Document Sample
					                                        Health Care for the Homeless
                                   RESEARCH UPDATE
Volume X, No. 1                                                                                                                              May 2009

A publication of the National Health Care for the Homeless Council, Inc. Production and distribution are made possible by a g rant from the Health
Services and Resources Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views
of HRSA or the National HCH Council.

                                                                                   Summary: A proportion of persistently homeless men with
Each quarter, research databases are searched for publications related to          psychosis are unable to function in the community, despite
health care and homelessness. This issue of the HCH R ESEARCH                      intensive outreach. The present study aimed to (i) develop a
UPDATE includes a sample of summaries resulting from the search of                 method to measure the numb er of homeless clients with a
publications from (approximately) November 2008 –April 2009.                       psychosis who are unable to maintain basic levels of function,
Summaries are categorized into themes which vary each quarter.                     despite the application of intensive co mmunity tr eatment; and (ii)
                                                                                   determine if the proportion of these men had increased in an
                                                                                   Australian inner urban setting o ver a 5-year period. Criteria were
                                                                                   developed and validated to define this group. A review of records
                                                                                   of clients engaged in homeless settings was conducted in order to
                                                                                   compare the proportion of men with these features in 2000 and
Title: Age Difference s among Homeless I ndividuals: Adole scence                  2005. In 2005, 23% met the cr iterion of long-term homelessness
through Adulthood                                                                  with poor function, despite intensive outreach, as compared with
Authors: To mpsett CJ, Fowler PJ and Toro PA                                       17% in 2000 (P = 0.62). The 2005 cohort was more likely to have
Source: Journal of Prevention & Intervention in the Community,                     attempted intensive community p sychiatric tr eatment (P = 0.04).
37(2):86-99, 2009                                                                  We conclude that a proportion of homeless men with a psychosis
Summary: The present study examines differ ences between                           in Australia do not achieve basic function, despite access to
homeless adolescents, young adults, and older adults served by                     intensive outreach. The proportion of these men did not change
homeless shelters or food programs to inform service provision.                    between 2000 and 2005. These men r equire additional sp ecialized
Four homeless studies using the sa me sampling and mea surement                    services, including access to long-term supported housing.
methods were pooled to p ermit comparisons across age groups.
Results showed that ho meless adolescents demonstrated greater                     Title: Mistrust of Outreach Workers and Lack of Confidence i n
resilience than younger and older adults. Adolescents reported the                 Available Services among Individuals Who Are Chronica lly
shortest duration of homelessness, lowest number of life stressors,                Street Homele ss
fewest physical symptoms, largest social networks, and fewest                      Authors: Kryda AD and Compton MT
clinically significant mental health problems. Adolescents also                    Source: Community Mental Health Journal, 45 (2):144-150, Apr
received fewer alcohol and drug abuse dia gnoses than younger and                  2009
older adults. Younger adults reported less time ho meless and                      Summary: This qualitative study explored ho w individuals who are
fewer physical symptoms than older adults, but more life stressors.                homeless p erceive outreach practices and available ser vices.
Younger adults also endorsed higher levels of hostile and paranoid                 Inter views were conducted with 24 people who had been ho meless
psycholo gical symptoms. Implications for service provision and                    for >=1 year and who consistently resided on the str eets of west
policy are discussed.                                                              midtown, Manhattan, New York. R easons why these individuals
                                                                                   refuse services include a pervasive mistrust of outreach workers
CHRONIC HOMELESSNESS                                                               and the a gencies that employ them, as well as a prominent lack of
                                                                                   confidence in ava ilable services. The findings suggest a need for an
Title: Lo ng-Term Homelessne ss i n Men with a Psy chosis:                         approach to outreach that incorporates giving individualized
Limitation of Services                                                             attention from outreach workers, using an empathetic listening
Authors: Burns A, Robins A , Hodge M and Holmes A                                  approach, minimizing stereotyping, providing gr eater cho ices, and
Source: International Journal of Mental Health Nursing, 18(2):126-                 employing formerly homeless p eople as outreach worker s.
132, Apr 2009

                                                                            - 1-
               For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
               website at All are searchable by keyword using the Search function on the homepage.
Title: Client-Level Measures of Services Integration among                       community tr eatment (NIA CT). Participants had to be ho meless,
Chronically Homeless Adults                                                      have a substance use disorder, and ha ve a severe mental illness to
Authors: Mares AS, Greenberg GA and Rosenheck RA                                 be eligible for the study. One hundred ninety-six individuals were
Source: Community Mental Health Journal, 44 (5):367-376, Oct                     randomly assigned to SC, ACTO, or IACT. Approximately two
2008                                                                             years later, 85 participants were assigned to N IACT. A quasi-
Summary: While several major studies ha ve examined services                     experimental design was employed to analyze the data. Clients in
integration at the system or interagency level, there has been far               the NIA CT program had b etter outcomes on consumer
less effort to measure the integration of services at the client-level           satisfaction than clients in the other conditions. Clients in
and its correlates. This study presents three client-level mea sures of          NIACT, IACT, and ACTO groups had better housing outco mes
services integration, two objective measures, representing the                   than clients in SC. Clients in NIA CT reduced their use of drugs
proportion of needed services received and the number of                         more than clients in the other programs, but there was no
outpatient services received by each client, and one subjective                  difference between conditions on the other sub stance abuse
measure, a five-item scale measuring perceived coordination of                   variables. There was no difference b etween conditions on
care among clients' service providers. Data from the evaluation of               psychiatric symptoms. lACT may need to b e augmented with
the collaborative initiative to help end chronic ho melessness                   other services to reduce substance use and produce better
(CICH) are used to examine b ivariate and multivariate                           psychiatric outcomes for dual-disorder homeless individuals.
relationships of these thr ee client-level measur es to two system-
level measures of services integration, one addressing interagency               ELECTRONIC MEDICAL RECORDS
services coordination/p lanning and the other interagency
trust/resp ect a s well as to baseline client characteristics among 734          Title: The Use of E lectroni c Medical Records for Homeless
chronically homeless adults in 11 cities. Client-level measures of               Outreach
service integration wer e not strongly associated to each other or to            Authors: Cavacuiti C and S voboda T
the system-level measures, except for weak associatio ns (r = 0.10)              Source: Journal of Health Care for the Poor and Underserved,
between one objective client measure and the system-level measure                19(4):1270-1281, Nov 2008
of service coordinatio n and planning, and another between client-               Summary: Objectives: To assess the features of Electronic Medical
level use of outpatient mental health services and system-level trust            Records (EMRs) used by North American homeless outreach
and respect. Multivariate analysis showed that clients who received              organizations. Methods: Twenty-eight homeless outreach agencies
a greater array of needed services received more service overall and             throughout North America were contacted. Nine used EMRs for
were more likely to have a diagnosis of PTSD and more medical                    homeless outreach. Ser vice providers from these nine agencies
problems, but less serious alcohol problems. Clients who reported                were interviewed to learn more about their E MRs. R esults: While
more outpatient mental hea lth and substance abuse visits were                   all of the agencies we interviewed were using different EMR
significantly more likely to be married, to be veterans, to have                 systems, the important features of these EMRs were quite similar.
more serious drug problems, and to be dually diagnosed. Clients                  Two of the mo st frequently cited essential features wer e: 1) the
with more ser ious drug problems reported poorer coordination                    ability of different sites and providers to access medical
among their service providers on the subjective measure of client-               information; and 2) the capacity to collect aggregated client data
level service integration. Three client-level measures of services               (such as numb ers of clients ser ved, services provided, and
integration wer e, at best, weakly associated with measures of                   outcomes) for planning, evaluation, and advocacy purposes.
system-level integration. Po sitive associations b etween client-level           Conclusion: An electronic medical record (EMR) available at
measures of integration and health status, outpatient service use                multip le locations to multiple providers is a powerful tool with the
and negative r elationships with indicators of substance abuse                   potential to improve the coordination, safety, efficiency, and
suggest they may usefully represent the exp eriences of chronically              quality of care to people who are homeless.
