Homelessness of Disclosures - UCSF CME · Winter Solstice (December 21) ... – Dental care is scary but can be life changing Top Ten Pearls 4. Appointments are the enemy 5. Understand

Treating Addiction in the Homeless Population | Barry Zevin, MD

CSAM State of the Art Conference | August 30 – September 1, 2018 | San Francisco

Homelessness and Health Care of People Experiencing Homelessness

Barry Zevin MD

San Francisco Department of Public Health

Whole Person Integrated Care

Medical Director

Street Medicine, Shelter Health, Urgent Care

[email protected]

DisclosuresBarry Zevin is an employee of the San Francisco Department of Public Health

There are no relevant financial or personal relationships that could cause bias in this presentation

Barry Zevin does not accept money, gifts, incentives from the pharmaceutical industry or addiction treatment industry

Case“ The ache for home lives in all of us, the safe place where we can go as we are and not be questioned.”

Maya Angelou—All God’s Children Need Traveling Shoes



• Homelessness is a Result of Poverty

• Poverty is a Result of Disadvantage, Discrimination, Disability

• Homelessness is a Result of Lack of Affordable Housing

• Lack of Affordable Housing is a Result of Policy

Stigma

Shame

Suffering

Survival

Poverty

A Really Brief History of Homelessness in America: Moral Model



A Really Brief History of Homelessness in America:(Somewhat) Enlightened Contemporary

Personal• Lazy, Crazy, & Bad• Mental Health

– Deinstitutionalization

• Substance Use– Requires treatment voluntary or coerced– If treatment does not result in cure go back to

moral model

• Disadvantage• Disability• Need for Supportive Housing

– Housing first, ACT, ICM

Structural

• Poverty

• Lack of Affordable Housing

• Lack of Appropriate Housing

• Lack of appropriate or effective treatment

• Various care coordination and case management models

How Many People Are Experiencing Homelessness In San Francisco?

• 8,035

• 9,784

• 17,653

• 151,278

• 567,715



People Experiencing Homelessness

• 8,035 ‐ 2019 Point in Time Count Fed Definition

• 9,784 ‐ 2019 Point in Time Count SF Definition

• 17,653 – DPH, HSH, registered as homeless

• 151,278 – 2019 California PIT Count

• 567,715 – 2019 USA PIT Count

• 102,968 US Homeless Children single night count

• 2,483,539 U.S. Department of Education’s count of homeless children in U.S. public schools /2013 U.S. Census data

• 2.3 million ‐ 3.5 million experience homelessness in a year (old data from before they stopped trying to count)

How Many Homeless People?

0

10

20

30

40

50

60

70

Mental Health Disorder Substance Use Disorder Cognitive Impairments Disability

US Population US Homeless Population

Prevalence of Illness & Disability



National Homeless Deaths MemorialWinter Solstice (December 21)

Homelessness and Aging

• Homeless Adult Population over 50– 1990s: 11% – 2003: 37%– 2018: >50%

• Mortality 4‐5X age‐standardized general population

• 20‐30 year earlier age of onset of chronic disease in homeless persons

Special Problems

• Violence and traumatization• High utilization of medical and other urgent and emergency services– Underutilization of preventative and wellness services

• Cognitive Impairment – HL + SUD– >50% acquired brain injury, developmental, etc

• Assault of homelessness on individuals integrity and sense of meaning



Homelessness is Traumatizing

Homelessness and Resilience

• Few homeless individuals are isolated and alone

– Street culture community may be essential for survival even if not “healthy”

• Strengths based approaches support resilience and coping

– Specific daily life skills training

– Spiritual support

common co‐occurring challenges in homeless

• Cognitive impairments– > 50% of HL with SUD with significant impairment– Use several forms of communication – Keep It Simple

• Mental Health Disorders– Trauma – Get practical about trauma informed approach– Psychiatric Disorders– Substance Use Disorders– Poorly recognized conditions– Complex trauma/Autism Spectrum/ADHD



Adaptations to Practice

• Ask about Homelessness and housing stability– “What is your Living Situation?”– “Will you be able to stay there? Is that safe?”

• Assess Homeless Street Smarts and Survival Skills– How will current illness change persons ability to

survive?– How can we scaffold persons success when back in the

community

Shelter

Street/Vehicle /Encampment

• Most people experiencing homelessness will remain homeless for the foreseeable future

• Use Bio‐Psycho‐Social‐Spiritual approach– Multi‐disciplinary, integrated, whole person

• Explore barriers to care specific to each patient• Develop action plan to overcome specific barriers• What is back up plan? What is back up plan to the back up plan?




