16916277
Shelter-based convalescence for homeless adults in Amsterdam: a descriptive study
BackgroundAdequate support for homeless populations includes shelter and care to recuperate from illness and/or injury. This is a descriptive analysis of diagnoses and use of shelter-based convalescence in a cohort of homeless adults in Amsterdam.MethodsDemographics of ill homeless adults, diagnoses, referral pattern, length of stay, discharge locations, and mortality, were collected by treating physicians during outreach care provision in a shelter-based convalescence care facility in Amsterdam, from January 2001 through October 2007.Results629 individuals accounted for 889 admissions to the convalescence care facility. 83% were male and 53% were born in the Netherlands. The mean age was 45 years (SD 10 years). The primary physical problems were skin disorders (37%), respiratory disorders (33%), digestive disorders (24%) and musculoskeletal disorders (21%). Common chronic conditions included addictions 78%, mental health disorders 20%, HIV/AIDS 11% and liver cirrhosis 5%. Referral sources were self-referred (18%), general hospitals (21%) and drug clinics (27%). The median length of stay was 20 days. After (self)discharge, 63% went back to the previous circumstances, 10% obtained housing, and 23% went to a medical or nursing setting. By March 2008, one in seven users (n = 83; 13%) were known to have died, the Standard Mortality Ratio was 7.5 (95% CI: 4.1-13.5). Over the years, fewer men were admitted, with significantly more self neglect, personality disorders and cocaine use. Lengths of stay increased significantly during the study period.ConclusionOver the last years, the shelter-based convalescence care facility users were mainly homeless single males, around 45 years of age, with chronic problems due to substance use, mental health disorders and a frail physical condition, many of whom died a premature death. The facility has been flexible and responsive to the needs of the users and services available.
72249837
The Cottage Project: Caring for the unwell homeless person
Objectives: The present study aims to describe the functioning of the Cottage, to describe the demographics of the patients using the Cottage, to examine benefits conveyed to patients relating to improvements in health and accommodation circumstances and to examine cost benefits of the Cottage. 
 
 
 
Setting: The Cottage is a six-bed, low-dependency residential facility adjacent to St Vincent's Hospital Melbourne, a 450-bed inner city adult tertiary teaching hospital. 
 
 
 
Methods: Retrospective chart analysis of 50 consecutive admissions from 1 June to 1 September 1996. 
 
 
 
Results: Seventy-eight per cent of patients were discharged in improved health. Eight per cent gained no health improvement. Four per cent required hospital admission and 2% required Cottage readmission. Forty-four per cent of patients were discharged to improved accommodation circumstances and 56% were discharged to the same circumstances. The cost of a Cottage bed was $82 /day. 
 
 
 
Conclusions: The Cottage fulfils an important, cost-effective role in caring for the unwell homeless person.
38898535
Hoptel Equalizes Length of Stay for Homeless and Domiciled Inpatients
Background.There is growing evidence that homeless individuals have longer inpatient lengths of stay with significantly higher medical costs than domiciled individuals. We compared adjusted mean lengths of stay among domiciled patients and homeless patients discharged to a hospital hotel (hoptel). Because the hoptel allowed homeless patients to be discharged when medically indicated, we hypothesized no significant differences in lengths of stay between the 2 groups after adjustment for severity of illness. Methods.Demographic, diagnosis, and length of stay data were obtained for all patients discharged from all inpatient wards at a large, urban Veterans Affairs Medical Center during the first 32 months of hoptel operation (1996 through 1998). Adjusted mean lengths of stay for domiciled patients and homeless patients discharged to the hoptel were compared. ANCOVA was used to adjust for demographic characteristics (age, income, race/ethnicity), diagnosis-related group (DRG), principal diagnosis, and substance abuse comorbidity. Three types of hospitalizations were analyzed on the basis of major DRG categories: general medical, psychiatric, and all hospitalizations. Results.No significant differences were found in adjusted mean lengths of stay between domiciled patients and homeless patients discharged to the hoptel. Homeless hoptel patients stayed an average 0.7, 0.3, and 0.4 days longer than domiciled patients for all, general medical, and psychiatric hospitalizations (P = 0.504, 0.627, and 0.839), respectively. Conclusions.These data suggest that hoptels may help equalize inpatient lengths of stay among domiciled and homeless patients discharged to a hoptel. Public health care systems seeking innovative ways of reducing inpatient lengths of stay among homeless patients ought to consider establishing hoptels.
11958401
Shelter-based convalescence for homeless adults.
OBJECTIVES
Homelessness is associated with increased hospital costs and length of stay, and medical or surgical conditions are typically complicated by secondary diagnoses of substance abuse or mental illness. Convalescence care to provide timely treatment has not been analyzed. This is a retrospective study of diagnoses and utility of shelter-based convalescence in a cohort of homeless subjects.