homeless clients, even though they are not strongly related to
system-level measures.                                                           FORMERLY HOMELESS
DUAL DIAGNOSIS                                                                   Title: Changes in Sources and Perceived Quality of Social
                                                                                 Supports among Formerly Homeless Perso ns Receiving Assertive
Title: Integrated Treatment for Homeless Clients with Dual                       Community Treatment Services
Disorders: A Qua si-Experimental Evaluation                                      Authors: Carton A, Young M and Kelly K
Authors: Morse GA , Calsyn RJ, Klinkenberg WD, Cunningham J                      Source: Community Mental Health Journal, Mar 5, 2009 [Epub
and Lemming MR                                                                   ahead of print]
Source: Journal of Dual Diagnosis 4(3):219-237, 2008                             Summary: We recruited a samp le of individuals who were formerly
Summary: The purpose of this study was to compare the                            homeless that received assertive community treatment (ACT)
effectiveness of four inter ventions in providing services to                    services to assess differences in their sources and perceived quality
homeless clients with dual disorders: standard care (SC), assertive              of social support related to changes in their residence status.
community tr eatment only (ACTO), integrated a ssertive                          Standardized questionnaires were administered to 22 participants
community tr eatment (IA CT), and new integrated assertive
                                                                          - 2-
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.
via face-to-face interviews, including various measures of social              the United States. A s an organization that exists to serve the
support and relationship quality. Results indicated that                       homeless and impoverished of Washington, D C, So Other s Might
participants mentioned ACT staff members significantly more                    Eat (SOME) works diligently to address this disparity. SOME's
often than any other relationship category (e.g., friends or family)           clients are primarily African Americans who often face obstacles to
as sources of social support. Participants also indicated that the             HIV care b ecause of low socioeconomic status, mistrust of the
quality of their r elationship s with ACT staff memb ers was                   medical establishment, and fear of being identified as HIV
significantly better than relatio nships mainta ined before and                positive. We relate the lessons we learned at SOME's medical
during their homelessness. These findings indicate that A CT staff             clinic while trying to better address the needs of our clients living
can serve as social supports for clients on their caseloads, and they          with HIV/A IDS. Chief among tho se lessons was the need to shift
further suggest that clients perceive these worker-consumer                    from considering our patients "noncompliant" with their HIV-
relationships to be of high quality. Implications related to                   related care to reco gnizing they had needs we were not addressing.
community integration are discussed.
                                                                               Title: The Health Impact of Supportive Housing for HIV-
Title: Factors Associated with Adherence to Highly Active                      Positive Homeless Patients: A Randomized Controlled Trial
Antiretroviral Therapy in Homele ss or Unstably Housed Adults                  Authors: Buchanan DR, Kee R, Sadowski LS and Garcia D
Living with HIV                                                                Source: American Journal of Public Health, Apr 16, 2009 [Epub
Authors: Royal SW, Kidder DP, Patrabansh S, Wolitski RJ,                       ahead of print]
Holtgrave DR, Aidala A, Pals S and Stall R                                     Summary: We assessed the health impact of a housing and case
Source: AIDS Care, 21(4):448-455, 2009                                         management program, the Chicago Housing for Health
Summary: The aim of this study is to investigate adher ence to                 Partnership, for homeless people with HIV. HIV-positive ho meless
highly active antiretroviral therapy (HAART) in per sons living                inpatients at a public hosp ital (n=105) were randomized to usual
with HIV/A IDS (PLWHA) who are homeless or unstably housed.                    care or permanent housing with intensive ca se management. The
We evaluated homeless or unstably housed PLWHA (n=644) in                      primary outcome was survival with intact immunity, defined as
three US cities were enrolled in the Housing and Health Study.                 CD4 count>200 and viral load<100000. Secondary outcomes
Using baseline data and co ntrolling for gender, race, age, and                were viral loads, undetectable viral loads, and CD4 counts.
education, we examined a ssociations between self-reported two-                Outcomes were available for 94 of 105 enrollees (90%). Of 54
and Seven-day adherence and access to healthcare, mental health,               inter vention participants, 35 (65%) reached p ermanent housing in
substance use, and attitudes toward HIV medical therapy. Of the                program housing agencies. After 1 year, 55% of the inter vention
644 participants, 358 (55%) were currently o n HAART. For two-                 and 34% of the usual care groups wer e alive and had intact
day adherence, 280 (78%) reported missing no prescribed do ses                 immunity (P=.04). Seventeen inter vention (36%) and 9 usual care
(100% adherence), and for seven-day adherence, 291 (81%)                       (19%) participants had undetectable viral loads (P=.051). Median
reported > or =90% adherence. Lo gistic regression analyses                    viral loads were 0.89 lo g lower in the interventio n group (P=.03).
indicated b eing younger, not having health insurance, and drug                There were no statistical differences in CD4 counts. Ho melessness
use wer e associated with missing > or =1 dose over the past two               is a strong pr edictor of poor health outcomes and complicates the
days. Scoring lo wer on SF-36 mental component summary scale                   medical management of HIV. This housing intervention improved
and having greater risk of depr ession ( CES-D) and stress                     the health of HIV-positive homeless people.
(Perceived Stress Scale) were a ssociated with poorer adherence for
both two- and seven-day outcomes. Negative attitudes toward HIV                Title: Ho using Status a nd HIV Risk Behaviors among Homeless
treatment were also associated with lower adherence. Adher ence                and Housed Perso ns with HIV
to HIV medications in this population is similar to other groups.              Authors: Kidder DP, Wolitski RJ, Pals SL and Camp smith ML
Coexisting problems of access to healthcare, higher risk of mental             Source: Journal of Acquired Immune D eficiency Syndromes,
health problems, along with poorer attitudes toward treatment are              49(4):451-455, 2008
associated with increased likelihood of missing do ses.                        Summary: The article presents a comparative study on alcohol,
Comprehensive models of HIV care that include a continuum of                   drug and sexual transmission of HIV risk behaviors between
medical and social services are essential for treating this                    housed and homeless people living with HIV/AIDS. The study
population.                                                                    reveals that homeless people living with HIV/AIDS are more
                                                                               engaged in sub stance use and are more likely to have HIV
Title: Mobilizing a Medica l Home to Improve HIV Care for the                  transmission. It suggests health departments and medical service
Homeless i n Washington, DC                                                    providers to provide stable housing and b ehavioral and health-
Authors: Wright MA and Knopf AS                                                related needs.
Source: American Journal of Public Health, 99(6):973-975, Jun
Summary: African Americans face a higher burden of HIV
infection, morbidity, and mortality than other ethnic groups in
                                                                        - 3-
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.
Title: Health Impacts of Supportive Housing for Homeless                       Title: Assessing Criminal History a s a Predictor of Future
Youth: A Pi lot Study                                                          Housing Success for Homeless Adults with Behavioral Health
Authors: Kisely SR, Parker JK, Campbell LA, Karabanow J, Hughes                Disorders
JM and Gahagan J                                                               Author: Malone DK
Source: Public Health, 122 (10):1089-1092, Oct 2008                            Source: Psychiatric Services, 60:224-230, Feb 2009
Summary: The article focuses on a study on the health impacts of               Summary: Homeless adults with serious mental illnesses and
supportive housing for homeless youth. It notes that                           chronic substance abuse problems have few housing optio ns, a
homelessness, which is an incr easing public health concern, is                problem compounded when a criminal background is present.
