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Toward cost-effective initial care for substance-abusing homeless.

ABSTRACT: In a randomized controlled trial, behavioral day treatment, including contingency management (CM+), was compared to contingency management components alone (CM). All 206 cocaine-dependent homeless participants received a furnished apartment with food and work training/employment contingent on drug-negative urine tests. CM+ also received cognitive-behavioral therapy, therapeutic goal management, and other intervention components. Results revealed that CM+ treatment attendance and abstinence were not significantly different from CM during 24 weeks of treatment. After treatment and contingencies ended, however, CM+ showed more abstinence than CM, indicating a delayed effect of treatment from 6 to 18 months. CM+ had more consecutive weeks abstinent across 52 weeks, but not during active treatment. We conclude that CM alone may be viable as initial care for cocaine-dependent homeless persons. That CM+ yields more durable abstinence indicates that it may be appropriate as stepped-up care for clients not responding to CM (Clinical Trials.gov, no. NCT00368524).

SUBMITTER: Milby JB

PROVIDER: S-EPMC2764243 | biostudies-literature | 2008 Mar

REPOSITORIES: biostudies-literature

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Toward cost-effective initial care for substance-abusing homeless.

Milby Jesse B JB Schumacher Joseph E JE Vuchinich Rudy E RE Freedman Michelle J MJ Kertesz Stefan S Wallace Dennis D

Journal of substance abuse treatment 20070523 2

In a randomized controlled trial, behavioral day treatment, including contingency management (CM+), was compared to contingency management components alone (CM). All 206 cocaine-dependent homeless participants received a furnished apartment with food and work training/employment contingent on drug-negative urine tests. CM+ also received cognitive-behavioral therapy, therapeutic goal management, and other intervention components. Results revealed that CM+ treatment attendance and abstinence were ...[more]

PMID: 17512156

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Project description:OBJECTIVES:The homeless population is aging, and their use of nursing homes is not well understood. We compared comorbidities (substance use, mental health conditions, and physical illness) and nursing home measures (source of admission, length of stay, and mortality in the facility) of veterans who were homeless, at risk for being homeless, or stably housed in the year prior to admission. DESIGN:Cross-sectional analysis. SETTING AND PARTICIPANTS:All veterans admitted to a nursing home between January 2010 and December 2016 and their housing status in the year prior to their nursing home admission. MEASUREMENTS:Adjusted relative risks (ARRs) for the association between housing status, comorbidities, and nursing home measures. RESULTS:Veterans who were homeless in the year prior to their community nursing home admission were younger (n = 3355; 62.5 years [SD = 10.3 years]) at admission compared to stably housed veterans (n = 64 884; 75.3 years [SD = 11.9 years]). After adjustment for demographic characteristics, homeless veterans were more likely to have diagnoses for alcohol abuse (ARR = 2.18; 95% confidence interval [CI] = 2.05-2.31), drug abuse (ARR = 3.03; 95% CI = 2.74-3.33), mental health condition (ARR = 1.49; 95% CI = 1.45-1.54), dementia (ARR = 1.14; 95% CI = 1.04-1.25), liver disease (ARR = 1.32; 95% CI = 1.23-1.41), lung disease (ARR = 1.08; 95% CI = 1.04-1.13), and trimorbidity (co-occurring substance abuse, mental illness, and physical illness) (ARR = 2.57; 95% CI = 2.40-2.74) compared to stably housed veteran nursing home users. Homeless veterans were more likely to be admitted to a nursing home from a hospital (ARR = 1.13; 95% CI = 1.08-1.17) and remain in the nursing home 90 days after admission (ARR = 1.10; 95% CI = 1.04-1.16), but were less likely to die in the facility (ARR = 0.72; 95% CI = 0.67-0.78) compared to stably housed veterans. CONCLUSIONS:Homeless veteran nursing home users have different characteristics than stably housed veteran nursing home users. These differences may challenge nursing home staff caring for homeless patients. Nursing homes should assess resident housing status to help provide linkages with existing social services. J Am Geriatr Soc 67:1707-1712, 2019.

