A Public Health Approach to Reducing Morbidity and Mortality Among Homeless People in Boston

Boston Health Care for the Homeless Program, 729 Massachusetts Avenue, Boston, MA 02118, USA.
Journal of public health management and practice: JPHMP (Impact Factor: 1.47). 07/2005; 11(4):311-6. DOI: 10.1097/00124784-200507000-00009
Source: PubMed


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.

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    • "Excluding studies which deal with a specific group of homeless people, e.g. persons in convalescence care [13], [17], persons with mental problems [18]–[20] or rough sleepers [12], mortality among the homeless has only been studied in the USA (Philadelphia [4], Boston [7], [21], [22], New York [1]), Canada (Toronto [3], [5], Montreal), Denmark (nationwide [10], Copenhagen [11]), Sweden (Stockholm [2], [18]), and the United Kingdom (Glasgow [9]). Of these, only 4 described mortality of homeless cohorts in the 21st century [2], [9], [10], [15]. "
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    ABSTRACT: Data on mortality among homeless people are limited. Therefore, this study aimed to describe mortality patterns within a cohort of homeless adults in Rotterdam (the Netherlands) and to assess excess mortality as compared to the general population in that city. Based on 10-year follow-up of homeless adults aged ≥ 20 years who visited services for homeless people in Rotterdam in 2001, and on vital statistics, we assessed the association of mortality with age, sex and type of service used (e.g. only day care, convalescence care, other) within the homeless cohort, and also compared mortality between the homeless and general population using Poisson regression. Life tables and decomposition methods were used to examine differences in life expectancy. During follow-up, of the 2096 adult homeless 265 died. Among the homeless, at age 30 years no significant sex differences were found in overall mortality rates and life expectancy. Compared with the general Rotterdam population, mortality rates were 3.5 times higher in the homeless cohort. Excess mortality was larger in women (rate ratio [RR] RR 5.56, 95% CI 3.95-7.82) as compared to men (RR 3.31, 95% CI 2.91-3.77), and decreased with age (RR 7.67, 95% CI 6.87-8.56 for the age group 20-44 and RR 1.63, 95% CI 1.41-1.88 for the age group 60+ years). Life expectancy at age 30 years was 11.0 (95% CI 9.1-12.9) and 15.9 (95% CI 10.3-21.5) years lower for homeless men and women compared to men and women in the general population respectively. Homeless adults face excessive losses in life expectancy, with greatest disadvantages among homeless women and the younger age groups.
    Full-text · Article · Oct 2013 · PLoS ONE
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    • "The medical conditions stated in our study are comparable to other studies of convalescence care in homeless persons. In convalescence care studies the users presented, more or less, with what O'Connell et al. refer to as tri-morbidity: a mix of addiction, mental and physical health problems [19]. We found 59% drug users, 28% alcohol users and 21% were known with a mental illness. "
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    ABSTRACT: Adequate 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. Demographics 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. 629 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. Over 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.
    Full-text · Article · Nov 2009 · BMC Health Services Research
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    • "Evictions can be considered a public health problem from two perspectives. Evictions are one of the major causes of homelessness [1] [2] [3] [4] [5] and, traditionally, public health interventions focus on homeless populations [6]. On the other hand, however, to apply upstream prevention strategies, households and their underlying social medical problems that precipitate evictions, can be the focus of public health interventions [7] [8] [9]. "
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    ABSTRACT: The public health problems precipitating eviction are understudied and no systemic data have been collected. We aim to identify the magnitude of eviction and the characteristics and social medical risk factors of households at risk in Amsterdam. This will help inform policies designed to prevent eviction. In 2003, case workers of housing associations dealing with rent arrears, and case workers of nuisance control care networks, were interviewed and completed questionnaires about households at risk of eviction. Questionnaires included the processes that resulted in eviction and the characteristics and social medical problems of the households involved. Evicted households were compared with non-evicted households. In Amsterdam, over recent years 1,400 eviction, or four per 1,000 dwellings, took place annually. Of 275 households with rent arrears, 132 were evicted. Of 190 nuisance households, 136 were evicted. In both groups, the largest household group were single male tenants between 25 and 44 years. For those reporting rent arrears, social problems were reported in 71%, medical problems in 23%; independent risk factors for eviction were being of Dutch origin (OR 2.38 (1.30-4.36)) and having a drug-addiction problem (OR 3.58 (0.96-13.39)). For the nuisance households, social problems were reported in 46% and medical problems in 82%, while financial difficulties were a risk factor for eviction (OR: 8.04 (1.05-61.7)). In Amsterdam, households at risk of eviction consisted mainly of single (Dutch) men, aged between 25 and 44 years, often with a combination of social and medical problems. Financial difficulties and drug addiction were independent risk factors for eviction. Because of the social medical problems that were prevalent, for prevention practice eviction should be considered both a socioeconomic and a public health problem. Preventing eviction deserves full attention as a potential effective public health intervention.
    Full-text · Article · Sep 2009 · Scandinavian Journal of Public Health
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