Little is known how older adults with a current or recent experience of homelessness navigated the switch to telehealth during the COVID-19 pandemic. Researchers examined the perceptions and use of telehealth, sampling from a larger longitudinal study on homeless-experienced adults in Oakland, CA. They found that the participants experienced challenges accessing the necessary technologies for telehealth.

This UCSF study examined whether permanent supportive housing reduces the use of acute health care and other services among people experiencing chronic homelessness. The Permanent Supportive Housing program intervention was able to house 86% of chronically homeless adults randomized to the treatment group based on their high use of multiple systems. Even the most frequent clients of medical, psychiatric, and emergency services were housed successfully, as demonstrated in this study of Project Welcome Home in Santa Clara County.

Cancer is the leading cause of mortality for people experiencing homelessness (PEH). However, not much is known about cancer-related surgical outcomes among PEH. This retrospective cohort study aimed to characterize access to care among PEH, evaluate postoperative outcomes, and assess costs associated with surgery for malignancy among PEH. Researchers found that PEH were less likely to undergo surgery for malignancy at cancer centers than hose who are housed. People experiencing homelessness also had a higher risk of requiring unplanned surgery.

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.

Research from BHHI in collaboration with the San Francisco Department of Public Health and UC Berkeley School of Public Health showed how shelter-in-place emergency housing during the C...

Older homeless-experienced adults have low rates of advance care planning (ACP) engagement. In this cross-sectional qualitative study, researchers examined potential barriers and solutions to ACP engagement. Researchers found that participants believed that ACP is important, but acknowledge the multiple barriers to engagement. Potential solutions include capitalizing on opportunities outside health care setting and focusing on the period after housing and tailoring content.

Patients who experience homelessness face a high burden on chronic disease, including colorectal cancer. There are many barriers in access to colonoscopy procedures. Researchers provide policy solutions to reduce health care disparity.

People living with HIV (PLH) experiencing homelessness or unstable housing have lower rates of viral suppression compared to people who are housed. In 2020, only 20% of PLH experiencing homelessness in San Francisco were virally suppressed, compared to 71% of those who were housed. Researchers examined case preferences among PLH experiencing homelessness during the COVID-19 pandemic in San Francisco. They found that the strongest preference were for the same provider, visit incentives, and drop-in visits.

Patients with prolonged hospitalizations often require alternative levels of care (ALC) and there stays strain hospital capacity and patient flow. This study aimed to descriptively compare prolonged ALC and short ALC. Researchers found that patients with prolonged ALC were more likely to be older and have experienced homelessness. Furthermore, prolonged ALC patients were more likely to be admitted for acute care and had greater psychosocial complexity.

This study from BHHI researchers describes five distinct subgroups of the highest users of the health care system in San Francisco with differential comorbidities, health care needs, and social determinants of health, spanning from patients with medical comorbidities solely using medical services to patients grappling with housing insecurity, incarceration, substance use disorder, and mental health comorbidities. Frequent users of the health care system are not a homogenous population as previously thought. This study sheds new light on how to help the most vulnerable patients and inform clinicians and care coordination teams on making sure patients get the care they need the most. 

Long-acting injectable antiretroviral therapy (LAI-ART) is approved for treatment-naive or experienced people with human immunodeficiency virus (HIV; PWH). The researchers performed the first LAI-ART demonstration project to include PWH unable to achieve or maintain viral suppression due to challenges adhering to oral ART at San Francisco's Ward 86. Researchers found preliminary short-term effectiveness of the treatment. More data on LAI-ART in hard-to-reach populations are needed.

People experiencing homelessness have worse mental and physical health than the general population. They also have limited access to primary care for reasons including the absence of health insurance, lack of money for co-payments or transportation, and communication barriers. In this JAMA Insights, researchers examine the adverse effects of homelessness on physical and mental health and suggest strategies to improve access to care.

In this invited commentary, Maria Raven, MD, and coauthors describe the challenges of providing quality care to unhoused people. Addressing an accompanying study about community primary...