classified into relative and absolute homelessness. Under the                  This study compared the cr iminal backgrounds and other
study, the a ssociation b etween supportive housing and health                 characteristics of homeless individuals who su cceeded in housing
among ho meless p eople within the 16-25-year-old age group in                 (retained housing continuously for two years) and those who failed
Halifax, Nova Scotia are examined with the cooperation of                      in housing. The study population consisted of homeless adults
Phoenix Youth Programs. Results sho w that tho se with supportive              with b ehavioral health disorders who moved into supportive
housing ha ve better self-reported health and lower rates of                   housing between January 1, 2000, and June 30, 2004, regardless of
substance abuse.                                                               criminal background. Data about criminal history and other
                                                                               characteristics wer e extracted from existing r ecords and analyzed
Title: Health Care and Pub lic Service Use and Costs before and                for associations with housing success. Chi square tests and logistic
after Provision of Housing for Chronically Homeless Persons                    regression analysis were used to find characteristics predictive of
with Severe Alco hol Prob lems                                                 subsequent housing success or failure. Data were available for 347
Authors: Larimer ME, Malone DK, Garner MD , Atkins DC,                         participants. Most (51%) had a criminal record, and 72% achieved
Burlingham B, Lonczak HS, Tanzer K, Ginzler J, Clifasefi SL,                   housing success. The presence of a criminal background did not
Hobson WG and Marlatt GA                                                       predict housing fa ilure. Younger age at mo ve-in, the presence of a
Source: Journal of the American Medical Asso ciation,                          substance abuse problem, and higher numbers of drug crimes and
301(13):1349-1357, Apr 2009                                                    property crimes were separately associated with more housing
Summary: Context: Chronically ho meless individuals with severe                failure; however, when they were adjusted for each of the other
alcohol problems often have multiple medical and p sychiatric                  variables, only mo ve-in age remained associated with the outco me.
problems and use costly health and cr iminal justice services at               The finding that cr iminal history does not provide good predictive
high rates. Objective: To evaluate a ssociation of a "Housing First"           information about the potential for housing success is important
inter vention for chronically ho meless individuals with severe                because it contradicts the exp ectations of housing operators and
alcohol problems with health care use and costs. Design, Setting               policy maker s. The findings suggest that policies and practices that
and Participants: Quasi-experimental design co mparing 95 housed               keep homeless p eople with criminal records out of housing may be
participants (with dr inking per mitted) with 39 wa it-list control            unnecessarily restrictive.
participants enrolled between November 2005 and March 2007 in
Seattle, Washington. Ma in Outcome Measur es: Use and cost of                  Title: Association between the Level of Housi ng Instability,
services (jail bookings, days incarcerated, shelter and sobering               Economic Standing a nd Health Care Access: A Meta-Regression
center use, hospital-based medical services, publicly funded                   Authors: R eid KW, Vittinghoff E and Kushel MB
alcohol and drug detoxification and treatment, emer gency medical              Source: Journal of Health Care for the Poor and Underserved,
services, and Medicaid-funded services) for Housing First                      19(4):1212-1228, Nov 2008
participants relative to wait-list controls. Results: Housing First            Summary: To determine the relationship between housing
participants had total costs of $8,175,922 in the year prior to the            instability, economic standing, and access to health care and use
study, or median costs of $4066 per person p er month                          of acute care services. W e p erformed a meta-regression using four
(interquartile range [IQR], $2067-$8264). Median monthly costs                 nationally representative surveys. The indep endent variable was an
decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-                       ordered mea sure of economic and housing instability: 1) the
$3200) after 6 and 12 months in housing, resp ectively. Poisson                general population, 2) low-income population, 3) never homeless
generalized estimating equation r egressions using propensity score            users-of-subsistence-ser vices, 4) unstably housed, 5) formerly
adjustments sho wed total cost rate reduction of 53% for housed                homeless, and 6) the actively homeless. Dep endent variables were
participants relative to wait-list controls (rate ratio, 0.47; 95%             four measures of health care access and three measures of acute
confidence inter val, 0.25-0.88) over the first 6 months. Total cost           health care utilization. Worsening housing instability and
offsets for Housing First participants r elative to controls averaged          economic standing was associated with poorer access: being
$2449 per person per month after accounting for housing                        uninsured (5.4% p er unit increase, 95% CI 1.7–9.2%, p=.011),
program costs. Conclusions: In this population of chronically                  postponing needed care (3.3%, 95% CI 1.9–4.7%, p=.001),
homeless individuals with high service use and costs, a Housing                postponing medications (6.1%, 95% CI 1.5–10.6%, p=.035), and
First program was associated with a relative decrea se in costs after          with one measure of acute health care utilization: higher
6 months. These b enefits increased to the extent that participants            hospitalization rates (2.9%, 95% CI 1.2–4.6%, p=.008). Economic
were retained in housing longer.                                               and housing instability should b e considered a graded risk factor
                                                                               for poor access to health care.

                                                                        - 4-
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.
Title: Effect of a Ho using a nd Case Management Program on                     Summary: For more than a decade, the Ho meBuy5 Program has
Emergency Department Visits and Hospitalizations among                          successfully help ed families who were ho meless find an apartment,
Chronically Ill Homele ss Adults: A Randomized Trial                            while working with them to develop a plan to move from
Authors: Sadowski LS, Kee RA, VanderWeele TJ and Buchanan D                     homelessness to homeo wnership. This article provides an
Source: Journal of the American Medical Asso ciation,                           historica l overview of how the program developed and evolved, a
301(17):1771-1778, 2009                                                         detailed discussion of the program's process and structure, the role
Summary: Context: Homeless adults, especially those with chronic                of organizational collaboration and co mmunity partners, and
medical illnesses, are fr equent users of costly medical services,              demographic information on the families that have been served. It
esp ecially emergency department and hosp ital services. Objective:             is argued that this program can b e a prototype for other
To assess the effectiveness of a case management and housing                    communities as they increase their efforts to eliminate
program in reducing use of urgent medical services among                        homelessness.
homeless adults with chronic medical illnesses. D esign, S etting
and Participants: Randomized controlled trial conducted at a                    INFECTIOUS DISEASES
public teaching hosp ital and a private, nonprofit hosp ital in
Chicago, Illinois. Participants were 407 social worker-referred                 Title: Infectious Di sease Exposures a nd Contact Tracing in
homeless adults with chronic medical illnesses (89% of referrals)               Homeless She lters
from Septemb er 2003 until May 2006, with follow-up through                     Authors: Hwang SW, Kiss A , Ho MM, Leung CS and Gundlapalli
December 2007. Analysis was by intention-to-treat. Intervention:                A
Housing offer ed as transitional housing after hospitalization                  Source: Journal of Health Care for the Poor and Underserved,
discharge, followed by p lacement in lo ng-term housing; case                   19(4):1163-1167, Nov 2008
management offered on-site at primary study sites, transitional                 Summary: An outbreak among ho meless shelter users of a
housing, and stable housing sites. Usual care participants received             communicable disea se with a short generation time would pose
standard discharge p lanning from hosp ital so cial workers. Ma in              serious public health challenges. Data from Toronto were used to
Outcome Measures: Hospitalizations, hosp ital days, and                         examine the numb er of shelter residents potentially exposed in the
emergency department visits measur ed using electronic                          event of such an outbreak. A shelter user had contact with a mean
surveillance, medical r ecords, and interviews. Models were                     of 97 other residents (range, 1–292) in one day and a mean of 120
adjusted for baseline differ ences in demographics, insurance                   (range, 2–624) in eight days. After a single week, co ntact tracing
status, prior hosp italization or emergency department visit, human             becomes difficult due to the challenge of locating homeless people
immunodeficiency virus infection, current use of alcohol or other               who have left the shelter system. Over an 8-day period, individuals
drugs, mental health symptoms, and other factors. Results: The                  who used more than o ne shelter had contact with an average of 98
analytic sample (n = 405 [n = 201 for the intervention group, n =               more other shelter residents than tho se who stayed in a single
204 for the usual care group]) was 78% men and 78% African                      shelter had. At the onset of a serious outbreak, it may b e desirable
American, with a median duration of homelessness of 30 months.                  to institute policies that strongly encourage individuals to remain
After 18 months, 73% of participants had at least 1                             at their current shelter for the duration of the outbreak.
hospitalization or emergency department visit. Co mpared with the
usual care group, the inter vention group had unadjusted                        Title: Respo nse to Hepatitis A Epidemic: Emergency
annualized mean reductions of 0.5 hospitalizations (95%
                                                                                Department Collaboration with Pub lic Health Commission.
