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Primary care provider experience and social support among homeless-experienced persons with tri-morbidity

Background

Persons living with mental illness, substance use disorder, and medical conditions, or “tri-morbidity,” have complex health needs. Tri-morbidity may be common among those who are homeless, and who face considerable obstacles to obtaining the high-quality, patient-centered health care and strong social support they need.

Measures

Tri-morbidity was operationalized as meeting the following criteria: 1) probable mental illness or major psychiatric distress, based on reporting a diagnosis of post-traumatic stress disorder or schizophrenia, having ever taken psychiatric medication for a significant period of time, or a score of 30+ on the Colorado Symptom Index (range: 5–70) [1]; 2) lifetime moderate- or high-risk alcohol or illicit drug use, as measured using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) v. 3 [2]; and 3) reporting at least 1 of 14 physician-diagnosed chronic medical conditions.

Primary care experience was measured using the Primary Care Quality-Homeless (PCQ-H) tool (range: 1–4) [3]. Social support was measured using the "strong ties" scale (range: 3–15) [4], which queries the degree to which persons are bothered by not having a close companion, enough friendships, or people to whom they feel close.

Methods

Patients (N = 601) from five geographically diverse primary care sites (four from the Department of Veterans Affairs [VA] and one health care for homeless program) were surveyed. Pearson’s chi-square, correlations, and t-tests assessed bivariate relationships. Multiple linear regression tested whether tri-morbidity predicted lower social support, compared to those without tri-morbidity, controlling for characteristics associated with strong ties.

Results

Tri-morbidity was present in 39 percent of this sample of primary care-engaged, homeless, and formerly homeless persons (Table 1). Associated characteristics are shown in Table 2. Primary care experience was positive overall, as well as on all four subscales, and did not differ for persons with tri-morbidity (all p > .15). In the multiple regression model, persons with tri-morbidity had lower levels of social support (about 1.2 points on the strong ties scale; p < .0001) than those without tri-morbidity; controlling for financial hardship, minority, employment, and housing statuses; PCQ-H score; and having a live-in partner.

Table 1 Tri-morbidity among Primary Care-Engaged Formerly and Currently Homeless Persons (N = 601)
Table 2 Bivariate Comparisons of Characteristics by Tri-morbid Status (% and Means) (N = 601)

Conclusions

Tri-morbidity was common in this sample of primary care-engaged formerly and currently homeless persons. Despite their increased complexity, the patient-reported primary care experience was not worse in the presence of tri-morbidity. Their lower social support, even compared to other homeless-experienced patients, might be relevant for primary care providers’ treatment plans.

References

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    Boothroyd RA, Chen HJ: The psychometric properties of the Colorado symptom index. Adm Policy Ment Health. 2008, 35 (5): 370-378. 10.1007/s10488-008-0179-6.

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    Humeniuk RE, Ali R, Babor TF, et al: Validation of the alcohol, smoking and substance involvement screening test (ASSIST). Addiction. 2008, 103 (6): 1039-1047. 10.1111/j.1360-0443.2007.02114.x.

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    Kertesz SG, Pollio DE, Jones RN, et al: Development of the primary care quality-homeless (PCQ-H) instrument: A practical survey of homeless persons’ experiences in primary care. Med Care. 2014, 52 (8): 734-742. 10.1097/MLR.0000000000000160.

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    Lin N, Dean A, Ensel WM: Social support, life events, and depression. 1986, New York: Academic Press

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Acknowledgments

This research was supported by the VA Veterans Health Administration, Health Services Research & Development Branch Award (IAA 07-069-2) and National Institute on Drug Abuse (NIDA) T32 Award (DA01035). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIDA, the National Institutes of Health, or the VA.

Author information

Correspondence to Erin J Stringfellow.

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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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Keywords

  • Social Support
  • Primary Care Provider
  • Financial Hardship
  • Lower Social Support
  • Homeless Person