Project description:BackgroundA model for triaging patients in primary care to provide immediate contact with the most appropriate profession to treat the condition in question has been developed and implemented in parts of Sweden. Direct triaging of patients with musculoskeletal disorders (MSD) to physiotherapists at primary healthcare centres has been proposed as an alternative to initial assessment by general practitioners (GPs) and has been shown to have many positive effects. The aim of this study was to evaluate the cost-effectiveness from the societal perspective of this new care-pathway through primary care regarding triaging patients with MSD to initial assessment by physiotherapists compared to standard practice with initial GP assessment.MethodsNurse-assessed patients with MSD (N = 55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1 year regarding health-related quality of life, utilization of healthcare resources and absence from work for MSD. Quality-adjusted life-years (QALYs) were calculated based on EQ5D measured at 5 time-points. Costs for healthcare resources and production loss were compiled. Incremental cost-effectiveness ratios (ICERS) were calculated. Multiple imputation was used to compensate for missing values and bootstrapping to handle uncertainty. A cost-effectiveness plane and a cost-effectiveness acceptability curve were construed to describe the results.ResultsThe group who were allocated to initial assessment by physiotherapists had slightly larger gains in QALYs at lower total costs. At a willingness-to-pay threshold of 20,000 €, the likelihood that the intervention was cost-effective from a societal perspective including production loss due to MSD was 85% increasing to 93% at higher thresholds. When only healthcare costs were considered, triaging to physiotherapists was still less costly in relation to health improvements than standard praxis.ConclusionFrom the societal perspective, this small study indicated that triaging directly to physiotherapists in primary care has a high likelihood of being cost-effective. However, further larger randomised trials will be necessary to corroborate these findings.Trial registrationClinicalTrials.gov NCT02218749 . Registered August 18, 2014.

Project description:BACKGROUND:People experiencing homelessness have higher rates of problematic substance use but difficulty engaging with treatment services. There is limited evidence regarding how problematic substance use treatment should be delivered for these individuals. Previous qualitative research has explored perceptions of effective treatment by people who are homeless, but these individual studies need to be synthesised to generate further practice-relevant insights from the perspective of this group. METHODS:Meta-ethnography was conducted to synthesise research reporting views on substance use treatment by people experiencing homelessness. Studies were identified through systematic searching of electronic databases (CINAHL; Criminal Justice Abstracts; Health Source; MEDLINE; PsycINFO; SocINDEX; Scopus; and Web of Science) and websites and were quality appraised. Original participant quotes and author interpretations were extracted and coded thematically. Concepts identified were compared to determine similarities and differences between studies. Findings were translated (reciprocally and refutationally) across studies, enabling development of an original over-arching line-of-argument and conceptual model. RESULTS:Twenty-three papers published since 2002 in three countries, involving 462 participants, were synthesised. Findings broadly related, through personal descriptions of, and views on, the particular intervention components considered effective to people experiencing homelessness. Participants of all types of interventions had a preference for harm reduction-oriented services. Participants considered treatment effective when it provided a facilitative service environment; compassionate and non-judgemental support; time; choices; and opportunities to (re)learn how to live. Interventions that were of longer duration and offered stability to service users were valued, especially by women. From the line-of-argument synthesis, a new model was developed highlighting critical components of effective substance use treatment from the service user's perspective, including a service context of good relationships, with person-centred care and an understanding of the complexity of people's lives. CONCLUSION:This is the first meta-ethnography to examine the components of effective problematic substance use treatment from the perspective of those experiencing homelessness. Critical components of effective problematic substance use treatment are highlighted. The way in which services and treatment are delivered is more important than the type of treatment provided. Substance use interventions should address these components, including prioritising good relationships between staff and those using services, person-centred approaches, and a genuine understanding of individuals' complex lives.

Project description:Preterm birth incidence has risen globally and remains a major cause of neonatal mortality despite improved survival. Demand and cost of initial hospitalization has also increased. This study assessed the cost of preterm birth during initial hospitalization from care provider perspective in neonatal intensive care units (NICU) of two hospitals in the state of Kedah, Malaysia. It utilized universal sampling and prospectively followed up preterm infants till discharge. Care provider cost was assessed using mixed method of top down approach and activity based costing. A total of 112 preterm infants were recruited from intensive care (93 infants) and minimal care (19 infants) units. Majority were from the moderate (23%) and late (36%) preterm groups followed by very preterm (32%) and extreme preterm (9%). Median cost per infant increased with level of care and degree of prematurity. Cost was dominated by overhead (fixed) costs for general (hospital), intermediate (clinical support services) and final (NICU) cost centers where it constituted at least three quarters of admission cost per infant while the remainder was consumables (variable) cost. Breakdown of overhead cost showed NICU specific overhead contributing at least two thirds of admission cost per infant. Personnel salary made up three quarters of NICU specific overhead. Laboratory investigation was the cost driver for consumables. Gender, birth weight and length of stay were significant factors and cost prediction was developed with these variables. This study demonstrated the inverse relation between resource utilization, cost and prematurity and identified personnel salary as the cost driver. Cost estimates and prediction provide in-depth understanding of provider cost and are applicable for further economic evaluations. Since gender is non-modifiable and reducing LOS alone is not effective, birth weight as a cost predictive factor in this study can be addressed through measures to prevent or delay preterm birth.

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Toward cost-effective initial care for substance-abusing homeless.

Publications

Toward cost-effective initial care for substance-abusing homeless.

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