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.

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.

Homelessness is detrimental to health, and clinicians can play an essential role in mitigating the deleterious effects of homelessness. Margot Kushel, MD,  director of the Benioff Homelessness and Housing Initiative, San Francisco, discusses this and more with JAMA Senior Editor Karen E. Lasser, MD, MPH. Dr. Kushel said, "When you are an individual provider, in a room, you are trying to understand the difficult environmental conditions that your patient has and do things to decrease that part."

In a cohort of over 100,000 patients who received care from the Department of Veterans Affairs (VA) health system, those experiencing homelessness were more likely to be diagnosed with stage IV colorectal cancer compared with those who had housing. The patients who experienced homelessness also had longer hospital stays for all the cancer types studied. However, the findings differed across healthcare settings. In a commentary accompanying the study, Maria C. Raven, MD, MPH, associate Professor and Chief of Emergency Medicine at UCSF, said "Reducing healthcare disparities for people experiencing homelessness is essential, and the [VA] can serve as an example of what it takes to do so."

Cancer is a leading cause of death among older people experiencing homelessness. In this retrospective cohort study, researchers sought to characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer. Researchers found that homelessness was associated with later stages at diagnosis for colorectal cancer.

Hospital emergency departments (ED) are on the frontlines of serving people experiencing homelessness, and this report investigated what ED data can reveal about homelessness in California. Hospitals operated by counties and the University of California reported higher shares of ED visits by people experiencing homelessness. Linking discharge data with homeless services programs can offer insights into how people engage with programs and help provide better resources to evaluate the programs and investments aimed at improving the lives of Californians experiencing homelessness.

In this commentary of the study "Housing Status, Cancer Care, and Associated Outcomes Among US Veterans", Maria C. Raven, MD, MPH, associate Professor and Chief of Emergency Medicine at UCSF, provides lessons from the Veterans Health Administration. In 2009, the VHA began a multipronged initiative designed to end and prevent homelessness among veterans, which led to a 45% reduction in veteran homelessness from 2009 to 2017. Dr. Raven writes, "The results of this study indicate that in addition to providing housing at comparatively high rates for unhoused veterans, the system’s initiative to prevent and end veteran homelessness has also likely helped reduce important disparities in oncologic care for this population."

 Traumatic injury is a major cause of morbidity for people experiencing homelessness (PEH), however, injury patterns and subsequent hospitalization among PEH have not been studied on a national scale. In this national retrospective observational cohort study, researchers evaluated whether differences in mechanisms of injury exist between PEH and housed trauma patients in North America and whether the lack of housing is associated with increased adjusted odds of hospital admission. Researchers found that injured PEH had a significantly adjusted greater odds of hospital admissions.

This UCSF study examined deaths among people experiencing homelessness in San Francisco from 2016 to 2018. Although heart disease and cancer are the first and second causes of death for California’s general population, the leading causes of homeless deaths were acute intoxication (unintended overdose) and trauma (including homicide and suicide rates over triple that of the US general population). The authors advocate that these differences in cause-specific mortality should inform death prevention efforts within the homeless population differently than the general population.

This study from UCSF BHHI researchers examined deaths among people experiencing homelessness in San Francisco during the first year of the COVID-19 pandemic. They found 82% of 331 deaths were associated with drug overdose, not COVID-19 infection. Traumatic injury, including homicide and suicide, was the second most common cause of death. This research highlights a need for strategies that address both homelessness and drug use, including housing, evidence-based treatment of opioid addiction, and overdose prevention programs.

Unhoused patients have worse surgical outcomes than the general population, resulting in premature mortality. Researchers conducted 26 semi-structured interviews of clinicians who care for patients with surgical disease. The researchers identified 5 themes, including, but not limited to: patients and clinicians face multiple challenges meeting preoperative requirements; although surgeons do not make major operative decisions based on housing status, some take it into consideration for minor care decisions; clinicians perceive that unhoused patients have negative postoperative experiences in the hospital.