Resource Center

The complex care evidence base continues to grow, but meaningful involvement of people with complex needs in the research process is lacking. Hemal Kanzaria, MD, Associate Professor of Emergency Medicine at University of California San Francisco spoke with The Better Care Playbook to learn more about how involving people with lived experience in research can help strengthen the complex care evidence base. Dr. Kanzaria said, "The partners are working together in every one of those steps and recognizing the skill set that everyone's bringing to it. That makes the work better than anyone could do by themselves."

A new report estimates California could end homelessness by 2035 if it spent at least $8.1 billion every year on the problem. Margot Kushel, MD, director of the UCSF Benioff Housing and Homelessness Initiative said, “The main way to solve homelessness is through housing.” She pointed out that research shows California is short by 1 million affordable and available housing units for extremely low-income renters—those making less than 30% of area median income. “By shrinking that deficit, we will reduce homelessness,” she said. “It will take a sustained investment by federal, state and local governments to do it.”

Housing First focuses on getting people into permanent housing and offering them support services. A 7-year randomized trial of chronically homeless individuals found those in the housing-first group spent 90% of their nights housed and made less use of psychiatric emergency services and more use of outpatient mental health services compared to the control group. “The experiment intentionally sought to try housing first for the very most complicated patients—those who society says are most hard to house—and it worked,” said study co-author Margot Kushel, MD, who directs the UCSF Benioff Homelessness and Housing Initiative.

This feature article reports on overdose mortality in the city's supportive housing program, the cornerstone of an effort to help people rebuild their lives after bouts of homelessness. "Anything that can create community and safety and wellness in these settings is going to make a difference," says UCSF Benioff Homelessness and Housing Initiative's Kelly Knight, MD.

San Francisco and California have been reckoning with the issue of housing instability for years, but additional complexities arise as people experiencing homelessness grow older. In this Grand Rounds, Margot Kushel, MD, one of the world’s leading experts on homelessness, discusses the drivers and precipitants of homelessness and the health consequences of aging in the homeless population. Dr. Kushel is a professor of medicine and directs both the UCSF Center for Vulnerable Populations and the UCSF Benioff Homelessness and Housing Initiative.

During the COVID-19 pandemic, UCSF partnered with government and community groups to address racial, economic, and cultural barriers with the goal of providing equitable care to vulnerable people. The UCSF Benioff Homelessness and Housing Initiative spearheaded many of those partnerships. “The secret sauce was putting the community-based organizations in charge,” said Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, who envisioned a program to serve people experiencing homelessness that became a national model.

During the COVID-19 pandemic there was a 50% increase in opioid overdose deaths in the Shelter in Place (SIP) hotels for individuals experiencing homelessness in San Francisco. Community Behavioral Health Services Pharmacy partnered with SIP hotel medical staff to launch a pilot project where on-site SIP medical providers prescribed buprenor-phine (BUP) and clinical pharmacists hand-delivered BUP to SIP residents to increase BUP initiation and engagement. Researcher’s findings suggest that this system of onsite medical care with pharmacist delivery is possible and could allow for more outreach and increased ease of obtaining medications for patients.

Programs in San Francisco that offer people living on the streets respite, shelter, and treatment often fall dismally short of the need. “There just isn’t enough of it,” Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, says. “Without the housing, it all falls apart.”

Formerly chronically homeless adults who live in permanent supportive housing (PSH) have a high prevalence of smoking. Smoke-free policies and smoking cessation services are among the most effective tobacco control interventions, but these policies are uncommon in PSH. Researchers outline a protocol for a cluster-randomized wait-list controlled trial to evaluate the efficacy of the same smoke-free home intervention on the primary outcome of voluntary adoption of a smoke-free home.

In this cohort study, UCSF BHHI researchers found that most older homeless-experienced adults needed caregiving assistance and few received such assistance. Interventions that increase caregiving access for homeless-experienced individuals may help avoid poor health outcomes and costly long-term care needs due to untreated disabilities.

Homeless street sweeps, where governmental agencies move unhoused individuals living in public areas, frequently occur in the US. In this qualitative study, researchers investigated and documented the health impacts on street sweeps from the perspective of healthcare providers. Researchers found that street sweeps negatively impacted health; there was material loss as well as instability and loss to follow-up.

By providing safe indoor spaces and safe supplies, overdose prevention centers treat overdoses and limit infections, while offering access to primary care services and evidence-based treatment for drug addiction. Leslie Suen, MD, MAS, explains why evidence-based harm reduction strategies like OPCs keep people safe while making treatment readily available to anyone who wants it.

High users of the health care system use a disproportionate amount of health services yet have poorer health outcomes. This study aimed to examine natural trends in emergency department visits among high users of health and social services and assess whether the trends differed during the COVID-19 pandemic. In this retrospective cohort study, researchers found that there was a decrease in emergency department visits. Further research is needed to elucidate COVID-19 pandemic specific factors associated with a decrease in emergency department visits.

California’s homeless population has increased in recent years, and so has public investment in addressing homelessness, making understanding the size and needs of the state’s homeless population more important than ever. Discharge data from emergency departments (EDs) can help. PPIC researcher Shannon McConville and UCSF professor Hemal Kanzaria, MD outlined key findings from a new report and discussed the implications for policymakers.

People living with HIV experiencing homelessness are more likely to have higher viral loads. The POP-UP model at the Ward 86 HIV clinic in San Francisco was designed to address barriers to care engagement. Researchers found an improvement in the 12-month HIV viral suppression from 0% to 44%. However, many patients were not virally suppressed. Researchers suggest that POP-UP clinics are promising to improve care engagement and HIV viral suppression among people experiencing homelessness.