Barriers to Treatment: Patient challenges– No insurance/medi‐cal

inactive– No ID– No phone– Getting to appointments on

time very difficult– Can’t / won’t leave stuff /

pets– Can’t / won’t leave partner– Will lose everything by

entering treatment– 86’d from clinics and services

– Can’t trust doctors– Feel ashamed due to

appearance, hygiene, chance of meeting other community members

– Warrants or other criminal justice complications

– Chaotic constant drug use– Acute medical issues

– “No one cares about my health”

Barriers to Treatment:Provider Perception of Patients

– “They just don’t care about their health”

– They don’t belong in the hospital but they don’t belong on the street

– Frequent lost or stolen medication

– If we are overly kind to them they’ll keep coming back

– Poor previous track record of adherence to medical plans

– Miss appointments– Safety risk– Poor hygiene– Disturbing to other

patients– Time consuming and

manipulative

Selected Adaptations

• No Insurance:

– Formulary of medications free on site or arrangements with a local pharmacy

– Exceptions to eligibility criteria to assure people get care

– Assistance to get on Medicaid (CA medi‐cal)

• benefits navigator In locations where HL are – Shelters, clinics,


• Appointments are the enemy of people experiencing homelessness– Open access – more than just drop in– Offer “meaningful waiting”– CAYA ‐ “Come as you are”

• Opportunities to practice in unconventional sites– Deliver services where people are– Respite, shelter, navigation center, needle exchange,

residential programs, etc




• Trauma histories including bad experience in health care and treatment– Trauma informed approach– Kind human interaction from first moments of encounter

• Cognitive impairments:– Multiple forms of communication– Outreach, frequent visits

Selected Adaptations• Victimization: Lost, Stolen, Destroyed Medications

– Short Rx duration –small Rx with refills rather than 1 month supply

– Strategies for safe storage– Shelters may offer daily dispensed

• Chaotic substance use and chaotic lives– Mutual goal setting– Welcome people back who are intermittent with follow up– Creative approaches to intensifying treatment


• Usual healthcare quality indicators may not be relevant for homeless populations

– Review indicators and eliminate or adapt them

– Add new indicators based on risks in population


• Patients leaving “Against Medical Advice”– Establish this as an “unusual occurrence” or critical marker to initiate quality improvement

– The reason is virtually never “don’t care about my health”

– Ask patients experiencing homelessness as a matter of course early in hospitalization whether there is anything that would interfere with their staying in the hospital until their condition is stabilized




• Immersion in substance using community– Naloxone for everybody

– Alternatives to abstinence from all drug use as treatment goal

– Retention in care as primary desirable outcome

– Improved functioning and safety as desirable outcomes


• Respite Care

• Street Medicine

• Shelter Health

• Formal and informal collaborations

• Ambulatory Intensive Care

Selected AdaptationsAdherence Assistance

• Recognize unique challenges and opportunities related to homelessness

• Ask about patient’s typical daily activities• Use patients’ already established habits

– E.g. when is there time to take meds, patterns of drug use,

• Consider patients limited choices when offering dietary / nutritional advice

Selected AdaptationsAdherence Assistance

• Diuretics or meds causing diarrhea may be major challenges when there are no bathrooms– May need to change usual advice of no diuretics at night

• Sedating meds may be problem for individuals who need to maintain vigilance

• Pay attention to interactions with street drugs



Top Ten Pearls

1. Lice Are Not Scary– Body lice: shower and fresh clothes – that’s all– Head lice: clip hair to <1cm if possible, nitpick!

2. TB among homeless is way down– Always symptoms screen– Test and document TB clearance early

3. Bad Teeth Suck– Dental care is scary but can be life changing

Top Ten Pearls4. Appointments are the enemy5. Understand the exact details of a persons daily life and

activities before attempting to make interventions and give advice– Staff involved in care and discharge planning need to see

shelters, navigation centers, drop in centers, etc

6. Trauma leads to disconnection of mind and body and will create challenges in providing care

7. Working with people experiencing homelessness will change you– Incorporate self‐care for vicarious trauma programmatically and

personally

Top Ten Pearls8. Create a trauma informed space

– Do a walk through with a consumer or imagine you’ve just been traumatized and are walking in.