confidence inter val [CI], -1.2 to 0.2), 2.7 fewer ho spital days (95%
                                                                                Authors: James TL, Aschkenasy M, Eliseo LJ, Olshaker J and
CI, -5.6 to 0.2), and 1.2 fewer emergency department visits (95%
                                                                                Mehta SD
CI, -2.4 to 0.03). Adjusting for baseline covariates, co mpared with
                                                                                Source: Journal of Emer gency Medicine, 36(4):412-416, May 2009
the usual care group, the intervention group had a relative
                                                                                Summary: In 2004, a hepatitis A outbreak occurred in Boston,
reduction of 29% in hospitalizations (95% CI, 10% to 44%), 29%
                                                                                Massachusetts with an incident rate of 14.8 per 100,000,
in ho spital days (95% CI, 8% to 45%), and 24% in emergency
                                                                                compared to 4.2 in 2003. The majority of ca ses had risk factors of
department visits (95% CI, 3% to 40%). Conclusion: After
                                                                                homelessness, injection drug use, or incarceration. In S eptember
adjustment, offering housing and case mana gement to a
                                                                                2004, the Boston Public Health Co mmission began an
population of homeless adults with chronic medical illnesses
                                                                                immunization campaign partnering with health center s,
resulted in fewer hosp ital days and emergency department visits,
                                                                                detoxification centers, homeless shelters, and our Emergency
compared with usual care.
                                                                                Department (ED) to increase the numb er of hepatitis A
                                                                                vaccinations and stem the epidemic. The ED rapidly develop ed
Title: Using Organizational Collaboration and Community
                                                                                (within days) a vaccination protocol. Hepatitis A vaccinations were
Partnerships to Transition Families from Homelessness to
                                                                                offered to patients over a ge 21 years who were homeless, substance
Home Ownership: The Homebuy5 Program
                                                                                users, or incarcerated. From October 2004 through January 2005,
Authors: Davey T and Ivery J
                                                                                the ED vaccinated 122 patients notable for 64% male, 61%
Source: Journal of Prevention and Intervention in the Community,
                                                                                homeless, 28% substance users, and 11% incarcerated. No
37(2):155-165, 2009
                                                                                reported vaccination reactions occurred. There was a 51%
                                                                                decrease in the numb er of cases of Hepatitis A in Boston in the
                                                                         - 5-
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.
first 4 months of 2005. As a partner, the ED help ed stem the                 the need for consideration of developmental disabilities when
epidemic by rapidly providing vaccinations to those most                      homeless and mental health providers are working with the
vulnerable. This project provides a model for future co llaborations          homeless community.
between EDs and local, state, and federal organizations to address
epidemics.                                                                    MENTAL HEALTH

Title: Feasibility of Completing an Acce lerated Vaccine Series for           Title: Impaired Immune Function in a Homeless Population
Homeless Adults                                                               with Stre ss-Related Disorders
Authors: Nyamathi A M, Sinha K, Saab S, Marfisee M, Greengo ld                Authors: Arranz L, de Vicente A, Muñoz M and de la Fuente M
B, Lea ke B and Tyler D                                                       Source: Neuroimmunomodulation, 16(4):251-260, Apr 9, 2009
Source: Journal of Viral Hepatitis, Feb 24, 2009 [Epub ahead of               [Epub ahead of print]
print]                                                                        Summary: Homeless people suffer high levels of p sycholo gical
Summary: Homeless adults are at high risk for hepatitis B virus               distress. The aim of the present work was to study the immune
(HBV) infection. In addition to culturally sensitive programmes               function in a group of homeless p eople with stress-related
designed to enhance vaccination compliance, accelerated HBV                   disorders and compare it with that of healthy non-homeless
vaccination (three do ses over 21 days) have also been suggested to           controls. W e included in the study 40 homeless per sons and 40
improve compliance among high-risk groups. In this paper, we                  housed controls r ecruited from the population of Madrid and
examined predictors of completers of two of three doses of a                  matched for age and gender. Samples from p eripheral blood were
HAV/HBV vaccine series, normally deliver ed over a 6-month                    collected and we studied several leukocyte functions previously
period, to simulate compliance with an accelerated series, dosed              descr ibed as good health and survival markers [adherence,
over 4 weeks. A convenience samp le of 865 homeless adults was                chemotaxis, pha gocytosis, sup eroxide anion levels, lymphocyte
randomized into a nurse ca se-managed approach (NCMIT) vs                     proliferation in response to phytohema gglutinin, N K activity and
standard programmes with (SIT) and without tracking (SI). Each                cytokine (IL-2, TNF-alpha) levels], as well as other related
group was assessed for comp letion of two of the three dose                   parameters, such as plasma cortisol levels and total antioxidant
HAV/HBV vaccine series a s well as the full three dose vaccine                capacity. There was a strongly suppressed immune r esponse in the
series. Sixty-eight percent of the NCMIT participants completed               homeless group, with decrea sed adherence, chemotaxis,
the thr ee dose vaccination series at 6 months compared to 61% of             phagocytosis, superoxide levels, lymphoproliferation and NK
SIT participants and 54% of SI participants. Eighty-one percent of            activity. IL-2 and plasma antioxidant levels were also impaired.
the N CMIT participants comp leted two of the vaccinations                    These findings suggest an altered immune function in the
compared to 78% of SIT participants and 73% of SI participants.               homeless population that might be responsib le for the higher
The N CMIT approach resulted in greater number s of comp leters               morbidity and mortality of homeless people. In addition, the
of two of three doses and of the full thr ee do se vaccine series.            present work points out dir ections for future r esearch attempting
Predictors of completers of two doses and the full three dose                 to increa se the quality of life and health status of homeless
vaccine series are provided. A greater number of ho meless persons            individuals, since it shows that oxidative stress seems to play a key
completed two doses across the three groups compared to the                   role in this immune function impairment.
three do se vaccine series. The use of nurse case-mana gement and
tracking, coupled with an accelerated HAV/HBV vaccination                     Title: A Systematic Review of Cognitive Deficits in Homeless
schedule, may optimize vaccination compliance in homeless                     Adults: Implications for Service Delivery
adults.                                                                       Authors: Burra TA, Ster giopoulos V and Rourke SB
                                                                              Source: Canadian Journal of Psychiatry, 54(2):123-133, Feb2009
INFORMED CONSENT                                                              Summary: The primary goals of this systematic review were to assess
                                                                              studies of homeless adults and co gnitive functioning, and to
Title: The Capacity to Give Informed Conse nt in a Homeless                   explore the clinica l implications and potential impacts on social
Population with Developmental Disabilities                                    functioning of these cognitive deficits. The MEDLINE, CINAHL,
Authors: Morton LI and Cunningham-Williams R                                  EMBASE, PsycINFO, Applied Social Sciences Index and
Source: Community Mental Health Journal, Mar 5, 2009 [Epub                    Abstracts, ERIC, Social Sciences Abstracts, Social Sciences
ahead of print]                                                               Citation Index, Social Services Abstracts, and Sociological
Summary: This study examined homeless persons with                            Abstracts databases were searched from 1970 (or their inception)
developmental disabilities and their ability to understand the                to October 2007. Abstracts from 582 studies were screened and
informed consent process for research using a capacity-to-consent             22 studies were found to meet inclusion criteria (published in the
screener. Bivariate associations with the inability to pass the               English language, reported r esults of neuropsychological tests, or
screener on the first attempt were noted with thr ee factors: an              screening tests for cognitive dysfunction in homeless people aged
eighth grade or less in education, chronic homelessness, and                  18 years or older). Two investigators indep endently reviewed each
mental retardation dia gnosis. With multiple r egression, the only            study and rated its quality based on well-defined criteria. Ten
outcome associated with inability to pass the screener on the fir st          studies were of good or fair quality. Studies that administered the
attempt wa s an eighth grade or less education. This study indicates          Mini Mental State Examination indicate about 4% to 7% of
                                                                       - 6-
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.
