Unhoused Persons Care Access, Retention, and Engagement (UP-CARE)

• There are more than 100 million people who experience homelessness worldwide. In the United States, each year, around 3.5 million Americans experience homelessness.
• Many of the homeless adults are in their fifties; 30% are women, and their healthcare issues are under-studied.
• The focus of the health system has, at best, been on addressing urgent issues of the homeless while neglecting preventive care, especially cancer screening.
• Perceived notion that the homeless have other important priorities or will later have the resources for preventive care/cancer screening, BUT
  • Many will become homeless again.
  • Significant numbers are chronically homeless.
  • Most are single adults without family or social support who will likely continue to be under or unemployed without access to preventive care while struggling with fundamental social issues.
• Despite proven benefits of multiple strategies to improve preventive care among the general population for chronic disease management and to improve access to care, significant healthcare gaps exist among homeless persons.
• Translation of the evidence-based approaches and their system requirements is necessary to reduce the enormous gaps in chronic disease-related outcomes among homeless persons, addressing strategic objectives of HHS and NIH, and to improve access to preventive services.

OUR WORK

• Breast Cancer
  In our study among homeless persons, the rate of completed biennial mammogram was around 30% (59% had a mammogram, BUT more than half did not know or followed up with the results)

   

• Cervical Cancer
  In our other study, despite a self-reported 76.5% rate of Pap test in the past 3 years, more than two-thirds of homeless women did not know the results or followed up with abnormal results (meaning that less than 50% actually completed cervical cancer screening)

  Intervention: In a quasi-experimental study, we introduced in-person patient navigation for breast and cervical cancer screening in homeless women at shelters/shelter-clinics in New York City. We demonstrated a completed breast cancer screening rate of 88.4% and a completed Pap test rate of 83.2%.

   

• Colorectal Cancer
  In our other study, only 19.7% of PEH had up-to-date colorectal cancer screening, compared to the national level of around 60%.

   

• Human Papilloma Virus (HPV)
  In our study with homeless women in New York City, almost all HPV knowledge and attitudes data were considerably below the national averages:

  • 42% never heard of HPV. Only 36 % knew that HPV is a sexually transmitted disease. 42% knew that HPV causes cervical cancer and only 20% and 17% received provider counseling regarding HPV testing and vaccine, respectively.

  • A lower rate of up-to-date Pap tests was associated with a lack of knowledge of the relationship between HPV and abnormal Pap tests (p < 0.01).

     

• Hypertension
  In a study evaluating rates and predictors of uncontrolled HTN in hypertensive adults, we documented that 40% of homeless persons with HTN had uncontrolled blood pressure compared to around 25% of the general population, and that 15% had stage 2 HTN.

   

• Diabetes
  We documented rates of 44% of uncontrolled diabetes (HbA1c ≥ 8) in the diabetic homeless adults (33% with HbA1c >9%) compared with 23% in domiciled diabetic patients using the same clinics in New York City, and 28% in the general population.

  Intervention: We are completing two Randomized Controlled Trial studies to evaluate the impact of the SMS texting in improving hypertension and diabetes control in homeless persons.

   

• Information/Misinformation & Health Literacy

  • Attitude toward cancer screening: In our qualitative study with homeless persons in NYC shelter clinics, they expressed positive attitudes, believed they had higher cancer risks, suggested targeted measures to address their barriers, including navigating the complex screening process, addressing providers’ bias on their priorities, and providing incentives, reminders, and cancer health education.

  • Attitude toward SMS texting: In a qualitative study in NYC shelters, we documented that 78% of PEH had working cell phones with SMS text capabilities, were comfortable using them, appreciated getting texts for their care, and suggested ways to adjust texts to the realities of their situation.

     

• Education of Physicians/Curriculum Development
  Medical providers often lack the skills to address the unique healthcare needs of the homeless, with their social conditions that affect clinical encounters:

  • Structured and formal integrated curricula to specifically address the primary care needs of the homeless, with their specific challenges and barriers, often do not exist.

  • Starting in 2012, a comprehensive curriculum was offered to medical students during their family medicine or ambulatory clerkship, covering clinical, social, advocacy, population-based, and policy aspects.
  • The overall scores improved significantly in knowledge, attitude, and self-efficacy domains using a paired t-test (p<0.01).
  • Specific skills in evaluating mental health, substance abuse, and risky behaviours improved significantly (p<0.05).