9. Train all staff on homeless related issues– Professional staff can have the best intentions to treat patients with dignity and respect but have poor outcome if other staff have stigmatized or shamed a patient

10. Celebrate small incremental positive outcome– Low Expectations High Hopes



Final Thoughts

• How else can you help?– Be generous with your local homeless service and advocacy agencies

– Join in advocacy– Volunteer

• Project Homeless Connect• Student homeless projects• Local HCH programs

Thank You To My Colleagues and My Patients Who I Learn From Every Day

Thank You to WRAP and Artists For Use of Images Under Creative Commons License

Appendix

• Bio‐Psycho‐Social‐Spiritual

• Policy Approach

• Resources

• References

Key Resources

• WRAP – Western Regional Advocacy Project– Policy understanding– Artwork used under Creative Commons Lic.– https://wraphome.org/

• The 2016 & 2017 Annual Homeless Assessment Report (AHAR) to Congress Part 1 and 2– https://www.hudexchange.info/programs/hdx/guides/ahar/#reports



Bio‐Psycho‐Social‐Spiritual care for people experiencing homelessness

• Consider unusual infections – lice borne, flea borne, rat borne, conditions of neglect– Bartonella, leptospirosis, deep tissue infections

• Medical effects of methamphetamine use are underestimated– High rates heart failure, neurological conditions, infections

• Methadone and buprenorphine for opioid use disorder are our most effective treatments for any substance use disorders– Project Shout https://www.projectshout.org/


• Violence and victimization are daily occurrences on the street, they are the constant accompaniment of the homeless person.

• Hospitalization (medical or psychiatric) is a good time to establish an accurate psychiatric diagnosis and initiate treatment


• Priorities such as obtaining food and shelter may be placed above medical care.

• Homeless people are often blamed for a variety of social ills and exploited for political purposes

• Getting beyond compassion fatigue– Homeless consult service (social medicine service)

– Empower staff to create ad‐hoc or informal multi‐disciplinary teams


• Widespread Depression, Addiction, and Other “Mental Illnesses” reflect something widespread wrong with our way of living

– materialism, consumerism, enormous wealth disparity, family and community disintegration, loss of meaning, loss of self value and worth




• Problem of Boredom and withdrawal from living on the edge– Homelessness and addiction are like a full time job

– Lack of a meaningful role in society is extremely destructive

• Authentic concern, engaged supportive listening, understanding of what it means to be homeless are key interventions

San Francisco 2019 Landscape• 18,000 registered as Homeless

– 4000+ psychotic disorder and severe SUD

• 300 – 1000 housing slots open per year• Effort to rationalize housing based on vulnerability

– coordinated entry assessment

• Effort to “Share priorities” between and within departments

• Shared Priority Project

55

Coordinated Entry Assessment?

17,653

YES6,510

NO11,143

Prioritized for Perm Supp Hsg?

NO5,266

YES1,001

Shared Priority Population

Adults Experiencing Homelessness Served by SFDPH and/or HSH in FY1819 (as of 7/31/19)

DPH Psych + SUD

237

DPH Psych + SUD

2,387

DPH Psych + SUD

1,0253,735

95%have a history of alcohol use disorder

65% utilized the ED but only 6% utilized the Sobering Center

22%had involuntary psychiatric holds

3% are currently conserved

11% are currently assigned an intensive case manager

An in‐depth analysis of public health data identified 3,735 (1 in 5 of the 12‐month total 17,638 unique individuals experiencing homelessness) who have a history of co‐occurring psychoses and substance use disorders…

40%have cycled in and out of homelessness for more than 13 years

29 died in FY1819

28%had at least one county jail interaction in FY1819

The average number of incarcerations is 2.3

40%are 50+ years of age

The average age of death for homeless adults is 51

113 individuals are 18‐24 years of age

35%identify as Black/African American

Blacks outnumber Whites in this population

74%have a serious medical condition

12% HIV/AIDS65% CHF35% Hypertension4% Renal Failure

80%used urgent/emergent care services in FY1819

223 individuals used over 24 services



57

Interagency Prioritization Method

WHOLE PERSON CARE DELIVERABLES

ACCOMPLISHMENTS:

- HSH (Dept of Homelessness and Supportive Housing) completed over 6,000 Coordinated Entry assessments in FY1819 and prioritized 1,001

- DPH endorsed HSH’s Coordinated Entry prioritization methodology- HSH endorsed DPH’s ranking methodology to prioritize those with co-occurring histories of

psychoses diagnoses and substance use disorders

WORKS IN PROGRESS:

- Individuals with histories of psychoses under-represented in Coordinated Entry pools:- assessed, but not prioritized- not yet assessed

• Prioritization process is fair, equitable, and transparent

• Pathway is clear to necessary resources and services

• Response is trauma-informed, culturally-competent, and adaptableto the unique needs of individuals

• For clients and staff, process is hopeful and reinforces belief that positive change is possible

• Process is built and success is measured with a racial equity lens

• Success and accountability are shared across agencies

Our Shared Principles

59

Alert!This individual is a Shared Priority client and is high priority for housing, health, and human services. Contact High Intensity Care Team at 415-816-6739 / [email protected] to coordinate next steps/discharge planning.

