Providing Health Care to People Experiencing Homelessness: Strategies and Challenges for Cross-Sector Initiatives

Over a third of US workers are employed in jobs that involve outdoor exposure or indoor conditions without cooling. Extreme heat exposure is linked to increased mortality and adverse health outcomes, disproportionately impacting workers in these occupations. Existing studies have highlighted elevated immediate risks for heat-related health issues (for example, heat stroke) in certain occupations, but little is known about the extent to which work in heat sensitive occupations exacerbates the link between heat exposure and both health and work disability over time or in the context of an aging workforce. These likely important interactions have not been assessed using nationally representative longitudinal data, or across all occupations. Further, no single data set exists linking necessary measures (longitudinal survey data, heat and occupation data, and administrative data) to analyze and document these risks.

Adopting a life course framework and offering an innovative data integration approach, this project fills this gap by assessing the mid-to-long term health and work disability consequences of exposure to heat-sensitive jobs using panel data from the Health and Retirement Study (HRS) linked with multiple sources of tract-level extreme heat data and occupational characteristics. The first aim is to investigate whether heat-sensitive work modifies the link between extreme heat and health outcomes, focusing on self-rated health, functional limitations, and chronic conditions, with analyses controlling for sociodemographic factors. The second aim is to examine whether heat-sensitive work influences the relationship between extreme heat and work disability outcomes, including self-reported work limitation and Supplemental Security Income/Social Security Disability Insurance (SSI/SSDI) claims. This research will enhance our understanding of the role of occupational heat exposure in shaping health and disability outcomes over the medium and long term and highlight those at greatest risk. Finally, the third aim is to carefully evaluate competing measures of occupational and heat exposure to shed light on the scientific value of these measures and inform their use in future research and practice. In sum, the project builds a valuable data infrastructure, informs public health, and guides future research at the nexus of heat, work, and health.

A major challenge for Robert Wood Johnson Barnabas Health (RWJBH) primary care practices is managing patients with co-occurring chronic and behavioral health conditions. Integrated behavioral health (IBH) is a solution for improving quality and clinical outcomes for patients with co-occurring behavioral and physical health conditions by embedding behavioral health providers into the primary care setting. This study is a mixed methods, comparative case study using learning health system science to establish the value of IBH at RWJBH, promoting system-wide adoption via three aims: 1) Identify the top critical metrics for establishing the value of IBH; 2) Align the critical metrics with existing datasets at RWJBH practices and build a pilot dashboard; and 3) Assess the preliminary value of IBH in the case study sites. This project is being led by investigators from Rutgers Center for State Health Policy and Rutgers University Behavioral Health Care and is supported by a grant from the Learning Health System Scientist Training and Research in New Jersey (LHS STAR NJ) Research Project Award Program through the U.S. Agency for Healthcare Research and Quality.

Homelessness and housing instability are strongly linked with overdose risk. Permanent supportive housing (PSH)—subsidized housing paired with support services—is a key part of the national strategy to end homelessness. PSH tenants face high overdose risk due to a confluence of factors. Despite this risk, little past research has examined overdose prevention in PSH or even as related to housing more generally. We propose a multi-sector, community-partnered, stepped wedge randomized controlled trial (RCT) to evaluate the impact of a technical assistance (TA) intervention designed to support PSH agencies in sustainably implementing evidence-based practices to reduce tenant overdose and improve tenant health more broadly. The intervention will be delivered to PSH agencies in New Jersey and New York by a collaborative multi-sector team led by community organizations with national footprints. The intervention addresses not only individual tenant behavioral risks but also acts at the larger agency and building levels. The study includes a UG3 planning phase and a UH3 trial phase, with milestones defined for each phase.

This study aims to: (1) assess the independent and synergistic effects of extreme heat and prescription opioids and other heat-sensitizing medications on heat-related adverse events in low-income pregnant women; (2) assess the independent and synergistic effects of air pollution, i.e., particulate matter (PM2.5), and medications associated with thromboembolic and bleeding events on these outcomes; and (3) assess the independent and synergistic effects of extreme heat/air pollution and potentially teratogenic medications on the incidence of congenital abnormalities. The results of this study will quantify the effects of extreme heat and air pollution exposure and their potential interactions with medication use in low-income pregnant women while also shedding light on potential mechanisms that confer increased risk to certain individuals. The evidence generated from our study will have a direct impact on shaping adaptation strategies and policies for extreme weather events to protect high-risk pregnant women from the effects of extreme heat and air pollution.

Improving maternal, infant and child health and wellbeing (MCH) is an urgent public health priority. Birthing people are experiencing increases in severe maternal morbidity (SMM) and other pregnancy-related health conditions, while infant mortality in the first year of life remains greater in the U.S. than any other higher- income country. There are substantial racial and ethnic inequities and disparities in MCH, which are strongly influenced by social determinants. Thus, successfully advancing MCH in the U.S. requires interventions that address underlying factors that affect health among disinvested communities, such as housing. Homelessness is a growing phenomenon in the U.S. More than 1.2 million people experience homelessness each year, and the number of people experiencing homelessness on a single night has been rising each year since 2016. Women and girls are one of the fastest growing demographic groups among people experiencing homelessness (PEH), and 4% of all birthing people experience homelessness in the year prior to delivery. Health outcomes and behaviors associated with homelessness, such as lacking access to a regular source of medical care, are known risk factors for pregnancy-related morbidity and adverse birth outcomes. Members of racial and ethnic minoritized groups, who are more likely to face health-limiting systemic disadvantages, are overrepresented among PEH, further exacerbating inequities in MCH. However, critical gaps in our understanding of how homelessness affects MCH, and how evidence-based housing services affect MCH, limit our ability to implement effective interventions. Our overall objective is to assess how and when the experience of homelessness affects maternal and infant health and racial and ethnic health inequities, and whether Permanent Supportive Housing (PSH) and Rapid Rehousing (RRH) interventions have a positive impact on these outcomes. 

Our multidisciplinary team will apply quasi-experimental methods to linked administrative data that include homeless and housing service information, Medicaid claims, all-payer hospital records, and birth records. In Aim 1, we estimate effects of homelessness on maternal health conditions, health behaviors and healthcare utilization during pregnancy. In Aim 2, we estimate effects of homelessness on postpartum maternal and infant health and healthcare utilization. Our longitudinal dataset allows us to explore the timing of exposure, account for preconception health and compare outcomes across different pregnancies for the same person. In Aim 3, we estimate effects of PSH and RRH in this population. We use a difference-in-differences framework to provide the first quantitative estimates of the impact of these interventions on maternal and infant health and racial and ethnic health inequities. Guided by our advisory board members’ lived experience and clinical training, findings will be used to develop intervention studies and inform policy to improve prenatal and postpartum care for birthing people and infants who have experienced homelessness.