater awareness of overlapping medical, psychiatric and psychosocial comorbidities. Inclusion of the needs of these most vulnerable patients in the development of evidence-based guidelines is an important step for effectively treating, preventing, and planning for the future of HIV/AIDS care.

Causes of Death in HIV Patients and the Evolution of an AIDS Hospice: 1988-2008.

This paper reports on the transformation that has occurred in the care of people living with HIV/AIDS in a Toronto Hospice. Casey House opened in the pre-HAART era to care exclusively for people with HIV/AIDS, an incurable disease. At the time, all patients were admitted for palliative care and all deaths were due to AIDS-defining conditions. AIDS-defining malignancies accounted for 22 percent of deaths, mainly, Kaposi sarcoma and lymphoma. In the post-HAART era, AIDS-defining malignancies dropped dramatically and non-AIDS-defining malignancies became a significant cause of death, including liver cancer, lung cancer and gastric cancers. In the post-HAART era, people living with HIV/AIDS served at Casey House have changed considerably, with increasing numbers of patients facing homelessness and mental health issues, including substance use. Casey House offers a picture of the evolving epidemic and provides insight into changes and improvements made in the care of these patients.

Rethinking measurement of neighborhood in the context of health research.

Systematic social observations have been gaining increasing recognition in neighborhood and health research as a way of measuring neighborhood attributes hypothesized to affect residents' well-being. Despite the growing popularity of this methodology, there has not been a critical discussion of potential shortcomings of this approach. This paper reviews some of the challenges and limitations in the systematic social observations methodology. We especially differentiate between limitations related to the methodology itself and challenges the approach presents for researchers in the field. We conclude by offering directions for future research utilizing this technique.

Examining methodological details of neighbourhood observations and the relationship to health: a literature review.

Neighbourhood research has been growing steadily over the past two decades across the social sciences, and, in particular in the area of public health. Despite this increase, there is currently no consensus on which measure and data source researchers should use to assess neighbourhood attributes. In the past, researchers have relied on census data and household surveys to assess neighbourhood conditions, but in recent years, neighbourhood observations have become a popular alternative method for characterizing neighbourhood environments. Rooted in sociology of crime research, observations are conducted by trained observers who use a checklist to observe and rate neighbourhoods on a number of conditions such as physical (e.g., traffic volume, housing conditions) and social (e.g., presence of people, gang activity) attributes. While this methodology has been gaining momentum in recent years, notably absent from the literature is a review to examine this methodology in detail. The purpose of the present study was to examine research that has used neighbourhood observations as a method. We do so by critically reviewing 51 English language studies published from 1990 onward paying particular attention to the areas of (1) methodological rigor (i.e. how observations are carried out in the field and how data are analyzed), (2) geographical boundaries (i.e. how neighbourhoods and areas of observation are spatially defined), and (3) the relationship between neighbourhood observations and residents' health (i.e. how studies examine and analyze the link between observed neighbourhood attributes and health). We find that little attention is given to details of neighbourhood observations as a method. Further, there is wide variability in how observations are conducted and analyzed making it impossible to confidently compare findings across studies. We see this review as a first step in developing sound observational measures of neighbourhood factors and conclude by providing recommendations for researchers undertaking neighbourhood observations in the future.

Community-based services for homeless adults experiencing concurrent mental health and substance use disorders: a realist approach to synthesizing evidence.

Consultations with community-based service providers in Toronto identified a lack of strong research evidence about successful community-based interventions that address the needs of homeless clients experiencing concurrent mental health and substance use disorders. We undertook a collaborative research effort between academic-based and community-based partners to conduct a systematic evidence synthesis drawing heavily from Pawson's realist review methodology to focus on both whether programs are successful and why and how they lead to improved outcomes. We examined scholarly and nonscholarly literature to explore program approaches and program elements that lead to improvements in mental health and substance use disorders among homeless individuals with concurrent disorders (CD). Information related to program contexts, elements, and successes and failures were extracted and further supplemented by key informant interviews and author communication regarding reviewed published studies. From the ten programs that we reviewed, we identified six important and promising program strategies that reduce mental health and, to a far lesser degree, substance use problems: client choice in treatment decision-making, positive interpersonal relationships between client and provider, assertive community treatment approaches, providing supportive housing, providing supports for instrumental needs, and nonrestrictive program approaches. These promising program strategies function, in part, by promoting and supporting autonomy among homeless adults experiencing CD. Our realist informed review is a useful methodology for synthesizing complex programming information on community-based interventions.

Neighborhood stressors, perceived neighborhood quality, and child mental health in New York City.

This paper examines the relationship between neighborhood stressors, stressors related to parenting, children's evaluations of neighborhood quality, and child depression. One hundred and twenty-six young adolescents in three disadvantaged New York City neighborhoods completed surveys on neighborhood quality and child depression and the children's parents provided information on their mental health and parenting practices. Neighborhood stressors were measured through observations by outside raters. Children's evaluations of neighborhood quality were positively related to their assessments of depression and there was an unexpected positive association between the neighborhood drug/alcohol stressor and child depression. Moreover, the relationship between the drug/alcohol stressor and child depression was fully mediated by the children's assessments of neighborhood quality. Future directions for neighborhood and health research are discussed.

Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness.

Despite the increase in consumer-driven interventions for homeless and mentally ill individuals, there is little evidence that these programs enhance psychological outcomes. This study followed 197 homeless and mentally ill adults who were randomized into one of two conditions: a consumer-driven "Housing First" program or "treatment as usual" requiring psychiatric treatment and sobriety before housing. Proportion of time homeless, perceived choice, mastery, and psychiatric symptoms were measured at six time points. Results indicate a direct relationship between Housing First and decreased homelessness and increased perceived choice; the effect of choice on psychiatric symptoms was partially mediated by mastery. The strong and inverse relationship between perceived choice and psychiatric symptoms supports expansion of programs that increase consumer choice, thereby enhancing mastery and decreasing psychiatric symptoms.