METHODS
A 20-bed shelter-based unit providing up to 3 months stay post hospital discharge, or for treatment of addictions or for those too ill to remain in the general shelter was studied. Charting was by the use of an electronic health record developed for the project. Demographics, reason for admission and outcomes are retrospectively described.


RESULTS
140 men had 181 admissions from July 2000-April 2003; 23.8% were post hospital discharge, 57.4% were from the general shelter. Average length of stay was 40 days. 83.4% were treated for a medical or surgical condition, 83.6% for psychiatric disease and 29.8% for addictions. Medication adherence was >80% in the majority. During admission, 20% obtained a new health card, 43.6% a new drug card, 89.3% received transportation to appointments, 60% applied for housing and 24.3% obtained housing.


CONCLUSION
A shelter-based convalescence unit can provide health care to homeless persons, treat medical and mental illness, ensure adherence to treatment regimes, decrease substance abuse and assist with housing.
25195869
The effects of respite care for homeless patients: a cohort study.
OBJECTIVES
Homeless individuals experience high rates of physical and mental illness, increased mortality, and frequent hospitalizations. Respite care provides homeless individuals with housing and services allowing more complete recovery from illnesses and stabilization of chronic conditions.


METHODS
We investigated respite care's impact on 225 hospitalized homeless adults consecutively referred from an urban public hospital during a 26-month period. The cohort was separated into 2 groups: (1) patients referred and accepted into the respite center and (2) patients referred but denied admission because beds were unavailable. All patients met the center's predefined eligibility criteria. Main outcome measures were inpatient days, emergency department visits, and outpatient clinic visits.


RESULTS
The 2 groups had similar demographic characteristics, admitting diagnoses, and patterns of medical care use at baseline. During 12 months of follow-up, the respite care group required fewer hospital days than the usual care group (3.7 vs 8.3 days; P=.002), with no differences in emergency department or outpatient clinic visits. Individuals with HIV/AIDS experienced the greatest reduction in hospital days.


CONCLUSIONS
Respite care after hospital discharge reduces homeless patients' future hospitalizations.
26179012
Post-Hospital Medical Respite Care and Hospital Readmission of Homeless Persons
Medical respite programs offer medical, nursing, and other care as well as accommodation for homeless persons discharged from acute hospital stays. They represent a community-based adaptation of urban health systems to the specific needs of homeless persons. This article examines whether post-hospital discharge to a homeless medical respite program was associated with a reduced chance of 90-day readmission compared to other disposition options. Adjusting for imbalances in patient characteristics using propensity scores, respite patients were the only group that was significantly less likely to be readmitted within 90 days compared to those released to Own Care. Respite programs merit attention as a potentially efficacious service for homeless persons leaving the hospital.
33936385
Medical Respite Care for Homeless People: A Growing National Phenomenon
The first known respite care facilities for homeless people emerged in the mid-1980s, but recent trends in health systems and services have driven their rapid proliferation across the country within the past decade. This report is the first attempt to describe these respite programs comprehensively.
38851677
[Health situation of homeless in a health care home in Hannover].
BACKGROUND AND AIM
Extension of the medical health care system for social fringe groups by means of a special 'Health Care Apartment' for homeless people with an ambulatory nursing service. Between 55-70 % of the homeless people in Germany are in-patients for medical treatment nearly once a year. Only 10-20 % have a family doctor.


METHOD
: The pilot experiment of a special Health Care Apartment for homeless people was scientifically evaluated for approximately one and a half year under socio-medical and socio-economic viewpoints. Every patient passes a standardized interview at admission and discharged with one validated systematic setup and one specifically developed questionnaire.