First Response

High Intensity Care Team(EMS6, Street Medicine & SFHOT)

Policy Approach

• No single “problem of homelessness”

– Define problems before solving them

– Adopt housing as a human right

– Provide housing and services that are effective and acceptable and recognize long term need

– Collaborate within community



• Until we house those experience homeless:– Provide Realistic / practical solutions

• Problem: people urinating and defecating in street, spread of contagious diseases

• Solution: more accessible toilets and handwashing where homeless people are

• Problem: Homeless people congregating in streets and parks

• Solution: Create compelling places for people to be during the day (and night) other than streets and parks

Policy Approach

– Realistic / practical solutions• Problem: people drinking alcohol and using drugs in plain view of the public, high rate of overdose deaths

• Solution: Sobering / safer recovery centers, supervised consumption facilities

• Problem: Overuse of emergency and acute healthcare services by individuals experiencing homelessness

• Solution: Careful analysis and then targeted solutions– Example SF and other counties Whole Person Care initiatives

Policy Approach



• “2016 AHAR: Part 2 ‐ Estimates of Homelessness in the U.S. ‐ HUD Exchange.” Accessed June 10, 2018. https://www.hudexchange.info/resource/5640/2016‐ahar‐part‐2‐estimates‐of‐homelessness‐in‐the‐us/.

• “2017 AHAR: Part 1 ‐ PIT Estimates of Homelessness in the U.S. ‐ HUD Exchange.” Accessed June 10, 2018. https://www.hudexchange.info/resource/5639/2017‐ahar‐part‐1‐pit‐estimates‐of‐homelessness‐in‐the‐us/.

• Baggett, Travis P., and Nancy A. Rigotti. “Cigarette Smoking and Advice to Quit in a National Sample of Homeless Adults.” American Journal of Preventive Medicine 39, no. 2 (August 2010): 164–72. https://doi.org/10.1016/j.amepre.2010.03.024.

• Bender, Kimberly, Samantha M. Brown, Sanna J. Thompson, Kristin M. Ferguson, and Lisa Langenderfer. “Multiple Victimizations before and after Leaving Home Associated with PTSD, Depression, and Substance Use Disorder among Homeless Youth.” Child Maltreatment 20, no. 2 (May 2015): 115–24. https://doi.org/10.1177/1077559514562859.

• Childress, Sarah, Lorraine R. Reitzel, Diane Santa Maria, Darla E. Kendzor, Alexis Moisiuc, and Michael S. Businelle. “Mental Illness and Substance Use Problems in Relation to Homelessness Onset.” American Journal of Health Behavior 39, no. 4 (July 2015): 549–55. https://doi.org/10.5993/AJHB.39.4.11.

• Davidson, Clare, Charles Neighbors, Gerod Hall, Aaron Hogue, Richard Cho, Bryan Kutner, and Jon Morgenstern. “Association of Housing First Implementation and Key Outcomes among Homeless Persons with Problematic Substance Use.” Psychiatric Services (Washington, D.C.) 65, no. 11 (November 1, 2014): 1318–24. https://doi.org/10.1176/appi.ps.201300195.

• Dunne, Eugene M., Larry E. Burrell, Allyson D. Diggins, Nicole Ennis Whitehead, and William W. Latimer. “Increased Risk for Substance Use and Health‐Related Problems among Homeless Veterans.” The American Journal on Addictions 24, no. 7 (October 2015): 676–80. https://doi.org/10.1111/ajad.12289.

• Fazel, Seena, Vivek Khosla, Helen Doll, and John Geddes. “The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta‐Regression Analysis.” PLoS Medicine 5, no. 12 (December 2, 2008): e225. https://doi.org/10.1371/journal.pmed.0050225.

