Housing Stability and Recovery Among Chronically Homeless Persons With Co-Occuring Disorders in Washington,DC

Pathways Housing First provides access to housing, support, and treatment services to clients having the most complex needs—persons who have been homeless for at least 5 years and have both a psychiatric disability and substance dependency. In a 2-year Housing and Urban Development-funded demonstration project in Washington, DC, in 2007 and 2008, we observed promising outcomes in housing retention and reductions in psychiatric symptoms, alcohol use, and demand for intensive support services. The program is designed to be fiscally self-sustaining through extant public disability benefits for housing, treatment, and support services. This approach shows strong support for first providing a permanently supported housing solution for chronically homeless and severely disabled individuals in need of housing and treatment of co-occurring disorders.

KEY FINDINGS

• ▪Housing retention of severely disabled and chronically homeless individuals having extensive service needs, each alcohol dependent and homeless for a minimum of 5 years at intake, was 97% in the first year and 84% in the second year.
• ▪Highly distressed individuals showed significant reduction in psychiatric symptoms within the first year of housing, with client-centered housing support and voluntary psychiatric treatment provided as desired by the client.
• ▪Psychiatrically disabled and alcohol-dependent individuals can make significant mental and behavioral health improvements in recovery within a year of housing without abstinence or treatment compliance demands upon enrollment and with voluntary addiction treatment as desired by the client.
• ▪Demand for intensive ACT services was reduced to much less intensive and costly community support services for 14% of clients within 2 years.

Individuals who remain chronically homeless frequently suffer debilitating effects of serious mental illness and addiction. These frequently co-occurring disorders represent an extremely difficult hurdle for individuals to overcome. Typical housing programs demand sobriety and compliance with psychiatric and behavioral treatment as a condition of admission and continued enrollment. A more realistic, compassionate, and effective approach provides housing without such prerequisites and instead provides immediate access to permanent housing with supports as a foundation for recovery.     

The Effect of Advance Directive Completion on Hospital Care Among Chronically Homeless Persons: a Prospective Cohort Study

Advance care planning is relevant for homeless individuals because they experience high rates of morbidity and mortality. The impact of advance directive interventions on hospital care of homeless individuals has not been studied. The objective of this study was to determine if homeless individuals who complete an advance directive through a shelter-based intervention are more likely to have information from their advance directive documented and used during subsequent hospitalizations. The advance directive included preferences for life-sustaining treatments, resuscitation, and substitute decision maker(s). A total of 205 homeless men from a homeless shelter for men in Toronto, Canada, were enrolled in the study and offered an opportunity to complete an advance directive with the guidance of a trained counselor from April to June 2013. One hundred and three participants chose to complete an advance directive, and 102 participants chose to not complete an advance directive. Participants were provided copies of their advance directives. In addition, advance directives were electronically stored, and hospitals within a 1.0-mile radius of the shelter were provided access to the database. A prospective cohort study was performed using chart reviews to ascertain the documentation, availability, and use of advance directives, end-of-life care preferences, and medical treatments during hospitalizations over a 1-year follow-up period (April 2013 to June 2014) after the shelter-based advance directive intervention. Chart reviewers were blinded as to whether participants had completed an advance directive. The primary outcome was documentation or use of an advance directive during any hospitalization. The secondary outcome was documentation of end-of-life care preferences, without reference to an advance directive, during any hospitalization. After unblinding, charts were studied to determine whether advance directives were available, hospital care was consistent with patient preferences as documented in advance directives, and hospital resource utilization during admission. During the 1-year follow-up period, 38 participants who completed an advance directive and 37 participants who did not complete an advance directive had at least one hospitalization (36.9 vs. 36.2 %, p?=?0.93). Participants who completed an advance directive were significantly more likely to have documentation or use of an advance directive in hospital, compared to participants who did not complete an advance directive (9.7 vs. 2.9 %, p?=?0.047). Without reference to an advance directive, documentation of end-of-life care preferences occurred in 30.1 vs. 30.4 % of participants, respectively (p?=?0.96), most often due to documentation of code status. There were no significant differences in resource utilization between admitted patients who completed and did not complete an advance directive. In conclusion, homeless men who complete an advance directive through a shelter-based intervention are more likely to have their detailed care preferences documented or used during subsequent hospitalizations.     

