Improving Health of Homeless Requires Coordinated Care

Interventions providing coordinated treatment and support for homeless adults usually results in greater health improvements than does the prevailing sporadic and substandard care, according to a new review of studies.

“We found evidence that a substantial number of different types of programs and interventions are effective in improving the health of homeless adults, especially those with mental illness and homelessness,” says lead investigator Stephen Hwang, M.D., of the Centre for Research on Inner City Health at St. Michael’s Hospital in Toronto.

However, the systematic review, published in the November American Journal of Preventive Medicine, found a decided lack of evidence on how to keep homeless children healthy.

“Very little is known about what works to help street youths and homeless families with children,” Hwang said. “This knowledge gap is striking, especially if one considers that what is done, or not done, to change the course of the lives of these young people will have enormous downstream consequences for years to come.”

“Homeless persons” were defined as those who lack a fixed, regular and adequate nighttime residence, including residents of supervised shelters or places not meant for human habitation.

The researchers reported that for homeless persons with mental illness, case management coordinated with other services effectively improved psychiatric symptoms, and assertive case management effectively decreased psychiatric hospitalizations and increased outpatient contacts. For those with substance abuse problems, case management produced larger benefits than non-intervention.

Of the 45 well-designed studies Hwang and colleagues looked at, six reported findings from the Access to Community Care and Effective Services and Supports (ACCESS) program, conducted in the 1990s to evaluate services for their effectiveness in helping persons with mental illness avoid homelessness and to improve their clinical outcomes, quality of life, and service use. ACCESS programs took place in Illinois, Connecticut, Missouri, North Carolina, Pennsylvania, Texas, Virginia and Washington. Clients at all sites where services were coordinated among agencies reported improvements in mental health and with substance abuse problems.

“The study by Hwang is thorough and systematic,” said Peter Muennig, M.D., assistant professor at Columbia University’s Mailman School of Public Health. “Given the limitations inherent to studying homeless populations, the studies they include in their review are sometimes imperfect. Taken as a whole, though, some consistent data emerge. Interventions are most effective if they are comprehensive and include a case management component.”

Muennig describes the roots of the current situation: “The present homeless epidemic emerged in the 1980s after three decades of de-institutionalization of psychiatric patients reached its peak. Despite [this] long duration, communities were remarkably ill prepared to manage patients on an outpatient basis. At present, approximately 60 percent to 70 percent of the homeless population has a mental illness, a drug addiction or both.”

The investigators conclude that the findings should challenge public health officials and clinicians to focus on ensuring that the homeless receive health care through coordinated treatment and support designed specifically to their needs — mental illness, substance abuse, tuberculosis — and that addresses specific subgroups — homeless or runaway youths, families with children and homeless women.

“Sadly, nearly a half century after patients were removed from institutions and treated in the community, we’ve done little but move from a model of abuse within institutions to abuse on the street,” Muenning said.

From Health Behavior News Service

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