• Gabrielian, Sonya, Elizabeth Bromley, Gerhard S. Hellemann, Robert S. Kern, Nicholas I. Goldenson, Megan E. Danley, and Alexander S. Young. “Factors Affecting Exits from Homelessness among Persons with Serious Mental Illness and Substance Use Disorders.” The Journal of Clinical Psychiatry 76, no. 4 (April 2015): e469‐476. https://doi.org/10.4088/JCP.14m09229.

• Gaetz, Stephen. “Commentary: Harm Reduction, Managed Alcohol Programs and Doing the Right Thing.” Drug and Alcohol Review 37 Suppl 1 (April 2018): S195–96. https://doi.org/10.1111/dar.12652.

• Guilcher, Sara J. T., Sarah Hamilton‐Wright, Wayne Skinner, Julia Woodhall‐Melnik, Peter Ferentzy, Aklilu Wendaferew, Stephen W. Hwang, and Flora I. Matheson. “‘Talk with Me’: Perspectives on Services for Men with Problem Gambling and Housing Instability.” BMC Health Services Research 16, no. a (02 2016): 340. https://doi.org/10.1186/s12913‐016‐1583‐3.

• Hall, Gerod, Sarah Walters, Hannah Gould, and Sungwoo Lim. “Housing versus Treatment First for Supportive Housing Participants with Substance Use Disorders: A Comparison of Housing and Public Service Use Outcomes.” Substance Abuse, March 12, 2018, 1–7. https://doi.org/10.1080/08897077.2018.1449049.

• Hyshka, Elaine, Jalene Tayler Anderson, and T. Cameron Wild. “Perceived Unmet Need and Barriers to Care amongst Street‐Involved People Who Use Illicit Drugs.” Drug and Alcohol Review 36, no. 3 (2017): 295–304. https://doi.org/10.1111/dar.12427.

• Leickly, Emily, Jordan Skalisky, Oladunni Oluwoye, Sterling M. McPherson, Debra Srebnik, John M. Roll, Richard K. Ries, and Michael G. McDonell. “Homelessness Predicts Attrition but Not Alcohol Abstinence in Outpatients Experiencing Co‐Occurring Alcohol Dependence and Serious Mental Illness.” Substance Abuse, November 21, 2017, 1–4. https://doi.org/10.1080/08897077.2017.1391926.

• Manseau, Marc W., Amit Rajparia, Adriana Joseph, Sarah Azarchi, Donald Goff, Ritvij Satodiya, and Crystal Fuller Lewis. “Clinical Characteristics of Synthetic Cannabinoid Use in a Large Urban Psychiatric Emergency Setting.” Substance Use & Misuse 52, no. 6 (12 2017): 822–25. https://doi.org/10.1080/10826084.2016.1263663.

• ORDP, OPPS. “Social Security Ruling: SSR 2013‐2p.” Accessed June 9, 2018. https://www.ssa.gov/OP_Home/rulings/di/01/SSR2013‐02‐di‐01.html.• Paquette, Kristen, and Laura A. Pannella Winn. “The Role of Recovery Housing: Prioritizing Choice in Homeless Services.” Journal of Dual Diagnosis 12,

no. 2 (June 2016): 153–62. https://doi.org/10.1080/15504263.2016.1175262.• Reitzel, Lorraine R., Nga Nguyen, Sara Eischen, Janet Thomas, and Kolawole S. Okuyemi. “Is Smoking Cessation Associated with Worse Comorbid

Substance Use Outcomes among Homeless Adults?” Addiction (Abingdon, England) 109, no. 12 (December 2014): 2098–2104. https://doi.org/10.1111/add.12688.

• Rosen, Marc I, Thomas J McMahon, HaiQun Lin, and Robert A Rosenheck. “Effect of Social Security Payments on Substance Abuse in a Homeless Mentally Ill Cohort.” Health Services Research 41, no. 1 (February 2006): 173–91. https://doi.org/10.1111/j.1475‐6773.2005.00481.x.

• Spinelli, Matthew A., Claudia Ponath, Lina Tieu, Emily E. Hurstak, David Guzman, and Margot Kushel. “Factors Associated with Substance Use in Older Homeless Adults: Results from the HOPE HOME Study.” Substance Abuse 38, no. 1 (March 2017): 88–94. https://doi.org/10.1080/08897077.2016.1264534.

• Stockwell, Tim, and Bernadette (Bernie) Pauly. “Managed Alcohol Programs: Is It Time for a More Radical Approach to Reduce Harms for People Experiencing Homelessness and Alcohol Use Disorders?” Drug and Alcohol Review 37, no. S1: S129–31. Accessed June 9, 2018. https://doi.org/10.1111/dar.12687.