An Examination of Fulfilled Housing Preferences and Quality of Life among Homeless Persons with Mental Illness and/or Substance Use Disorders

This study examined the types of housing features considered important to a sample of homeless persons diagnosed with a mental illness and/or substance use disorder and the relationship between the degree to which important features were obtained in subsequent housing and subjective quality of life, clinical and housing outcomes at 3-month and 1-year follow-up periods. After controlling for significant clinical and sociodemographic covariates, results from regression analyses indicate that the degree to which a client's individual housing preferences were realized in dwellings is significantly associated with greater quality of life in the future, but not clinical outcomes or housing tenure.This study was conducted at the Yale Department of Psychiatry, VA Northeast Program Evaluation Center, 950 Campbell Avenue, West Haven, CT 06516, USA.Robert Rosenheck, MD, is a professor at the Yale Department of Psychiatry and Yale Department of Epidemiology and Public Health, and director of the VA Northeast Program Evaluation Center, 950 Campbell Ave., West Haven, CT 06516, USA.Wesley Kasprow, PhD, is a project director at the Yale Department of Psychiatry and VA Northeast Program Evaluation Center, 950 Campbell Ave., West Haven, CT 06516, USA.Linda Frisman, PhD, is a director of research at the Connecticut Department of Mental Health and Addiction Services, Hartford Connecticut, and University of Connecticut Department of Psychology, Storrs, CT, Psychology Building, Storrs Campus, 406 Babbidge Road, Storrs, CT 06269-1020, USA.     

Group and Organizational Involvement Among Persons with Psychiatric Disabilities in Supported Housing

This study examined the patterns and correlates of group and organizational involvement among persons with psychiatric disabilities using a cross-sectional, probability sample of 252 residents in supported independent housing (SIH). Groups and organizations were classified according to whether or not they have a behavioral health focus. Demographic, clinical, and service use characteristics were examined as potential predictors of membership using Poisson regression models. Findings indicated that 60% of the sample was involved in some kind of behavioral or nonbehavioral health organization. Similar to the findings from the general population, higher rates of membership were found among older persons, Blacks, those with more years of education, and those with higher incomes. Other correlates specific to the SIH sample included prior homelessness, perceived discrimination, substance abuse history, psychiatric symptoms, psychiatric diagnosis, and contact with service providers. Implications of study findings for developing intervention strategies to enhance organizational membership and for future research are discussed.     

Tripling of Methamphetamine/Amphetamine Use among Homeless and Marginally Housed Persons, 1996–2003

Methamphetamine/amphetamine (MA)-related morbidity and mortality has been increasing in the United States. MA use is associated with high-risk sexual behavior and syringe-sharing practices. Homeless and marginalized housed persons (H/M) have high rates of substance use and mental health disorders. Little is known about trends of MA use among the H/M. The objective of this study was to quantify increases in MA use among H/M in San Francisco and to determine which demographic and behavioral subgroups have experienced the greatest increases in MA use. We conducted serial cross-sectional population-based studies in three waves: 1996–1997, 1999–2000, and 2003 and studied 2,348 H/M recruited at shelters and lunch lines. The main outcome was self-reported current (30-day) MA use. We found a tripling of current MA use among H/M persons from 1996 to 2003, with a sevenfold increase in smoked MA use. MA use doubled to tripled in most demographic and behavioral subgroups, whereas it quadrupled in those under age 35, and there was a fivefold increase among HIV-infected persons. The increase in MA use among H/M places a vulnerable population at additional increased risk for HIV infection and MA-use related morbidity and mortality. Among HIV-infected H/M, the increase in MA use has important public health implications for the development and secondary transmission of drug-resistant HIV caused by synergistic neurocognitive decline, poor adherence to HIV medications, and increased sexual risk behavior. Clinicians caring for H/M persons should inquire about MA use, refer interested MA users to MA dependence treatment programs and provide targeted HIV sexual risk reduction counseling. For HIV-infected H/M MA users, clinicians should closely monitor adherence to HIV or other chronic medications, to avoid unnecessary morbidity and mortality. Further research is needed to elucidate the most effective prevention and treatment for MA use and dependence among the H/M. Das-Douglas and Bangsberg are with the Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA; Das-Douglas, Bangsberg, and Hahn are with the Epidemiology and Prevention Interventions Center, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA; Das-Douglas and Bangsberg are with the Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA; Colfax is with the Epidemiology Section, AIDS Office, San Francisco Department of Public Health, San Francisco, CA, USA; Moss is with the Epidemiology and Biostatistics, University of California, San Francisco, USA.     

