BACKGROUND: The homeless population in the United States is aging. Aging-associated comorbidities are associated with increased symptoms. OBJECTIVE: To describe the prevalence of symptoms among older homeless-experienced adults, analyze factors associated with moderate-high physical symptom burden, and identify symptom clusters. DESIGN: Cross-sectional analysis within longitudinal cohort study. PARTICIPANTS: Using population-based sampling from shelters, meal programs, encampments, and a recycling center in Oakland, CA, we recruited homeless adults aged ≥ 50 for a longitudinal cohort. This study includes participants who participated in the 18-month follow-up visit. MAIN MEASURES: We assessed physical symptoms using the Patient Health Questionnaire-15 (PHQ-15); psychological symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D), Primary Care PTSD Screen (PC-PTSD), and psychiatric section of the Addiction Severity Index (ASI); loneliness using the Three-Item Loneliness Scale; and regret using a six-item regret scale. KEY RESULTS: Two hundred eighty-three participants (75.6% men and 82.3% African-Americans) completed symptoms interviews. Over a third (34.0%) had moderate-high physical symptom burden. The most prevalent physical symptoms were joint pain, fatigue, back pain, and sleep trouble. Over half (57.6%) had psychological symptoms; 39.6% exhibited loneliness and 26.5% had high regret. In a multivariate model, being a woman (

Homelessness causes and exacerbates physical and psychological distress. Interventions should address multiple interconnected dimensions of suffering. Health systems that care for homeless patients should adapt palliative care practices using a stepwise approach. Homeless shelters should adopt policies and modifications that increase privacy and autonomy while promoting community building. Housing interventions should promote community building. All who work with people experiencing homelessness should avoid stigmatizing language and recognize homeless individuals' sources of strength and coping.

BACKGROUND Permanent supportive housing (PSH) is an evidence-based practice to address homelessness. More research is needed to understand the impact of PSH on health-related outcomes. OBJECTIVE This paper describes the protocols for a mixed-methods comparative effectiveness study of two distinct approaches to implementing PSH and patient-centered quality of life, health care utilization, and health behaviors that reduce COVID-19 risk. METHODS People experiencing homelessness who are placed in either (a) single-site (place-based) PSH or (b) scatter-site PSH completed 6 monthly surveys after move-in using smartphones provided by the study team. A subsample of participants completed three qualitative interviews at baseline, 3 months, and 6 months. Two stakeholder advisory groups, including one featuring people with lived experience of homelessness, helped guide study decisions and interpretations of findings. RESULTS Recruitment during the pandemic was challenging given that in-person contact was not permitted at times either by the recruitment sites or research institutions during COVID-19 surges and high community transmission, which particularly affected homelessness programs. To overcome these challenges, flexible strategies were employed that included extending the recruitment period and distribution of cell phones with paid data plans. CONCLUSIONS Study protocols to examine the comparative effectiveness of single-site versus scatter-site PSH were developed and implemented during the COVID-19 pandemic to examine health-related outcomes. CLINICALTRIAL NCT04769349

Background Permanent supportive housing (PSH) is an evidence-based practice to address homelessness that is implemented using 2 distinct approaches. The first approach is place-based PSH (PB-PSH), or single-site housing placement, in which an entire building with on-site services is designated for people experiencing homelessness. The second approach is scatter-site PSH (SS-PSH), which uses apartments rented from a private landlord while providing mobile case management services. Objective This paper describes the protocols for a mixed methods comparative effectiveness study of 2 distinct approaches to implementing PSH and the patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk. Methods People experiencing homelessness who are placed in either PB-PSH or SS-PSH completed 6 monthly surveys after move-in using smartphones provided by the study team. A subsample of participants completed 3 qualitative interviews at baseline, 3 months, and 6 months that included photo elicitation interviewing. Two stakeholder advisory groups, including one featuring people with lived experience of homelessness, helped guide study decisions and interpretations of findings. Results Study recruitment was supposed to occur over 6 months starting in January 2021 but was extended due to delays in recruitment. These delays included COVID-19 delays (eg, recruitment sites shut down due to outbreaks and study team members testing positive) and delays that may have been indirectly related to the COVID-19 pandemic, including high staff turnover or recruitment sites having competing priorities. In end-July 2022, in total, 641 people experiencing homelessness had been referred from 26 partnering recruitment sites, and 563 people experiencing homelessness had enrolled in the study and completed a baseline demographic survey. Of the 563 participants in the study, 452 had recently moved into the housing when they enrolled, with 272 placed in PB-PSH and 180 placed in SS-PSH. Another 111 participants were approved but are still waiting for housing placement. To date, 49 participants have been lost to follow-up, and 12% of phones (70 of the initial 563 distributed) were reported lost by participants. Conclusions Recruitment during the pandemic, while successful, was challenging given that in-person contact was not permitted at times either by program sites or the research institutions during COVID-19 surges and high community transmission, which particularly affected homelessness programs in Los Angeles County. To overcome recruitment challenges, flexible strategies were used, which included extending the recruitment period and the distribution of cell phones with paid data plans. Given current recruitment numbers and retention rates that are over 90%, the study will be able to address a gap in the literature by considering the comparative effectiveness of PB-PSH versus SS-PSH on patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk, which can influence future public health approaches to homelessness and infectious diseases. Trial Registration ClinicalTrials.gov NCT04769349; https://clinicaltrials.gov/ct2/show/NCT04769349 International Registered Report Identifier (IRRID) DERR1-10.2196/46782

Background: Permanent supportive housing (PSH) is an evidence-based practice to address homelessness. This paper describes the protocols for a mixed-methods comparative effectiveness study of two distinct approaches to implementing PSH and patient-centered quality of life, health care utilization, and health behaviors that reduce COVID-19 risk. Methods: People experiencing homelessness who are placed in either (a) single-site (place-based) PSH or (b) scatter-site PSH completed 6 monthly surveys after move-in using smartphones provided by the study team. A subsample of participants completed three qualitative interviews at baseline, 3 months, and 6 months. Two stakeholder advisory groups, including one featuring people with lived experience of homelessness, helped guide study decisions and interpretations of findings. Discussion: Recruitment during the pandemic was challenging given that in-person contact was not permitted at times either by the recruitment sites or research institutions during COVID-19 surges and high community transmission, which particularly affected homelessness programs. To overcome these challenges, flexible strategies were employed that included extending the recruitment period and distribution of cell phones with paid data plans. Trial registration: NCT04769349