homeless p eople exhibit global co gnitive deficits. Focal deficits in          and a control group that was matched by propensity score. Mental
verbal and visual memory, attention, sp eed of cognitive                        health services co sts for ca se management, outpatient services,
processing, and executive function wer e also apparent. No studies              inpatient and emergency services, criminal justice system ser vices,
of the functional implications of co gnitive deficits were found.               and total services were summarized for two-year per iods before
Cognitive deficits in homeless people likely ha ve a significant                and after clients initiated REACH. Incremental costs of the
mediating impact on the effectiveness of skills training and                    program were calculated as the difference in cost among clients in
rehabilitatio n programs. Clinicians should be co gnizant that                  the REACH group, from pre- to postintervention, less the
cognitive deficits probably impair homeless patients' ability to                difference in cost among those in the control group from pre- to
maintain housing stability and follow treatment                                 postintervention. A total of 177 REACH clients and 161 clients
recommendations. Imp lications for housing optio ns and health                  in a co ntrol group matched by propensity score wer e identified.
service delivery should also be considered. Research is lacking o n             Among REACH participants, case management costs incr eased by
inter ventions to improve cognitive functio ning in the homeless.               $6,403 (p<.001) from pre- to postintervention, inpatient p lus
                                                                                emergency services costs declined by $6,103 (p=.034), and costs for
Title: The Prevalence of Mental Disorders among the Homeless                    mental health ser vices provided by the criminal justice system
in Western Countries: Systematic Review and Meta-Regression                     declined by $570 (p=.020) compared with the control group. The
Analysis                                                                        standardized difference-in-difference estimate of the total costs
Authors: Fazel S, Khosla V, Doll H and Geddes J                                 between REACH clients and the control group was not
Source: Public Library of Science Medicine, 5(12):e225, 2008                    significant. Participation in REACH was associated with
Summary: Ther e are well o ver a million homeless p eople in                    substantial increases in outpatient services as well as cost offsets in
Western Europe and North America, but reliable estimates of the                 inpatient and emergency services and criminal justice system
prevalence of major mental disorders among this population are                  services. The net cost of ser vices, $417 over two years, was
lacking. We undertook a systematic review of surveys of such                    substantially lower than the total cost of services ($20,241).
disorders in homeless people. W e searched for surveys of the
prevalence of psychotic illness, major depression, alcohol and drug             Title: Investigating the Roles of Neighborhood Environments
dependence, and per sonality disorder that were based on                        and Housing-Based Social Support in the Relocation of Persons
inter views of samples of unselected homeless p eople. We searched              Made Homeless by Hurricane Katri na
bibliographic indexes, scanned refer ence lists, and corresponded               Authors: Kloos B, Flory K, Hankin BL, Cheely CA and Segal M
with authors. We explored potential sources of any observed                     Source: Journal of Prevention and Intervention in the Community,
heterogeneity in the estimates by meta-regression analysis,                     37(2):143-154, 2009
including geographical r egion, sample size, and diagnostic                     Summary: This study examined whether social support tied to
method. Twenty-nine eligible surveys provid ed estimates obtained               relocation efforts and neighborhood social climate may mediate
from 5,684 homeless individuals from seven countr ies. Substantial              the effects of stressful life events on mental health outco mes
heterogeneity wa s obser ved in prevalence estimates for mental                 following Hurricane Katrina. Participants were 108 adult persons
disorders amo ng the studies (all Cochran's χ2 significant at p <               made homeless by Hurricane Katrina and evacuated to Columbia,
0.001 and all I2 > 85%). The mo st co mmon mental disorders were                South Carolina. Civic leaders develop ed an intervention model
alcohol dep endence, which ranged from 8.1% to 58.5%, and drug                  that empha sized (a) a one-stop point of entry, (b) living in hotels
dependence, which ranged from 4.5% to 54.2%. For psychotic                      and apartments rather than shelters, and (c) matching hotels with
illness, the prevalence ranged from 2.8% to 42.3%, with similar                 volunteer "ho sts" to assist in relo cation efforts. Results revealed
findings for major depression. The prevalence of alcohol                        that perceived neighborhood factors and satisfaction with host
dependence was found to have incr eased over r ecent decades.                   relationship wer e related to several mental health outcomes.
Homeless p eople in Western countries are substantially more                    Neighborhood social climate partially mediated several mental
likely to have alcohol and drug dep endence than the age-matched                health outcomes. Implications of this intervention model and the
general population in those countries, and the prevalences of                   utility of social eco logical per spectives on homelessness
psychotic illnesses and per sonality disorders are higher. Models of            inter ventions are discussed.
psychiatric and social care that can b est meet these mental health
needs r equires further investigation.
                                                                                Title: "I'm G lad You Asked": Homeless Clients with Severe
Title: A Co st Analysi s of San Diego County's REACH Program                    Menta l Illness Evaluate Their Re sidential Care
for Homeless Persons                                                            Authors: McCr ea KT and Spravka L
Authors: Gilmer TP, Manning WG and Ettner SL                                    Source: Journal of Sociology & Social Welfare 35(4):133-159, 2008
Source: Psychiatric Services, 60(4): 445-450, Apr 2009                          Summary: Homeless clients with severe mental illness can offer
Summary: This study examined mental health service utilization                  considerable insight about their residential care, but there are
and costs associated with the California A ssembly Bill 2034                    significant methodological challenges in eliciting their service
housing-first program for homeless p ersons in San Diego County:                evaluations: maximizing participation, facilitating self-expression,
Reaching Out and E ngaging to Achieve Consumer Health                           and preser ving clients' natural meanings. This study addresses
(REACH). Encounter data were used to identify REACH clients                     those challenges and presents qualitative data residential care staff

                                                                         - 7-
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.
obtained from 210 clients. While clients prioritized meeting their              homeless population in Greater Glasgow National Health Ser vice
subsistence needs, they emphasized attaining inner well-being and               Board area for comparison. Over 5 years of observation, 1.7%
mutually resp ectful relatio nships, and that group ser vices needed            (209/12 451) of the general population and 7.2% (457/6323) of
to reduce confrontational interactions in order to be helpful. For              the ho meless cohort died. The hazard ratio of all-cause mortality
after-care services, clients sought sustained relationships with staff          in ho meless compared with non-homeless cohorts was 4.4 (95%
grounded in client initiative, combining resp ect for their                     CI: 3.8-5.2). After adjustment for age, sex and previous
autonomy with psychosocial support.                                             hospitalization, homelessness wa s associated with an all-cause
                                                                                mortality hazard ratio of 1.6 (95% CI: 1.3-1.9). Homelessness had
MORBIDITY/MORTALITY                                                             differential effects on cause-sp ecific mortality. Among patients
                                                                                who had been hospitalized for drug-related conditions, the
Title: Phy sical Diseases among Homeless People: Gender                         homeless cohort experienced a 7-fold increa se in risk of death
Differences and Comparisons with the General Population                         from drugs co mpared with the general populatio n. Ho melessness
Authors: Beijer U and Andr easson S                                             is an indep endent risk factor for deaths from specific causes.
Source: Scandinavian Journal of Public Health, 37(1):93-100, Jan                Preventive programmes might b e most effectively targeted at the
2009                                                                            homeless with these conditions.