社区残疾人心理健康状况调查和干预初探

目的了解社区残疾人心理健康状况,探索社区卫生服务人员为残疾人身心康复服务的方法。方法随机将120例持有残疾证、登记在册的残疾人分成干预组和对照组,后两组各脱落2例,共完成116例。对干预组进行团体咨询、个别辅导和家庭干预等心理综合干预,为期1年;对照组则不干预。采用焦虑自评量表(SAS)和抑郁自评量表(SDS)对研究对象进行评估。结果干预后,干预组SAS、SDS量表分数分别为(35.91±7.16)分、(35.83±10.79)分,明显优于对照组(40.56±8.54)分、(40.03±10.73)分,差异具有显著性(P0.05,P0.01)。在改善人际关系和家庭支持方面,干预组也明显优于对照组(P0.05,P0.01)。结论心理综合干预对残疾人的心理康复有积极作用。     

Transitions between Housing States among Urban Homeless Adults: a Bayesian Markov Model

The purpose of this study is to explore how marginalization, substance abuse, and service utilization influence the transitions between streets, shelters, and housed states over the course of 2 years in a population of urban homeless adults. Survey responses from three yearly interviews of 400 homeless adults were matched with administrative services data collected from regional health, mental health, and housing service providers. To estimate the rates of transition between housed, street, and shelter status, a multi-state Markov model was developed within a Bayesian framework. These transition rates were then regressed on a set of independent variables measuring demographics, marginalization, substance abuse, and service utilization. Transitions from housing to shelters or streets were associated with not being from the local area, not having friends or family to count on, and unemployment. Pending charges and a recent history of being robbed were associated with the shelters-to-streets transition. Remaining on the streets was uniquely associated with engagement in “shadow work” and, surprisingly, a high use of routine services. These findings paint a picture of unique and separate processes for different types of housing transitions. These results reinforce the importance of focusing interventions on the needs of these unique housing transitions, paying particular attention to prior housing patterns, substance abuse, and the different ways that homeless adults are marginalized in our society.     

Housing First for Long-Term Shelter Dwellers with Psychiatric Disabilities in a Suburban County: A Four-Year Study of Housing Access and Retention

Housing First is an effective intervention that ends and prevents homelessness for individuals with severe mental illness and co-occurring addictions. By providing permanent, independent housing without prerequisites for sobriety and treatment, and by offering support services through consumer-driven Assertive Community Treatment teams, Housing First removes some of the major obstacles to obtaining and maintaining housing for consumers who are chronically homeless. In this study, consumers diagnosed with severe mental illness and who had the longest histories of shelter use in a suburban county were randomly assigned to either one of two Housing First programs or to a treatment-as-usual control group. Participants assigned to Housing First were placed in permanent housing at higher rates than the treatment-as-usual group and, over the course of four years, the majority of consumers placed by both Housing First agencies were able to maintain permanent, independent housing. Results also highlight that providers new to Housing First must be aware of ways in which their practices may deviate from the essential features of Housing First, particularly with respect to enrolling eligible consumers on a first-come, first-served basis and separating clinical issues from tenant or housing responsibilities. Finally, other aspects of successfully implementing a Housing First program are discussed.     

Project-Based Housing First for Chronically Homeless Individuals With Alcohol Problems: Within-Subjects Analyses of 2-Year Alcohol Trajectories

