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 AGE DIFFERENCES 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 www.nhchc.org. 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 www.nhchc.org. 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. HOUSING HIV/AIDS 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 2009 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 www.nhchc.org. 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 www.nhchc.org. 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 www.nhchc.org. 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 www.nhchc.org. 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 www.nhchc.org. 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 www.nhchc.org. 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 www.nhchc.org. 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 www.nhchc.org. 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 www.nhchc.org. 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 Adults 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 www.nhchc.org. All are searchable by keyword using the Search function on the homepage.