BACKGROUND: The COVID-19 pandemic intersected with a housing crisis for unsheltered Veterans experiencing homelessness (VEHs); congregate settings became high risk for viral spread. The VA Greater Los Angeles responded by creating the Care, Treatment, and Rehabilitation Service (CTRS), an outdoor, low-barrier-to-entry transitional housing program on VA grounds. This novel emergency initiative offered a protected outdoor environment (sanctioned encampment) where VEHs lived in tents and had access to three meals a day, hygiene resources, and health and social services. OBJECTIVE: To identify contextual factors that supported and impeded CTRS participants access to healthcare and housing services. DESIGN: Multi-method, ethnographic data collection. PARTICIPANTS: VEHs residing at CTRS, CTRS staff. APPROACH: Over 150 hours of participant observation were conducted at CTRS and at eight town hall meetings; semi-structured interviews were conducted with 21 VEHs and 11 staff. Rapid turn-around qualitative analysis was used to synthesize data, engaging stakeholders in iterative participant validation. Content analysis techniques were used to identify key factors that impacted access to housing and health services among VEHs residing in CTRS. KEY RESULTS: Staff varied in their interpretation of CTRS mission. Some conceptualized access to health services as a central tenet, while others viewed CTRS as an emergency shelter only. Regardless, staff burnout was prevalent, which lead to low morale, high turnover, and worsened access to and quality of care. VEHs endorsed trusting, long-term relationships with CTRS staff as paramount for facilitating access to services. Though CTRS addressed basic priorities (food, shelter, etc.) that traditionally compete with access to healthcare, some VEHs needed on-site healthcare services, at their tents, to access care. CONCLUSIONS: CTRS provided VEHs access to basic needs and health and housing services. To improve access to healthcare services within encampments, our data suggest the value of longitudinal trusting relationships, adequate staff support, and on-site health services.

Objective

The purpose of this study was to examine associations between homelessness and length of psychiatric hospitalization and to explore the role of mental health conservatorship in determining discharge location for patients who are homeless and have a grave disability from serious mental illness.

Methods

This observational study used administrative data from a safety-net psychiatric hospital in Los Angeles. The sample included 795 adults (≥18 years) who were hospitalized on an involuntary psychiatric hold between 2016 and 2018. The outcome variables were length of stay (days) and discharge location (home, locked psychiatric facility, unlocked psychiatric facility, unhoused). The predictor variables were homelessness status and whether a mental health conservatorship was initiated during hospitalization. Multiple regression models were used to estimate associations between variables.

Results

Homelessness status was associated with 27.5 additional days (SE=3.5 days) of hospitalization in adjusted models. Homeless patients for whom conservatorship was initiated comprised 6% of the sample but 41% of total inpatient days. Among people who were homeless, initiation of a conservatorship was associated with significantly longer length of inpatient stay (mean=154.8 days versus 25.6 days for the whole sample) but also with lower odds of being unhoused at the time of discharge (risk ratio=0.19, 95% confidence interval=0.09-0.34).

Conclusions

A mental health conservatorship can be a mechanism for helping homeless people with a grave disability from mental illness to transition from the streets to residential psychiatric treatment, but it requires substantial resources from facilities that initiate such conservatorships and does not guarantee resolution of long-term supportive housing needs.

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

PURPOSE OF REVIEW:We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions. RECENT FINDINGS:There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.