Summary: To study morbidity amongst homeless men and women
by comparing prevalence of hospital care for so matic diseases and              NURSE-MANAGED CARE
injuries with a control group of men and wo men from the general
population. A cohort of 1,364 men and 340 women wer e                           Title: Improving Health Status of Homeless Patients at a Nurse-
documented a s homeless in 1996. Compariso ns are made                          Managed Clini c in the Midwest USA
concerning ho spital care for somatic diseases and injuries (1996-              Authors: Savage CL, Lindsell CJ, Gillesp ie GL, Lee RJ and Corbin
2002) among 3,750 men and 1,250 women from t he general                         A
population. The relative risk (RR) for homeless men and wo men                  Source: Health & Social Care in the Co mmunity 16 (5):469-475,
of being ho spitalised was double that of the men and wo men in                 Sep 2008
the controls (1.93 and 1.96 respectively). Homeless women had a                 Summary: Homeless adults have a higher rate of morbidity and
slightly, not significant, increased risk compared to ho meless men             mortality than their housed counterparts. Improving the hea lth of
(RR 1.10). Younger homeless women had a significant higher risk.                homeless adults is a complex problem because of the overlay of
Among diagno stic categories, the highest prevalence was found                  individual risk factors, social issues and lack of econo mic
among ho meless men in the diagnosis group injury/poisoning                     resources. Due to the incr eased morbidity and mortality rate in
(22%). The highest risk was found for skin diseases (RR 36.96)                  homeless adults, it is imperative to develop interventions with
and concerned homeless women. There wer e a number of gender                    demonstrated efficacy that result in improved health outcomes.
specific dia gnoses, where risks were co nsiderably elevated, such a s          The purpose of this pre-post p ilot study was to compare pre- and
diseases of the genital organs, viral hepatitis, and poisoning for              post-test scores on specific health outcomes in a group of homeless
homeless women, and cerebrovascular diseases, diseases of the                   adults receiving a nurse intervention when utilising a nurse-
liver, and concussion for homeless men. Ho meless people had                    managed clinic located in the urban core of a Midwestern city in
twice the r isk of being hosp italised for physical diseases compared           the USA. Between September of 2004 and January 2006, 43
to the general population. Younger wo men were particularly at                  homeless adults completed a health sur vey at baseline and 2
risk compared to homeless men and to women in the controls.                     months later that included measures of health-related quality of
There were a number of gender specific diagnoses that are                       life (HRQOL), substance use and health resource use. There was a
important to take into account when p lanning services for                      significant improvement on the post-test scores including
homeless p eople.                                                               substance use, perceived quality and availability of health care, and
                                                                                on two domains of HRQOL: mental health and vitality. This
Title: Homele ssness a s an Independent Risk Factor for Morta lity:             study provides evidence that a nursing intervention can result in
Results from a Retrospective Cohort Study                                       improved health outcomes for adult homeless p ersons.
Author: Morrison DS
Source: International Journal of Epidemiology, 2009 Mar 21 [Epub                ORAL HEALTH
ahead of print]
Summary: Homelessness is associated with increased risks of                     Title: The Pediatric Nurse Pra ctitioner's Role in Reduci ng Ora l
mortality but it has not previously b een possible to distinguish               Health Disparities in Homeless Children.
whether this is typ ical of other socio-economically deprived                   Authors: D iMarco MA, Huff M, Kinion E and Kendra MA
populations, the r esult of a higher preva lence of morbidity or an             Source: Journal of Pediatric Health Care, 23(2):109-116, Mar 2009
indep endent r isk of homelessness itself. The aim of this study was            Summary: Dental caries is the most common infectious disease of
to descr ibe mortality among a cohort of homeless adults and                    childr en. The majority of children in the United States who
adjust for the effects of morbidity and socio-eco nomic deprivation.            experience dental decay are from low-income, minority families.
Retrospective 5-year study of two fixed cohorts, ho meless adults               Many lo w- income, minority families are at risk for homelessness
and an age- and sex-matched random samp le of the local non-

                                                                         - 8-
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.
and, indeed, mothers with children are the fastest growing                     addiction problems. Indicators of involvement in crime and
homeless group. Once homeless, families end up in shelters.                    addiction problems with gambling and alcohol were not
Shelters are a unique source for the provision of health care;                 indep endently associated with homelessness. The findings
however, the provision of dental care to mothers and childr en in              underscore the relationship between sp ecific indicators of
shelters is limited. At a shelter-based clinic, of a total number of           adversity in childhood and risk of ho melessness and point to the
childr en assessed in a 24-month period (n = 264), 22.7% (n = 60)              importance of early intervention efforts. Consistent with the
had obvious gross denta l cavities. The school-aged childr en (6-12            extant research literature, mental health problems also appear to
years) (n = 41) had the highest prevalence of dental cavities (34%).           be associated with homelessness, highlighting the potentially
Consistent with the literature, dental caries was the most prevalent           complex service needs of this populatio n.
condition of homeless children and the mo st difficult for which to
obtain treatment. Follow-up was difficult b ecause of the transient            RESPITE
nature of homeless families.
                                                                               Title: Post-Hospital Medical Respite Care and Hospita l
PREVENTING HOMELESSNESS                                                        Readmission of Homeless Persons
                                                                               Authors: Kertesz SG, Po sner MA, O'Connell JJ, S wain S, Mullins
Title: Preventing Homelessness: An Examination of the                          AN, Shwartz M and Ash AS
Transition Resource Action Center                                              Source: Journal of Prevention & Intervention in the Community,
Authors: Senteio C, Marshall KJ, Ritzen EK and Grant J                         37(2):129-142, 2009
Source: Journal of Prevention and Intervention in the Community,               Summary: Medical resp ite programs offer medical, nursing, and
37(2):100-111, 2009                                                            other care as well as acco mmodation for homeless p ersons
Summary: Each year in the United States, as adolescents age out or             discharged from acute hospital stays. They r epresent a community-
are emancipated from the foster care system, they are at risk of               based adaptation of urban health systems to the specific needs of
experiencing homelessness. It is essential that ser vices and                  homeless p ersons. This article examines whether post-hosp ital
programs focus on encouraging and supporting youth in                          discharge to a homeless medical respite program was asso ciated
transition from foster care to a life of indep endence, and The                with a reduced chance of 90-day readmission compared to other
Transition Resource Action Center (TRAC) strives to provide                    disposition options. Adjusting for imbalances in patient
these ser vices. The r esearchers sought to determine if TRAC's                characteristics using propensity scores, r esp ite patients wer e the
residential program provides their clients with a chance of a stable           only group that was significantly less likely to be r eadmitted within
life (e.g., housing, emp loyment, health care). Findings suggest that          90 days compared to those r eleased to Own Care. R espite
fewer clients of TRAC became homeless and more acquired                        programs mer it attention as a potentially efficacious ser vice for
transitional or temporary housing from screening 1 to scr eening 2,            homeless p ersons leaving the hosp ital.
demonstrating promise that these services have fostered change in
the lives of their clients.                                                    Title: Medical Re spite Care for Homeless People : A Growing
                                                                               National Phenomeno n
Title: Risk Factors for Homele ssness: Evidence from a                         Authors: Zerger S, Doblin B and Thompson L
Population-Based Study                                                         Source: Journal of Health Care for the Poor and Underserved,
Authors: Shelton KH, Taylor PJ, Bonner A and van den Br ee M                   20(1):36-41, Feb 2009
Source: Psychiatric Services, 60(4):465-472, Apr 2009                          Summary: The first kno wn respite care facilities for homeless
Summary: This study examined factors associated with lifetime                  people emerged in the mid-1980s, but recent trends in health
experience of ho melessness a mong young adults. Data were                     systems and services have driven their rapid proliferation across
analyzed for 14,888 young adults (mean+/-SD age 21.97+/-1.77;                  the country within the past decade. This report is the first attempt
7,037 men and 7,851 women) who participated in the National                    to descr ibe these resp ite programs comprehensively.
