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Bridging gaps in care coordination for homeless populations is a complex task that requires addressing attitudinal and behavioral changes, as patients hold more control over chronic and preventive care. Despite these challenges, organizations like the Patient Care Intervention Center (PCIC) have made significant strides in improving health equity for vulnerable populations in Houston. PCIC integrates data, fosters collaboration between social services and medical providers, and provides comprehensive and targeted services, positively impacting the health and social outcomes of 98,838 individuals. By addressing diverse needs and integrating medical and social care, PCIC offers a model for developing comprehensive solutions to prevent and reduce homelessness while improving health equity for socially and medically vulnerable populations. PCIC's approach involves data sharing partnerships and care coordination initiatives with various agencies in Harris County and Houston. This cross-sector collaboration, integrating data from multiple sources such as hospital systems, managed care organizations, and government agencies, enables the development of more effective interventions. PCIC demonstrates the limits of fragmented interventions and the importance of integrating medical and social care. PCIC's model serves as an example of how collaboration, targeted services, and data integration can improve health equity and contribute to the prevention and reduction of homelessness. [ABSTRACT FROM AUTHOR]

Homelessness is among the most important problems in social medicine. While traditional studies provide useful answers (albeit for increasingly narrow phenomena), unique perspectives and first-person accounts hold potential to influence broader thinking about the field. Here, we provide a first-person account from physician-activist David Buck, a health policy expert and founder of Healthcare for the Homeless-Houston, on what it takes to tackle the homelessness epidemic, fix the broken aid industry, and challenge the status quo. [ABSTRACT FROM AUTHOR]

Despite a persistent link between homelessness, mental illness, and increased psychiatric hospitalizations, there is a dearth of research examining risk factors for higher utilization of mental health treatment among this vulnerable population. This study utilizes machine learning in electronic health record data to examine admissions from 2010 to 2019 at a regional psychiatric safety-net hospital among individuals experiencing homelessness compared to non-homeless individuals. Of the 64 social, demographic, clinical and treatment predictors examined, 12 were identified as the strongest predictors of homelessness status at psychiatric hospital admission. Admissions for patients identified as homeless were driven by social determinants of health. The strongest predictor was having no income (+267% increase in the odds of being homeless). The study results demonstrate how machine learning can be used to explore electronic health record data collected during psychiatric hospital admission, including social determinants of health, to elucidate the clinical and social needs of homeless individuals seeking psychiatric treatment. These findings have implications for the development of targeted prevention/treatment interventions to address homeless patients' needs during psychiatric hospitalization to improve social and health outcomes. [ABSTRACT FROM AUTHOR]

The Jail Inreach Project was initiated in 2007 as a pilot program by Healthcare for the Homeless-Houston, an FQHC serving homeless individuals in Harris County, Texas, as a collaborative effort with the Harris County Sheriff's Office and the Mental Health Mental Retardation Authority of Harris County. It addresses the disproportionate number of homeless individuals with behavioral health diagnoses cycling through the Harris County Jail without provisions for continuity of care. Throughout the years, several evaluations have been conducted to inform programmatic planning and assess the success of the program on affecting patterns of recidivism of mentally ill homeless clients being served. Findings reinforce the importance of linking releasees to services immediately upon release as a measure for breaking the cycle of repeated incarceration and chronic homelessness. This paper illuminates characteristics of a successful intervention by examining three program evaluations conducted at different times in the program's history. It further illustrates how program evaluation has been utilized to help shape the program design and related policies. [ABSTRACT FROM AUTHOR]

The authors discuss the need to reconsider the debate over permanent supportive housing for homeples people in the U.S., highlighting the need to focus on best approach to meet the needs of homeless people. They mention the challenges faced by homeless person in terms of physical and health conditions, sexual assaults, and efforts to prevent and end homelessness. Also discussed are studies exploring the degree of homelessness and solutions to homelessness through housing programs.