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,
SeriesHealth interventions for people who are homeless
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
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