Objectives. Two-year alcohol use trajectories were documented among residents in a project-based Housing First program. Project-based Housing First provides immediate, low-barrier, nonabstinence-based, permanent supportive housing to chronically homeless individuals within a single housing project. The study aim was to address concerns that nonabstinence-based housing may enable alcohol use.Methods. A 2-year, within-subjects analysis was conducted among 95 chronically homeless individuals with alcohol problems who were allocated to project-based Housing First. Alcohol variables were assessed through self-report. Data on intervention exposure were extracted from agency records.Results. Multilevel growth models indicated significant within-subjects decreases across alcohol use outcomes over the study period. Intervention exposure, represented by months spent in housing, consistently predicted additional decreases in alcohol use outcomes.Conclusions. Findings did not support the enabling hypothesis. Although the project-based Housing First program did not require abstinence or treatment attendance, participants decreased their alcohol use and alcohol-related problems as a function of time and intervention exposure.A review of 29 studies conducted worldwide estimated an alcohol dependence prevalence of 37.9% among homeless populations.1 Among chronically homeless individuals (i.e., people with long-term, often-repeated episodes of homelessness2), the prevalence of alcohol dependence is even higher.3 Alcohol dependence is associated with greater levels of alcohol problems, resulting from acute intoxication or long-term alcohol use, as well as increased risk for alcohol-related deaths.4–7Unfortunately, traditional housing infrastructures designed to serve chronically homeless individuals with alcohol problems often fail to engage residents and comprehensively address their complex needs.8,9 One reason for this failure might be perceived barriers to housing imposed by housing agencies, such as requiring psychiatric or substance abuse treatment attendance or abstinence from substance use.10 Policymakers have therefore called for the development of low-barrier housing programs that might more effectively engage these individuals, house them, and attend to their needs.11,12Housing agencies have begun to respond to this call by designing project-based Housing First approaches to fit the specific needs of chronically homeless individuals with alcohol problems.13 As in other Housing First approaches (e.g., scattered-site Housing First), project-based Housing First for this population entails the provision of low-barrier, nonabstinence-based (i.e., not requiring abstinence from substance use), immediate, and permanent housing.14,15 Specific to the project-based Housing First model, however, individuals are offered units within a single housing project, where they can elect to receive on-site case management and other supportive services. Although project-based Housing First programs are receiving increased interest in the supportive housing field,16 only a couple of studies to date have examined their effectiveness in this population.13,17 These studies have shown that project-based Housing First programs are associated with increased housing stability, reduced use of publicly funded services and associated costs, and short-term reductions in typical daily alcohol use.13,17Despite encouraging initial findings for the project-based Housing First approach,13 abstinence-based programs are the mainstay of housing models in the United States.18 Alcohol abstinence and abstinence-based treatment requirements are typical across a wide range of housing models (e.g., emergency shelters, transitional housing, halfway houses, permanent supportive housing).19 Even as Housing First models are being recommended as evidence-based best practice12 and are receiving more attention in the press,20,21 debate continues about whether nonabstinence-based housing approaches, such as project-based Housing First, are appropriate for chronically homeless individuals with alcohol problems.22The argument for abstinence-based approaches is typically derived from the disease model of alcohol use disorder etiology, which conceptualizes alcohol dependence as a “chronic, relapsing brain disease.”23,24 Proponents of the disease model posit that alcohol dependence should be treated through interventions designed to help people achieve and maintain abstinence.24 The corollary is that by not prohibiting alcohol use and by supporting clients’ choices about their drinking goals, nonabstinence-based approaches may “enable” or facilitate continued, harmful drinking.25 Despite this widespread belief, there is little empirical data to support it. Recent studies have shown that abstinence-based housing is not necessarily more effective than Housing First approaches26,27 and have indicated that clients and providers prefer the autonomy and sense of stability of Housing First over traditional housing models.28,29The study aim was to address concerns about the appropriateness of project-based Housing First designed for chronically homeless individuals with alcohol problems. Specifically, we tested the enabling hypothesis,25,30 which posits that the provision of nonabstinence-based Housing First would result in stable or increasing levels of alcohol use and alcohol-related problems. We predicted that the enabling hypothesis would not be confirmed and that participants in project-based Housing First would, on the contrary, show significant, within-subjects decreases in alcohol use and alcohol-related problems over a 2-year follow-up.     

Housing Circumstances are Associated with Household Food Access among Low-Income Urban Families

Household food insecurity is a pervasive problem in North America with serious health consequences. While affordable housing has been cited as a potential policy approach to improve food insecurity, the relationship between conventional notions of housing affordability and household food security is not well understood. Furthermore, the influence of housing subsidies, a key policy intervention aimed at improving housing affordability in Western countries, on food insecurity is unclear. We undertook a cross-sectional survey of 473 families in market rental (n = 222) and subsidized (n = 251) housing in high-poverty urban neighborhoods to examine the influence of housing circumstances on household food security. Food insecurity, evident among two thirds of families, was inversely associated with income and after-shelter income. Food insecurity prevalence did not differ between families in market and subsidized housing, but families in subsidized housing had lower odds of food insecurity than those on a waiting list for such housing. Market families with housing costs that consumed more than 30% of their income had increased odds of food insecurity. Rent arrears were also positively associated with food insecurity. Compromises in housing quality were evident, perhaps reflecting the impact of financial constraints on multiple basic needs as well as conscious efforts to contain housing costs to free up resources for food and other needs. Our findings raise questions about current housing affordability norms and highlight the need for a review of housing interventions to ensure that they enable families to maintain adequate housing and obtain their other basic needs.     