RESULTS
: The mean age of the 36 investigated persons was 48.7. 36.1 % (13) of the patients lived in divorce. About 86.1 % (31) of the patients had secondary school qualifications, 69.4 % (25) had learnt a profession. All were unemployed. Two-thirds of them stated they had been found guilty of a criminal offence within the last few years. 44.5 % (16) had been homeless for 3 or more years. Approximately x of the homeless were addicted to alcohol, according to the employees entrusted with looking after the inmates. The main reasons for the average 8-week stay in the medical department were diseases of the skin and skeletal system, which had caused several hospital admissions in the past. The satisfaction of their own health status improved by 66 % from the day of their admission to the day of their discharge. 72.2 % (26) said they could get easier medical support in the Health Care Apartment. Supported by intensive socio-pedagogical care, 55.5 % (20) of the homeless people could be discharged from the special Health Care Apartment to other arrangements for homeless people, respectively to own apartments.


CONCLUSION
: The pilot study of the special Health Care Apartment for homeless people in Hannover closes a gap in the provision of medical care which exists in many major cities. Moreover, hospital admissions for homeless people can be prevented and their social reintegration promoted.
25891651
Shelter-based palliative care for the homeless terminally ill
Background: The homeless have high rates of mortality, but live in environments not conducive to terminal care. Traditional palliative care hospitals may be reluctant to accept such patients, due to behavior or lifestyle concerns. The Ottawa Inner City Health Project (OICHP) is a pilot study to improve health care delivery to homeless adults. This is a retrospective analysis of a cohort of terminally ill homeless individuals and the effectiveness of shelter-based palliative care. As proof of principle, a cost comparison was performed. Methods: 28 consecutive homeless terminally ill patients were admitted and died at a shelter-based palliative care hospice. Demographics, diagnoses at admission and course were recorded. Burden of illness was assessed by medical and psychiatric diagnoses, addictions, Karnofsky scale and symptom management. An expert panel was convened to identify alternate care locations. Using standard costing scales, direct versus alternate care costs were compared. Results: 28 patients had a mean age 49 years; average length of stay 120 days. Diagnoses: liver disease 43%, HIV/AIDS 25%, malignancy 25% and other 8%. Addiction to drugs or alcohol and mental illness in 82% of patients. Karnofsky performance score mean 409 / 16.8. Pain management with continuous opiates in 71%. The majority reunited with family. Compared to alternate care locations, the hospice projected $1.39 million savings for the patients described. Conclusion: The homeless terminally ill have a heavy burden of disease including physical illness, psychiatric conditions and addictions. Shelter-based palliative care can provide effective end-of-life care to terminally ill homeless individuals at potentially substantial cost savings.
743458
A public health approach to reducing morbidity and mortality among homeless people in Boston.
Urban homeless populations suffer disproportionately high rates of premature death. In response to a wave of highly publicized deaths on the streets of Boston during the winter of 1998-1999, the Massachusetts Department of Public Health (MDPH) convened a task force to investigate these deaths and implement an integrated response to this public health crisis. Comprised of a broad coalition of public and private agencies as well as homeless persons and advocacy groups, the MDPH Task Force reviewed the circumstances surrounding the 13 deaths, monitored subsequent deaths among homeless persons in Boston, and implemented a comprehensive plan to address critical needs and prevent further deaths. Contrary to the task force's initial assumption, the 13 decedents had multiple recent contacts with the medical, psychiatric, and substance abuse systems. In response to this finding, the MDPH Task Force sought to improve continuity of care and prevent future deaths among Boston's street population. Coordination of needed services was achieved through the creation of new, and often unconventional, partnerships. This case study exemplifies a public health practice response to the vexing health care challenges confronting homeless people who must struggle to survive on the streets and in shelters.
9388028
Integrated care for homeless people--sharing knowledge and experience in practice, education and research: results of the networking efforts to find homeless health workers.
‘Everything we do, is a drop in the ocean. But, if we don't do it, that drop will be lost for ever’                 Mother Teresa Over the last dozen years, as doctors for homeless people in Pittsburgh, USA and Amsterdam, the Netherlands, we have been networking internationally and travelled the streets to find social and medical workers who bring care to homeless people. We felt the need to reach out on the streets to meet homeless people and their problems, and to reach into mainstream services, academic centres and research institutes, to meet the needs of professionals in housing, social and medical work to deliver integrated care.1,,2 We sought knowledge and experience to be integrated in practice, education and research, to better serve homeless people.3–6

