Health care utilization following a homeless medical respite pilot program.

OBJECTIVE: The purpose of this study was to evaluate a homeless medical respite pilot program to determine if program participants had health care utilization pattern changes and improved connection to income, housing, and health care resources post program. DESIGN: This is a quantitative descriptive pre-/post-program evaluation. SAMPLE: A total of 29 patients experiencing homelessness and discharged from an acute care hospital in the southeastern United States were provided with housing and nursing case management. MEASUREMENTS: Demographics including age, sex, race, and ethnicity were collected. Connection to primary care, mental health, substance abuse services, income, insurance, and housing were assessed at program entry and completion. Health care utilization and charge and payment data were collected 1 year prior and 1 year post-respite stay. RESULTS: Participants demonstrated reduced hospital admissions (-36.7%) and when admitted, fewer inpatient days (-70.2%) and increased outpatient provider visits (+192.6%). Health care charges for the cohort decreased by 48.6% from the year prior to the program. Housing and income improved. CONCLUSIONS: The medical respite pilot program was successful in guiding patients to community resources for more appropriate health care at a demonstrated cost savings. Participants also derived benefits in the form of improved housing and income.

Low barrier medication for opioid use disorder at a federally qualified health center: a retrospective cohort study.

BACKGROUND: Medication for opioid use disorder (MOUD) reduces mortality, but few patients access MOUD. At a Federally Qualified Health Center (FQHC), we implemented a low barrier model of MOUD, including same-day MOUD initiation and a harm reduction philosophy. OBJECTIVE: To investigate whether low barrier MOUD improved retention in care compared to traditional treatment. DESIGN AND PARTICIPANTS: Retrospective cohort study of patients with at least one visit seeking MOUD at the FQHC during a historical control period (3/1/2018-3/31/2019) and a low barrier intervention period (11/1/2019-7/31/2020). MAIN MEASURES: Primary outcomes were any MOUD prescription within 6 months of the index visit and 3- and 6-month retention in treatment without care gap, with care gap defined as 60 consecutive days without a visit or prescription. Secondary outcomes were all-cause hospitalization and emergency department visit within 6 months of the index visit. KEY RESULTS: Baseline characteristics were similar between the intervention (n = 113) and control (n = 90) groups, except the intervention group had higher rates of uninsured, public insurance and diabetes. Any MOUD prescription within 6 months of index visit was higher in the intervention group (97.3% vs 70%), with higher adjusted odds of MOUD prescription (OR = 4.01, 95% CI 2.08-7.71). Retention in care was similar between groups at 3 months (61.9% vs 60%, aOR = 1.06, 95% CI 0.78-1.44). At 6 months, a higher proportion of the intervention group was retained in care, but the difference was not statistically significant (53.1% vs 45.6%, aOR 1.27, 95% CI 0.93-1.73). There was no significant difference in adjusted odds of 6-month hospitalization or ED visit between groups. CONCLUSIONS: Low barrier MOUD engaged a higher risk population and did not result in any statistically significant difference in retention in care compared with a historical control. Future research should determine what interventions improve retention of patients engaged through low barrier care. Primary care clinics can implement low barrier treatment to make MOUD accessible to a broader population.

Differences in Clinical Outcomes of Adults Referred to a Homeless Transitional Care Program Based on Multimorbid Health Profiles: A Latent Class Analysis.

Background: People experiencing homelessness face significant medical and psychiatric illness, yet few studies have characterized the effects of multimorbidity within this population. This study aimed to (a) delineate unique groups of individuals based on medical, psychiatric, and substance use disorder profiles, and (b) compare clinical outcomes across groups. Methods: We extracted administrative data from a health system electronic health record for adults referred to the Durham Homeless Care Transitions program from July 2016 to June 2020. We used latent class analysis to estimate classes in this cohort based on clinically important medical, psychiatric and substance use disorder diagnoses and compared health care utilization, overdose, and mortality at 12 months after referral. Results: We included 497 patients in the study and found 5 distinct groups: "low morbidity" (referent), "high comorbidity," "high tri-morbidity," "high alcohol use," and "high medical illness." All groups had greater number of admissions, longer mean duration of admissions, and more ED visits in the 12 months after referral compared to the "low morbidity" group. The "high medical illness" group had greater mortality 12 months after referral compared to the "low morbidity" group (OR, 2.53, 1.03-6.16; 95% CI, 1.03-6.16; p = 0.04). The "high comorbidity" group (OR, 5.23; 95% CI, 1.57-17.39; p < 0.007) and "high tri-morbidity" group (OR, 4.20; 95% CI, 1.26-14.01; p < 0.02) had greater 12-month drug overdose risk after referral compared to the referent group. Conclusions: These data suggest that distinct groups of people experiencing homelessness are affected differently by comorbidities, thus health care programs for this population should address their risk factors accordingly.

Associations between positive emotional well-being and stress-induced myocardial ischemia: Well-being scores predict exercise-induced ischemia.

OBJECTIVE: Depressive symptoms have been associated with myocardial ischemia induced by mental (MSIMI) and exercise (ESIMI) stress in clinically stable ischemic heart disease (IHD) patients, but the association between positive emotions and inducible ischemia is less well characterized. The objective of this study was to examine the associations between ratings of well-being and stress-induced ischemia. METHODS: Subjects were adult patients with documented IHD underwent mental and exercise stress testing for the Responses of Myocardial Ischemia to Escitalopram Treatment (REMIT) trial. The General Well-Being Schedule (GWBS), with higher scores reflecting greater subjective well-being, and the Center for Epidemiologic Studies Depression Scale (CES-D) were obtained from the REMIT participants. Echocardiography was used to measure ischemic responses to mental stress and Bruce protocol treadmill exercise testing. Data were analyzed using logistic regression adjusting for age, sex, resting left-ventricular ejection fraction (LVEF), and resting wall motion score index, as well as health-related behaviors. RESULTS: GWBS scores were obtained for 210 individuals, with MSIMI present in 92 (43.8%) and ESIMI present in 64 (30.5%). There was a significant inverse correlation between GWBS-PE (Positive Emotion subscale) scores and probability of ESIMI (OR=0.55 (95%CI 0.36-0.83), p=0.005). This association persisted after additional control for CESD subscales measuring negative and positive emotions and for variables reflecting health-related behaviors. A similar inverse correlation between GWBS-PE and MSIMI was observed, but did not reach statistical significance (OR=0.81 (95%CI 0.54-1.20), p=0.28). CONCLUSION: This is, to our knowledge, the first study demonstrating that greater levels of self-reported positive emotions are associated with a lower likelihood of ESIMI among patients with known IHD. Our results highlight the important interface functions of the central nervous and cardiovascular systems and underscore areas for future investigation.