Access to Primary Health Care Among Persons With Disabilities in Rural Areas: A Summary of the Literature

Despite the prevalence of disabilities among persons living in rural areas, scarce data exist on their health care needs. While rural residents generally experience barriers to access to primary health care, these problems are further exacerbated for people with disabilities. This article summarizes findings from the published literature on access to primary health care among people with disabilities living in rural locations. A comprehensive computerized literature search turned up 86 articles meeting the study criteria, focused on the following rural populations affected by disabilities: children and adolescents, working-age adults, the elderly the mentally ill, and people with AIDS. For each of these populations, substantial problems in accessing appropriate health care have been documented. The literature consistently emphasizes the failure of local health care systems in nonmetropolitan areas to adequately address the complex medical and related needs of individuals with disabilities. In the absence of specialized expertise, facilities, and primary care providers trained specifically to care for disabled persons, local programs rely heavily on the use of indigenous paraprofessionals and alternative models of care. Further research is needed to identify and test the efficacy of innovative service delivery strategies to improve health care access for this population.     

The Effect of a Housing First Intervention on Acute Health Care Utilization among Homeless Adults with Mental Illness: Long-term Outcomes of the At Home/Chez-Soi Randomized Pragmatic Trial

We assessed the effects of the Toronto Site Housing First (HF) intervention on hospitalizations and emergency department (ED) visits among homeless adults with mental illness over 7 years of follow-up. The Toronto Site is part of an unblinded multi-site randomized pragmatic trial of HF for homeless adults with mental illness in Canada, which followed participants up to 7 years. Five hundred seventy-five participants were recruited and classified as having high (HN) or moderate need (MN) for mental health support services. Each group was randomized into intervention (HF) and treatment as usual groups, and 567 (98.6%) consented to link their data to health administrative databases. HF participants received a monthly rent supplement of $600 (Canadian) and assertive community treatment (ACT) support or intensive care management (ICM) support based on need level. Treatment as usual (TAU) participants had access to social, housing, and health services generally available in the community. Outcomes included all-cause and mental health-specific hospitalization, number of days in hospital, and ED visit. We used GEE models to estimate ratio of rate ratios (RRR). The results showed HF with ACT had no significant effect on hospitalization rates among HN participants, but reduced the number of days in hospital (RRR = 0.32, 95% CI 0.16-0.63) and number of ED visits (RRR = 0.57, 95% CI 0.34-0.95). HF with ICM resulted in an increase in the number of hospitalizations (RRR = 1.69, 95% CI 1.09-2.60) and ED visit rates (RRR = 1.42, 95% CI 1.01-2.01) but had no effect in days in hospital for MN participants. Addressing the health needs of this population and reducing acute care utilization remain system priorities. Trial registration: http://www.isrctn.com/identifier: ISRCTN42520374Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-021-00550-1.     

Postpartum Hospital Utilization among Massachusetts Women with Intellectual and Developmental Disabilities: A Retrospective Cohort Study

Objectives This study examined the risk of postpartum hospital admissions and emergency department (ED) visits among US women with intellectual and developmental disabilities (IDD). Methods We used the 2002–2012 Pregnancy to Early Life Longitudinal Data System and identified deliveries to women with and without IDD. Women with IDD (n?=?1104) or case subjects were identified from the International Classification of Diseases and Related Health Problems 9th Revision (ICD-9 CM) codes. The study primary outcome measures were any postpartum hospital admission and any ED visit during three critical postpartum periods (1–42, 43–90, and 1–365 days). We conducted unadjusted and adjusted survival analysis using Cox proportional hazard models to compare the occurrence of first hospital admission or ED visits between women with and without IDD. Results We found that women with IDD had markedly higher rates of postpartum hospital admissions and ED visits during the critical postpartum periods (within 1–42, 43–90, and 91–365 days) after a childbirth. Conclusion for Practice Given the heightened risk of pregnancy complications and adverse birth outcomes and the findings of this study, there is an urgent need for clinical guidelines related to the frequency and timing of postpartum care among new mothers with IDD. Further, this study provides evidence of the need for evidence-based interventions for new mothers with IDD to provide preventive care and routine assessments that would identify and manage complications for both the mother and the infant outside of the traditional postpartum health care framework.