Elsevier

The Lancet

Volume 384, Issue 9953, 25–31 October 2014, Pages 1541-1547
The Lancet

Series
Health interventions for people who are homeless

https://doi.org/10.1016/S0140-6736(14)61133-8Get rights and content

Summary

Homelessness has serious implications for the health of individuals and populations. Primary health-care programmes specifically tailored to homeless individuals might be more effective than standard primary health care. Standard case management, assertive community treatment, and critical time intervention are effective models of mental health-care delivery. Housing First, with immediate provision of housing in independent units with support, improves outcomes for individuals with serious mental illnesses. Many different types of interventions, including case management, are effective in the reduction of substance misuse. Interventions that provide case management and supportive housing have the greatest effect when they target individuals who are the most intensive users of services. Medical respite programmes are an effective intervention for homeless patients leaving the hospital. Although the scientific literature provides guidance on interventions to improve the health of homeless individuals, health-care providers should also seek to address social policies and structural factors that result in homelessness.

Introduction

Homelessness is a serious social problem with far-reaching implications for the health of individuals and populations. A review1 of morbidity and mortality in people who are homeless is provided in an accompanying paper. Although rates vary depending on sampling and ascertainment strategies, a large proportion of homeless individuals have mental illnesses or substance misuse problems, or both.1 Because of the high prevalence of serious health conditions in this marginalised population, effective action is urgently needed to address both ill health in people who are homeless and the underlying issue of homelessness itself.

The aim of this Series paper is to provide a narrative outline of interventions to improve the health of people who are homeless. We focus on homelessness in high-income countries, where most of the research on this topic has been done and conclude with a set of practical suggestions for health-care providers who are working with people who are homeless.

Section snippets

Primary health-care services

Primary health-care programmes that are specifically tailored to meet the needs of homeless individuals might be more effective in the achievement of positive health outcomes than standard primary health care. However, few controlled studies2, 3, 4 have compared different primary care models for homeless patients. In the UK, the main models of primary care delivery are mainstream general practice with a special interest in the care of homeless individuals, specialised general practice

Specific versus integrated services

Specific services for homeless individuals with mental illnesses have been tested against generic or standard care.7, 8 Outcome measures generally include a reduction in homelessness (eg, number settled in accommodation or nights homeless during follow-up), reductions in hospital use (inpatient stays or emergency department attendances), or a range of symptom, criminal justice, quality of life, and cost outcomes. Results from most studies have identified improved outcomes for specific services,

Multifaceted interventions with permanent supportive housing

A few controlled trials have examined the efficacy of multifaceted interventions that include the provision of permanent supportive housing.3, 4 Three important trials have focused on specific subgroups of homeless individuals: those with severe alcohol problems and high service use,40 those with chronic illnesses being discharged from hospital,19 and those with HIV infection.41 A study done in Seattle, WA, USA,40 examined the effect of a one-site Housing First programme for homeless adults

Medical respite programmes

When people who are homeless are admitted to hospital, discharge planning might become problematic when the patient recovers to the point that he or she is well enough to leave the hospital but still too ill to return to a shelter or the street. This situation might lead to either a prolonged hospital stay or discharge with a high risk of readmission. Medical respite programmes are transitional facilities that address this dilemma by providing homeless patients with a suitable environment for

Interventions for substance users

Several studies have examined a heterogeneous range of interventions for homeless individuals who are substance users.3, 4 Standard case management has been shown to be effective in reducing substance misuse and emergency department use.9, 45 Although many interventions are effective in reducing substance use in homeless individuals compared with no intervention or usual care, there is little direct evidence to suggest the superiority of any particular programme over another.3 Several

Interventions for homeless young people

Published research has consistently identified homeless young people as a group that is distinct from homeless adults. However, relatively few controlled studies have examined interventions for homeless young people.3, 4, 49, 50, 51 Many of these interventions have focused on achievement of short-term reductions in substance misuse or risky sexual behaviour.49, 50 Systematic reviews have noted wide variation in the nature of the interventions and outcome measures used, a substantial risk of

Key points for health-care providers

Panel 2 summarises key points for health-care providers who work with people who are homeless. Health-care providers who work with individuals who are homeless should keep in mind the crucial importance of establishment and maintenance of a positive interpersonal relationship between themselves and the person who is homeless.52 As noted in one synthesis review, the key ingredients for such a relationship include respect for the individual, upholding the person's dignity, building mutual trust,

Search strategy and selection criteria

We did two literature searches. The first literature search identified recent systematic reviews and knowledge syntheses related to interventions of any type for homeless individuals. Because of the high prevalence of mental illness and substance misuse problems in homeless populations and extensive previous research in this area, the second literature search specifically identified articles on mental health services for homeless individuals. For the first search, we searched Medline,

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