• Stringfellow, Erin J., Theresa W. Kim, Adam J. Gordon, David E. Pollio, Richard A. Grucza, Erika L. Austin, N. Kay Johnson, and Stefan G. Kertesz. “Substance Use among Persons with Homeless Experience in Primary Care.” Substance Abuse 37, no. 4

• (December 2016): 534–41. https://doi.org/10.1080/08897077.2016.1145616.

• Tsai, Jack, and Robert A. Rosenheck. “Risk Factors for Homelessness among US Veterans.” Epidemiologic Reviews 37 (2015): 177–95. https://doi.org/10.1093/epirev/mxu004.

• ———. “Smoking Among Chronically Homeless Adults: Prevalence and Correlates.” Psychiatric Services 63, no. 6 (June 1, 2012): 569–76. https://doi.org/10.1176/appi.ps.201100398.

• ———. “VA Disability Compensation and Money Spent on Substance Use Among Homeless Veterans: A Controversial Association.” Psychiatric Services (Washington, D.C.) 66, no. 6 (June 2015): 641–44. https://doi.org/10.1176/appi.ps.201400245.

• Upshur, Carole C., Darlene Jenkins, Linda Weinreb, Lillian Gelberg, and Elizabeth Aaker Orvek. “Homeless Women’s Service Use, Barriers, and Motivation for Participating in Substance Use Treatment.” The American Journal of Drug and Alcohol Abuse 44, no. 2 (2018): 252–62. https://doi.org/10.1080/00952990.2017.1357183.

• Whitbeck, Leslie B., Brian E. Armenta, and Melissa L. Welch‐Lazoritz. “Borderline Personality Disorder and Axis I Psychiatric and Substance Use Disorders among Women Experiencing Homelessness in Three US Cities.” Social Psychiatry and Psychiatric Epidemiology 50, no. 8 (August 2015): 1285–91. https://doi.org/10.1007/s00127‐015‐1026‐1.

• Brown, Rebecca T., Leah Goodman, David Guzman, Lina Tieu, Claudia Ponath, and Margot B. Kushel. “Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study.” PLOS ONE 11, no. 5 (May 10, 2016): e0155065. https://doi.org/10.1371/journal.pone.0155065.

• Chang, Jamie Suki. “Health in the Tenderloin: A Resident‐Guided Study of Substance Use, Treatment, and Housing.” Social Science & Medicine (1982)176 (2017): 166–74. https://doi.org/10.1016/j.socscimed.2017.01.014.

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• García Murillo, Lourdes, Maria A. Ramos‐Olazagasti, Salvatore Mannuzza, Francisco Xavier Castellanos, and Rachel G. Klein. “Childhood Attention‐Deficit/Hyperactivity Disorder and Homelessness: A 33‐Year Follow‐Up Study.” Journal of the American Academy of Child and Adolescent Psychiatry 55, no. 11 (November 2016): 931–36. https://doi.org/10.1016/j.jaac.2016.07.772.

• Hurstak, Emily, Julene K. Johnson, Lina Tieu, David Guzman, Claudia Ponath, Christopher T. Lee, Christina Weyer Jamora, and Margot Kushel. “Factors Associated with Cognitive Impairment in a Cohort of Older Homeless Adults: Results from the HOPE HOME Study.” Drug and Alcohol Dependence 178 (01 2017): 562–70. https://doi.org/10.1016/j.drugalcdep.2017.06.002.

• Nikoo, Mohammadali, Anne Gadermann, Matthew J. To, Michael Krausz, Stephen W. Hwang, and Anita Palepu. “Incidence and Associated Risk Factors of Traumatic Brain Injury in a Cohort of Homeless and Vulnerably Housed Adults in 3 Canadian Cities.” The Journal of Head Trauma Rehabilitation 32, no. 4 (August 2017): E19–26. https://doi.org/10.1097/HTR.0000000000000262.

• Stergiopoulos, V., A. Cusi, T. Bekele, A. Skosireva, E. Latimer, C. Schütz, I. Fernando, and S. B. Rourke. “Neurocognitive Impairment in a Large Sample of Homeless Adults with Mental Illness.” Acta Psychiatrica Scandinavica 131, no. 4 (April 2015): 256–68. https://doi.org/10.1111/acps.12391.

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Homelessness of Disclosures - UCSF CME · Winter Solstice (December 21) ... – Dental care is scary but can be life changing Top Ten Pearls 4. Appointments are the enemy 5. Understand