The effect of homelessness on health care use

Adrienne-Cheung-and-Anita-Palepu

VFMP student, Adrienne Cheung and Dr. Anita Palepu stand outside St. Paul’s Hospital. The two worked together on a 2013 SSRP project where they investigated the effect on homelessness on health care use.

Melissa Carr (Communications Coordinator, VFMP)

Adrienne Cheung, Vancouver Fraser Medical Program Class of 2016, stands amid the hustle and bustle of St. Paul’s Hospital. She has just returned home from Toronto, after spending some time with her family. Cheung is waiting for Dr. Anita Palepu, a nationally renowned general internist. Dr. Palepu weaves her way through a group of people towards, Cheung. Her smile is absolutely infectious and the two cheerfully chat about their weekend.

St. Paul’s is a busy hospital, serving a diverse population, which includes some of Vancouver’s neediest and most vulnerable citizens. The patient population here is representative of the individuals Cheung and Palepu observed during a research project they worked on last summer, where they explored the relationship between homelessness, substance dependence and health care.

Dr. Palepu runs an accomplished urban health program and is particularly interested in vulnerable populations such as drug users, those infected with HIV, and the homeless.

Cheung is eager to learn about the diverse patient population in the Vancouver Fraser region and speaks compassionately about the men and women she observed over the course of the project. She describes how their stories opened her eyes to the factors which contribute to health issues faced by the homeless. Cheung emphasizes how, although there is some teaching about social aspects in the medical curriculum, her research with Dr. Palepu will be instrumental in shaping the kind of doctor she becomes, admitting that, “without this experience, I might not have the chance to look deeper into these (kinds of) issues and how addiction is tied to psychiatric care, public services and homelessness.”

The project’s findings highlight a surprising lack of correlation between substance dependence and ER visits. Cheung explains:

“There is a general perception that (drug dependant) individuals tend to have a higher rate of health care use and continue to use services at a higher rate if substance use persists; however, we found no association between substance dependence and emergency department visits or hospitalizations in this study during the two-year follow-up period.”

Cheung goes on to describe how it is primarily environmental and mental health issues that bring homeless individuals to the hospital and how understanding these factors can assist medical professionals in their approach to treatment. She emphasizes how participating in the project has allowed for a greater appreciation teamwork in an urban hospital environment.

Reflecting, Cheung states how she “can now better appreciate the importance of a multidisciplinary team including nurses, social workers, case managers and other specialists in longitudinal care for those with mental disorders.”

As for Dr. Palepu, she expresses how having students participate enriches her research:

“Students often ask questions which force even the most seasoned researchers to step back and reflect on our assumptions, and often results, in more clarity.”

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Below are subsequent and more detailed questions that posed to Anita regarding her SSRP:

MC: Please briefly describe the SSR Project you were involved in?

AC: We were interested in whether homeless adults with substance dependence were less likely than those without substance dependence to experience a reduction in health care utilization at 2 years follow-up in a supported housing program. We looked at results from the “Vancouver At Home Study”, a large, randomized controlled trial that assigned homeless adults with mental disorder to either a Housing First program or to treatment as usual (i.e. no intervention). Housing First is a low-barrier, supportive housing program that sets no preconditions such as abstinence from substance use or adherence to psychiatric medications in order to remain housed. This program has been associated with improved residential stability and reductions in hospital use in previous studies. Homeless adults with concurrent mental and substance use disorders face a number of challenges in managing their health. There is a general perception that these individuals tend to have a higher rate of health care use and continue to use services at a higher rate if substance use persists; however, we found no association between substance dependence and emergency department visits or hospitalizations in this study during the two-year follow-up period.

MC: What, specifically, about the research topic interested you?

What attracted my interest were the complex social factors that are involved in managing the health of this population. I was also interested in learning how scientific methods and designs would be applied in this setting. The At Home trial has a strong methodological design but the conduct of the study was complicated by many issues that are less likely to arise in clinical or basic science studies. For example, an important consideration was the follow-up of participants as they often lacked reliable contact information and may move between public and private housing, hospitals or institutions between follow-up periods.

MC: What did you learn both (a) academically and (b) clinically?

A valuable part of this project was learning how to analyze the data to answer our research question. With a wealth of data collected from the At Home trial, it was an exercise to determine which outcomes would best answer our research question and what variables could potentially affect those outcomes.

What may be useful clinically is a slightly better understanding of the circumstances of those who are homeless or precariously housed. Through shadowing participant interviews, I heard fairly detailed accounts of experiences with finding stable housing and some of the important events that have had a lasting impression on individuals’ lives. Even after finding a place to live, one may face issues such as unhealthy living conditions, poor nutrition, lack of continuity of care and support, and the negative effect of these combined factors on mental health.

MC: What did you learn to appreciate while participating in this project? Has this influenced your perspective on medicine and patient care?

Shadowing participant interviews and reviewing the literature allowed me to gain an appreciation of the number of challenges faced by homeless adults with mental disorders. Health care is quite limited in what we can do when we see patients from this group. Physicians can help improve the physical and mental health of their patients but these are very connected to the environment in which the patient is living, their financial situation and numerous other social stressors that might be present. I can now better appreciate the importance of a multidisciplinary team including nurses, social workers, case managers and other specialists in longitudinal care for those with mental disorders.

What do you feel participating in this project will have contributed to your medical education? (for Student only)

The medical curriculum at UBC includes a course called Doctor, Patient and Society which focuses on social aspects of medicine that are not covered in other courses. One block of this course focused on addiction medicine and invited guest speakers to share their experiences with us. Although I appreciated and learned from this component of the course, I felt that there was a great deal that could not be covered by the course alone. The research project I was involved in gave me a chance to look deeper into these issues and how addiction is tied to psychiatric care, public services and homelessness.

Finally, I was interested to know why Dr. Palepu involves and draws from students in her research…

MC: How do you feel involving students in your research influences your work?

AP: The involvement of students in my research program enriches the experience of all of team members. The student often asks questions that force us to step back and reflect on our assumptions and often results in more clarity. The team enjoyed explaining their roles and responsibilities and included Adrienne in interviewer training and shadowing participant interviews as well. Developing the understanding of people’s context is critical to working with vulnerable groups both clinically and in a research setting. Finally, mentoring in research is an important and critical ingredient to develop the next generation of clinician scientists.

Thank you to Adrienne and Dr. Palepu for taking the time to share their work and findings with the VFMP community!