HCC DAta research projects
Homelessness, Trauma & Emergency department service utilization
Background and Purpose
Homelessness is a complex public health problem in the United States, contributing to adverse mental and physical health outcomes. Individuals experiencing homelessness are more prone to suffer from physical and mental trauma compared to non-homeless counterparts. Due to the pronounced disparities, trauma, and toxic stress faced by homeless individuals, they tend to adapt to destructive coping behaviors such as self-harm leading to severe psychological and substance abuse disorders. Individuals experiencing homelessness are also four times more likely to use emergency department services (ED) than the general population. Despite the abundance of research on homelessness and ED service utilization, there are gaps in the literature examining the relationship between trauma and self-harm among individuals who have used ED services. Our study aims to assess the moderating effect of self-harm behavior on the association between ED utilization and homelessness due to trauma among adults in Texas.
Methods
Sample: A sample of 282 adults, aged 21 to 75 years who completed their baseline Vulnerability Index Service Prioritization Decision Assistance Prescreen Tool (VI-SPDAT) assessment between February 2021 to February 2022 were selected from a Local Mental Authority (LMHA) organization in Texas. The LMHA is a part of a state-funded program called Healthy Community Collaborate (HCC).
Measures: The primary outcome variable was current period of homelessness due to trauma (Y/N). The main predictor was ED service utilization (0-10+). The moderating variable was self-harm or inflicting harm on others in the past year (Y/N). Other covariates such as age, gender, race, ethnicity, and marital-status were also included.
Analysis: A multivariate logistic regression with a moderation analysis was conducted.
Results
84% of the sample reported homelessness due to trauma. 65% were males, and 58% were white, with a mean age of 50 years. Individuals used ED service an average of three times, with almost 55% of the sample engaging in risky behaviors and self-harm. Females were more likely to be homeless due to trauma compared to males. Individuals who engaged in risky behaviors and self-harm had a higher rate of experiencing homelessness due to trauma. Individuals who used ED services were 1.26 times more likely to be homeless due to trauma. Individuals who performed in risky behaviors were 3.57 times more likely to face homelessness due to trauma. Individuals who engaged in self-harm were more likely to suffer from homelessness due to trauma. Engaging in self-harm behavior was found to be an overall significant moderator. Individuals who used ED services 10+ times and engaged in self-harm had the highest likelihood to experience current period of homelessness due to trauma compared to those who used ED services only three times.
Conclusions and Implications
Findings from this study demonstrated that individuals who used ED services had higher odds of experiencing homelessness due to emotional, physical, psychological, sexual, or other types of abuse or trauma. Furthermore, self-harm behavior was a significant moderator of the relationship between ED use and experiencing homelessness due to trauma or abuse. Coping with complex trauma can be highly challenging, especially among homeless populations. This study may help inform efforts to develop targeted strategic early interventions and promote resilience-based approaches among homeless and clinical service providers to help reduce ED use and improve mental health outcomes and quality of life among individuals experiencing homelessness due to trauma or abuse.
Invisible Needs of Transition-Age Youth with Developmental Disabilities in Access to the Permanent Supportive Housing Services
Background and Purpose
Transition-age youth (TAY) from 16 to 24 years old are among the most vulnerable subgroups of the homeless population (Hagan & McCarthy, 2005; Sullivan-Walker et al., 2017), experiencing multiple challenges transitioning into adulthood. TAY is at a higher risk of being chronically homeless, with even greater homeless risk for TAY with developmental disabilities (DD) (O’Connor & MacDonald, 2018). With a lack of disability assessment and documentation, the specific needs of TAY with DD are often undetected, leading to maladjustment in a homeless shelter and exclusion from homeless services and policies (Collins et al., 2018). This creates overwhelming barriers for TAY in accessing housing services. However, their unique challenges remained largely unexplored. Permanent supportive housing (PSH) intervention, as a combined model of affordable housing and supportive services, has been proven effective for individuals experiencing homelessness with multiple risk factors (Rog et al., 2014). Thus, this study aims to critically examine the factors that contribute to PSH eligibility to better accommodate the complex needs of TAY with DD.
Methods
13,815 unhoused participants and 1,155 PSH housed participants were selected from a homeless service collaborative in San Antonio, Texas (01/2018 – 10/2021). Each group was divided into TAY and older participants. We calculated percentages of participants by race/ethnicity, gender orientation, type of disabilities, and PSH accessibility. ANOVA and independent t-test were conducted to compare the total mean score and the mean score of each subsection of the SPDAT (Service Prioritization Decision Assistance Tool) test by age range and housing status.
Results
Overall, unhoused TAY participants were overrepresented in all racial/ethnic groups (American Indian, Black, Multi-racial, Native Hawaiian) when compared to both the unhoused adults and housed group. There was a housing disparity in TAY, comprising 2.2% of the housed participants, compared to the 9.9% of unhoused participants. In addition, unhoused TAY had a 4.7 times higher prevalence of developmental disabilities than the housed group and 1.8 times more than unhoused older adults. Housed TAY had a high percentage of both physical disabilities and developmental disabilities, and all had substantial mental health issues. There were no significant differences in total SPDAT mean score between unhoused TAY and housed TAY (p>.05). However, housed TAY had higher need scores in mental health, physical health, substance abuse, and medication subsections. Unhoused TAY demonstrated higher needs in self-care, daily living skills, social relationships, personal administration, money management, and managing tenancy.
Conclusions and Implications
This study found significant housing disparities among TAY with DD. The current practices prioritize visibly severe disabling conditions in access to housing services. Invisible difficulties such as having DD, limited self-care, daily living skills, and personal administration skills were not examined as important factors when considering housing eligibility, potentially leading to long-term homelessness in the youth’s future. There should be a more thorough examination of the invisible, potential risk factors in the assessment for housing eligibility. In addition, preventive policy and practices are critical to support TAY with DD to receive tailored services to achieve housing stability and successful transition into adulthood.