Longitudinal Study of Adolescent Health (Add Health), a U.S.
nationally representative, population-based sample. Data were                  SUBSTANCE ABUSE
collected from young adults through computer-assisted interviews
six years after they had enrolled in the study as adolescents.                 Title: Drug and Alcohol Use among Homeless Older Adults:
Variables that ha ve been associated with lifetime homelessness in             Predictors of Reported Current and Lifetime Sub stance Misuse
at least one service sample wer e mapped to Add Health survey                  Problems in a National Sample.
items. Data wer e analyzed by logistic regr ession. A total of 682             Author: D ietz TL
respondents (4.6%) were classified as ever being homeless. Several             Source: Journal of Applied Gerontolo gy, 28(2):235-255, Apr 2009
factors related to childhood exp eriences of poor family                       Summary: Using data from the National Survey of Homeless
functioning, socio economic disadvantage, and separation from                  Assistance Providers and Clients (NSHAPC), predictors of current
parents or caregivers were independently associated with ever                  alcohol and drug misuse problems among homeless, previously
being ho meless. Other significant independent factors included                homeless, and marginally housed o lder adults are identified.
current socioeconomic difficulty, mental health problems, and                  Childhood sexual assault, victimization, and neglect, being male,

                                                                        - 9-
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.
being younger, being homeless or previously ho meless, being a               health care in Birmingha m, Alabama, comparing two p eriods,
minority, and having income below US $499 per month increased                1995 and 2005. We assessed whether a period effect was
the odds of reporting a drug problem. Being male, b eing younger,            indep endent of characteristics of p ersons surveyed. A nalysis of two
being ho meless, having mental illness incr eased the odds of                surveys conducted with identical methods among representative
reporting an alcohol problem. R eporting any typ e of substance use          samples of homeless persons in 1995 (n = 161) and 2005 (n =
problem increased the odds of reporting the other.                           161). Report of unmet need (inability to obtain care when needed)
                                                                             was the dependent variable. Two survey p eriods (1995 and 2005)
TRAUMATIC BRAIN INJURY                                                       were compared, with multivariable adjustment for
                                                                             sociodemographic and health characteristics. R easons for unmet
Title: The Effect of Traumatic Brain I njury on the Health of                need were determined a mong the subset of p ersons reporting
Homeless People                                                              unmet need. Unmet need for health care was more co mmon in
Authors: Hwang SW, Colantonio A, Chiu S, Tolomiczenko G, Kiss                2005 (54%) than in 1995 (32%) (p < 0.0001), especially for non-
A, Cowan L, R edelmeier DA and Levinson W                                    Blacks (64%) and females (65%). Adjusting for individual
Source: Canadian Medical A ssociation Journal, 179 (8):779-784,              characteristics, a survey year of 2005 independently predicted
Oct 2008                                                                     unmet need (odds ratio 2.68, 95% CI 1.49-4.83). Among p ersons
Summary: We sought to determine the lifetime prevalence of                   reporting unmet need (87 of 161 in 2005; 52 of 161 in 1995),
traumatic brain injury and its asso ciation with current health              financial barriers were more commonly cited in 2005 (67% of 87)
conditions in a representative sa mple of homeless people in                 than in 1995 (42% of 52) (p = 0.01). A rise in unmet health-care
Toronto, Ontario. Methods: We surveyed 601 men and 303                       needs was reported among Birmingham's ho meless from 1995 to
women at homeless shelters and meal programs in 2004-2005                    2005. This per iod effect was independent of population
(response rate 76%). We defined traumatic brain injury as any self-          characteristics and may implicate a local safety net inadequacy.
reported head injury that left the p erson dazed, confused,                  Additional data are needed to determine if this represents a
disoriented or unconscious. Injuries resulting in unconsciousness            national trend.
lasting 30 minutes or longer were defined as moderate or sever e.
We assessed mental health, a lcohol and drug problems in the past            VETERANS
30 days using the Addiction S everity Index. Physical and mental
health status was a ssessed using the SF-12 health survey. W e               Title: Co-Location of Health Care Services for Homeless
examined associations between traumatic brain injury and hea lth             Veterans: A Case Study of Innovation in Program
conditions. Results: The lifetime prevalence a mong homeless                 Implementation
participants was 53% for any traumatic brain injury and 12% for              Authors: Blue-Howells J, McGuir e J and Nakashima J
moderate or severe traumatic brain injury. For 70% of                        Source: Social Work in Health Care, 47(3):219-231, Aug 2008
respondents, their first traumatic brain injury occurred b efore the         Summary: This ca se study examines how the Veterans Affairs
onset of homelessness. After adjustment for demographic                      Greater Los A ngeles Healthcare System (GLA) improved homeless
characteristics and lifetime duration of homelessness, a history of          veteran service utilization through program innovation that
moderate or severe traumatic brain injury was associated with                addressed service fragmentation. The new program offered same-
significantly incr eased likelihood of seizures (odds ratio [OR] 3.2,        day co-located mental health, medical, and homeless ser vices with
95% confidence inter val [CI] 1.8 to 5.6), mental health problems            a coordinated intake system. The program is analyzed using a
(OR 2.5, 95% CI 1.5 to 4.1), drug problems (OR 1.6, 95% CI 1.1               framework proposed by Rosenheck (2001) that has four phases:
to 2.5), poorer physical health status (–8.3 points, 95% CI –11.1            the decision to implement, initial implementation, susta ined
to –5.5) and poorer mental health status (–6.0 points, 95% CI –              maintenance, and terminatio n or transformation. GLA was able
8.3 to –3.7). Prior traumatic brain injury is very common among              to successfully implement a new program that remains in the
homeless p eople and is associated with poorer health.                       sustained maintenance phase five years after the initial decision to
                                                                             implement. Key factors from the Rosenheck innovation model in
UNMET NEEDS                                                                  the program's success included coalition building, linking the
                                                                             project to legitimate goals, program monitoring, and developing
Title: Risi ng Inability to Ob tain Needed Health Care among                 communities of practicing clinicians. The key lesson from the case
Homeless Persons in Birming ham, Alabama (1995-2005)                         study is the need for a coalition to persistently problem solve and
Authors: Kertesz S, Hwang S, Irwin J, R itchey F and Lagory M                act as advocates for the program, even after successful initial
Source: Journal of General Internal Medicine, May 5, 2009 [Epub              implementatio n. Social work leader ship was critical in all phases
ahead of print]                                                              of program implementation.
Summary: Homeless persons depend disproportionately on the
health-care safety net for medical services. Natio nal reports               Title: Access to Primary Care for Homeless Veterans with
identify financial strains to this safety net. W hether this has             Serious Mental Illness or Substance Abuse : A Follow-up
affected homeless persons is unknown. We quantified changes in               Evaluation of Co-Located Primary Care and Homeless Social
the proportion of homeless persons r eporting unmet need for                 Services
                                                                             Authors: McGuire J, Gelberg L, Blue-Howells J and Rosenheck R

                                                                        - 10 -
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.
Source: Administration and Policy in Mental Health, Mar 12, 2009            and substance use in this population. Fifty ho meless women with
[Epub ahead of print]                                                       trauma histories participated. In line with predictions, more
Summary: To examine the hypothesis that a demonstration clinic              current sub stance use was r elated to less PTG, more r eliance on
integrating ho meless, primary care, and mental health ser vices for        avoidant coping once approach coping was accounted for, and
homeless veterans with serious mental illness or substance abuse            greater PTSD symptomatology. Levels of growth were co mparable
would improve medical health care access and physical health                to those found in samples with less trauma exposure.
status. A quasi-exp erimental design comparing a 'usual VA care'
group before the demonstration clinic op ened (N = 130) and the             Title: A Pilot of a Tripartite Prevention Program for Homeless
'integrated care' group (N = 130). Regression models indicated              Young Women i n the Tra nsition to Adulthood
that the integrated care group was more rapidly enrolled in                 Authors: W enzel SL, D'A mico EJ, Barnes D and Gilbert ML
primary care, received more prevention ser vices and primary care           Source: Women's Health Issues, Apr 3, 2009 [Epub ahead of print]
visits, and fewer emergency department visits, and was not                  Summary: Among young wo men who are impoverished and
different in inpatient utilization or in physical health status over        homeless, the transition to adulthood (ages 18-25) is associated
18 months. The demonstration clinic improved access to primary              with alcohol and drug use, risky sexual activity, and increased risk
care services and r educed emer gency services but did not improve          of being victimized by intimate partner violence. "The Power of
perceived physical health status o ver 18 months. Further research          YOU," a program using motivational interviewing (MI), was
is needed to determine generalizability and longer term effects.            designed to address these problems. W e tested the "Po wer of
                                                                            YOU" with 31 ho meless women (ages 18-25) in 7 focus groups.