The networking efforts resulted in several meetings in the USA and Europe. In the USA, in 2005, the inaugural International Street Medicine Symposium was held in Pittsburgh, the second in Santa Barbara in 2006, and the third in Houston in 2007, www.streetmedicine.org. In Europe, a ‘Doctors for Homeless’ workshop was organized in cooperation with homeless health workers from Oxford University, Harvard University and the US Street Medicine Network, during the fifth International Conference on Urban Health in Amsterdam, www.icuh2006.com

Building on the strength and goals of FEANTSA, the European Federation of National Organisations working with the Homeless www.feantsa.org, meetings were held to integrate social and medical care for homeless people, which resulted in the European Network of Homeless Health Workers (ENHW). The efforts of FEANTSA's policy officer Dearbhal Murphy have resulted in a seasonal …
10001908
Pathways into homelessness: recently homeless adults problems and service use before and after becoming homeless in Amsterdam
BackgroundTo improve homelessness prevention practice, we met with recently homeless adults, to explore their pathways into homelessness, problems and service use, before and after becoming homeless.MethodsRecently homeless adults (last housing lost up to two years ago and legally staying in the Netherlands) were sampled in the streets, day centres and overnight shelters in Amsterdam. In April and May 2004, students conducted interviews and collected data on demographics, self reported pathways into homelessness, social and medical problems, and service use, before and after becoming homeless.Resultsamong 120 recently homeless adults, (male 88%, Dutch 50%, average age 38 years, mean duration of homelessness 23 weeks), the main reported pathways into homelessness were evictions 38%, relationship problems 35%, prison 6% and other reasons 22%. Compared to the relationship group, the eviction group was slightly older (average age 39.6 versus 35.5 years; p = 0.08), belonged more often to a migrant group (p = 0.025), and reported more living single (p < 0,001), more financial debts (p = 0.009), more alcohol problems (p = 0.048) and more contacts with debt control services (p = 0.009). The relationship group reported more domestic conflicts (p < 0.001) and tended to report more drug (cocaine) problems. Before homelessness, in the total group, contacts with any social service were 38% and with any medical service 27%. Despite these contacts they did not keep their house. During homelessness only contacts with social work and benefit agencies increased, contacts with medical services remained low.Conclusionthe recently homeless fit the overall profile of the homeless population in Amsterdam: single (Dutch) men, around 40 years, with a mix of financial debts, addiction, mental and/or physical health problems. Contacts with services were fragmented and did not prevent homelessness. For homelessness prevention, systematic and outreach social medical care before and during homelessness should be provided.
26193628
Transitions in Drug Use in a New Generation of Problem Drug Users in Amsterdam: a 6-Year Follow-Up Study
Aims: This study describes the transitions in drug use in Amsterdam among young drug users (YDUs) who are inhaling or injecting cocaine or using illicitly obtained opiates. Methods: From 2000 until 2003, 187 YDUs (≤30 years) were recruited of whom 126 were followed into 2007. Results: During the 6 months prior to inclusion, 95% used cocaine, 60% used illicit opiates, and 9% injected more than once a week. During follow-up, the incidence of new-onset heroin use was 4.8/100 person-years. The incidence of injecting was much lower for never-injectors (2.1/100 person-years) than for ever-injectors who relapsed (13.2/100 person-years). Transition to abstinence or nonfrequent drug use is common (23/100 person-years), mostly followed by a relapse (73/100 person-years). Polydrug users were less likely to discontinue their frequent drug use than monodrug users. Conclusions: Treatment services should target the crack cocaine users to prevent further marginalization and, during abstinence, to prevent relapse. Although the prevalence and incidence of injecting are relatively low, it is still an option for opiate users, especially those with a history of injecting.