WOMEN                                                                       Women completed questionnaires assessing background
                                                                            characteristics and satisfaction at the end of each group. Each
Title: Developing a Tripartite Prevention Program for                       group was follo wed by a feedback session that was audiorecorded
Impoverished Young Women Transitioning to Young                             and transcribed. Key themes wer e identified. During a past 6-
Adulthood: Addressi ng Substance Use, HIV Risk, a nd                        month p eriod, 38.7% of women reported alcohol intoxication,
Victimization by Intimate Partners                                          19.3% reported 2-3 male sex partners, and 22.2% reported major
Authors: D'A mico EJ, Barnes D, Gilbert ML, Ryan G and W enzel              physical violence from a partner. Women expressed satisfaction
SL                                                                          and provided consistently positive feedback on the inter vention,
Source: Journal of Prevention & Intervention in the Community,              reporting, for example, that it was "helpful to know ho w to put a
37(2):112-128, 2009                                                         condom on" and that they appreciated the attention paid to safety
Summary: Little is known about the transition to adulthood for              planning. Results from this p ilot suggest that "The Power of YOU"
                                                                            may hold promise in help ing homeless young women in the
adolescent females and young women who are impoverished and
                                                                            transition to adulthood make healthier choices and plan for high-
homeless. Co-occurrence of drug use and abuse, HIV r isk, and
                                                                            risk situations, and that the nonconfrontational, nonjudgmental
victimization is notable among homeless women, highlighting the
                                                                            approach of MI appeared appropriate for this population.
need for comprehensive interventions. Unfortunately, evidence-
based prevention approaches addressing these inter-related
problems among impoverished women transitioning into                        YOUTH AND ADOLESCENTS
adulthood are lacking. To address this gap, we designed an
innovative prevention program by utilizing open- and closed-                Title: Comparisons of Prevention Programs for Homeless Youth
ended interview data from impoverished women (n = 20), focus                Authors: Arnold E and Rotheram-Borus MJ
groups with co mmunity experts and providers (2 groups; n = 9),             Source: Prevention Science, 10(1):76-86, Mar 2009
and a theoretical framework to direct the research. Information             Summary: Ther e are six HIV prevention programs for homeless
provided by our focus groups and interviews with women                      youth whose efficacy ha s been or is currently being evaluated:
supported our theoretical framework and highlighted the                     STRIVE, the Community Reinforcement Approach, Strengths-
importance of addressing normative information, providing skills            Based Case Management, Ecologically-Based Family Therapy,
training, and utilizing a non-confrontational approach when                 Street Smart, and AESOP ( street outreach access to resources).
discussing these sensitive issues.                                          Programs vary in their underlying framework and theoretical
                                                                            models for understanding homelessness. All programs presume
Title: The Relationship between Posttraumatic Growth and                    that the youths' families lack the ability to support their adolescent
Substa nce Use i n Homele ss Women with Histories of Traumatic              child. Some programs deemphasize family involvement while
Experience                                                                  others focus on r ebuilding connections among family member s.
Authors: Stump MJ and Smith JE                                              The programs either normalize current family conflicts or,
Source: American Journal on Addictions, 17(6 ):478-487, 2008                alternatively, provide education about the importance of parental
Summary: Posttraumatic growth (PTG)--namely, the exper ience of             monitoring. A ll programs aim to reduce HIV-related sexual and
positive change in oneself or one's life following trauma--is               drug use acts. A coping skills approach is common across
particularly relevant for homeless women because they have                  programs: Problem-solving skills are sp ecifically addressed in four
greater trauma exposur e than the general population, a s well as           of the six programs; alternatively, parents in other programs are
higher rates of sub stance use. The present study examined PTG              encouraged to contingently reward their children. Each program
                                                                       - 11 -
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.
also engineers ongo ing social support for the families and the               districts, but these students also constitute a heterogeneous group
youth, either by providing access to needed resources or by                   of childr en likely to ha ve markedly diverse educational needs.
substituting a new, supportive relatio nship for the ex isting family         Efforts to close gaps or enhance achievement in H/HM children
caretaker. All of the interventions provide access to health and              require more differentiated kno wledge of vulnerability and
mental health ser vices as basic program resources. A comparison              protective processes that may shape individual development and
of HIV prevention programs for homeless youth identifies the                  achievement.
robust components of each and suggests which programs
providers may choose to r eplicate.                                           Title: Risk Factors for Trading Sex among Homeless Young
Title: Who I s Doing We ll? A Typology of Newly Homeless                      Author: Tyler KA
Adolescents                                                                   Source: Archives of Sexual Behavior, 38(2):290-297, Apr 2009
Authors: Milburn N, Liang L-J, Lee S-J, Rotheram-Borus MJ,                    Summary: Although numerous homeless youth r eport trading sex,
Rosenthal D, Ma llett S                                                       few studies have examined r isk factors associated with trading sex
Source: Lightfoot M and Lester P Journal of Community                         and even fewer ha ve employed multivariate analyses to examine
Psycholo gy, 37(2):135-147, Mar2009                                           this relationship, even though trading sex is a ssociated with many
Summary: Ther e is growing evidence to support developing new                 negative health outcomes. Based on a sample of 151 homeless
typologies for ho meless adolescents. Current typologies focus on             young adults in the midwestern United States, lo gistic regression
the risks associated with b eing homeless, with less consideration of         analyses revealed that for each additional year of age, youth were
the positive attributes of homeless adolescents. The authors                  37% more likely to have traded sex (AOR = 1.37; 95% CI = .99-
examined both risk and protective factors in a sample of newly                1.90). White youth were 84% less likely to have traded sex than
homeless adolescents. Using cluster analysis techniques, they                 non-white youth (AOR = .16; 95% CI = .03-.77). Furthermore,
identified three distinct clusters of newly homeless adolescents:             youth who had been employed full time were 80% less likely to
those who are protected and doing relatively well while out of                have traded sex (AOR = .20; 95% CI = .05-.85). For every one unit
home with more protective than r isk factors, tho se who are at-risk,         increa se in depressive sympto ms, ther e wa s an 11% incr ease in the
and those who are risky with more risk than protective factors.               likelihood of ever having traded sex (AOR = 1.11; 95% CI = .99-
Over half (51.9%) of these newly homeless adolescents were in the             1.24). Additionally, those who had friends who traded sex were
protected cluster. This typology has implications for the design              approximately five times more likely to have ever traded sex
and implementation of services and inter ventions for newly                   themselves compared to those with no friends who had traded sex
homeless adolescents to r econnect them with stable housing                   (AOR = 5.17; 95% CI = .95-28.12). Finally, youth who were
situations.                                                                   propositioned to trade sex were almost five and one-half times
                                                                              more likely to have ever done so compared to youth who had not
Title: Academic Achievement of Homeless and Highly Mobile                     been propositioned (AOR = 5.45; 95% CI = 1.02-29.17). Overall,
Children i n an Urban School District: Longitudi nal Evidence o n             the results ha ve important implications for the health and well-
Risk, Growth, and Resilience                                                  being of this high-risk population.
Authors: Obradovic J, Long J, Cutuli J, Chan C, Hinz E, Heistad D
and Masten A
Source: Development and Psychopathology, 21(2):493-518, 2009
Summary: Longitudinal growth trajectories of reading and math
achievement were studied in four primary school grade cohorts
(GCs) of a large urban district to examine academic risk and
resilience in homeless and highly mobile (H/HM) students. Initial
achievement was assessed when student cohorts were in the
second, third, fourth, and fifth grades, and aga in 12 and 18
months later. A chievement trajectories of H/HM students were
compared to low-income but no nmobile students and all other
tested students in the district, controlling for four well-established
covariates of achievement: sex, ethnicity, attendance, and English
language skills. Both disadvantaged groups sho wed markedly lower
initial achievement than their more advanta ged p eer s, and H/HM
students manifested the greatest r isk, consistent with an expected
risk gradient. Moreover, in so me GCs, both disadvanta ged groups
showed slower growth than their relatively advanta ged p eer s.
Closer examination of H/HM student trajectories in relation to
national test norms r evealed striking variability, including cases of
academic resilience as well as problems. H/HM students may
represent a major component of "achievement gaps" in urban

                                                                         - 12 -
                 For previous issues of HCH Research Update, visit the National Health Care for th e Homeless Council
                 website at All are searchable by keyword using the Search function on the homepage.

Jun Wang Jun Wang Dr
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