(48) Opportunities for Harm Reduction: Multi-domain Needs Assessment of Unhoused Individuals

Background & Introduction: An estimated 582,642 Americans are currently experiencing homelessness. The disjointed provision of health and social services for homeless individuals has hindered our understanding of their resource requirements. To this end, needs assessment instruments for individuals experiencing homelessness are often focus entirely on social risk factors while negating health status and access to healthcare resources and health screening instruments rarely adequately measure the social determinants of health. Harm reduction programs are only optimized if they can be tailored to the demands of the population they are intended to serve. The objective of this study was to pilot a comprehensive health and social support needs assessment instrument that could be used to design and implement regionally tailored, comprehensive harm reduction and health programs for individuals experiencing homelessness.

Methods: A multidisciplinary team including peer recovery support specialists, homelessness service providers, and researchers was convened to identify key information needed to support evidence-based and geographically tailored harm reduction health resource delivery for people experiencing homelessness. Six key domains were identified by the group: general homelessness history, health resource utilization, physical health history, mobile technology use, and substance use disorder history. The first three domains, homelessness history, health resource utilization, and physical health history were measured using items from the Los Angeles Homeless Service Authority Coordinated Entry Survey. Mental health status was measured by the PHQ-2, GAD-2, and PC-PTSD-5 scales. Mobile technology use was measured using a proprietary thirteen-item set. Substance use disorder screening, was conducted using the ASSIST. Adaptive testing and skip logic were used to accelerate administration of the instrument where appropriate. Pharmacy and graduate students were trained to administer the instrument in person. Interviewers administered the needs assessment at a mobile shower site servicing individuals experiencing homelessness in a dense urban area in Houston, Texas on twelve occasions between July 2022 and October 2023. Unhoused adults were provided the opportunity to complete the instrument while waiting to use the shower on-site and were provided a $5 incentive.

Results: In total, 57 unhoused adults completed the needs-assessment instrument. Approximately one-third (31%) of participants were between the ages of 45 and 54, 46% identified as Black or African American, and 78% identified as male. Most (53%) had been unhoused for twelve months or longer. Mental health conditions were prevalent with 44% of participants screening positive for depression, anxiety, or post-traumatic stress disorder and 17% screening positive for more than one of these conditions. Illicit substance use, as evaluated by the ASSIST, was prevalent among this sample. Over a third (38%) of participants had used cocaine, 54% cannabis, 22% hallucinogens, and 24% amphetamines in the past three months. Only 12.8% admitted opioid use in the past three months. Of the 43 individuals with ongoing illicit drug use, 19 (44%) were polysubstance users. Interpretation of ASSIST scores indicated that 29% of respondents would benefit from referral to substance use disorder treatment for a non-alcohol or non-tobacco related substance used disorder yet utilization of care remained low. Despite the advanced age and multimorbidity of this sample, 39% had not seen a primary care provider in over a year with an additional 14% indicating that they had never seen a primary care provider. A series of items were used to evaluate the feasibility of mobile health interventions in this sample. In total, 64% currently owned a cell phone with the majority (59%) owning a phone for five years or longer. Several potential barriers to mobile health were identified including experience of theft (61%), concerns for personal safety (44%), and inability to always keep a phone charged (41%). Of note, 77% of participants with a phone noted that they were always able to pay for their phone. The prevalence of polysubstance use led the research team to introduce an additional six-item set on personal and observed overdose experience after data collection was underway. Of the fourteen individuals who have completed these items to date, seven have observed an overdose. No respondents indicated that they or anyone they know carries naloxone.

Conclusion & Discussion: In this sample, a high proportion of unhoused individuals had an untreated mental health condition, substance use disorder, and gaps in primary care utilization. Programs that prioritize low or no barrier management of physical and mental health conditions alongside substance use disorder treatment are needed. Mobile hygiene sites, such as the one where this screening was administered, may also facilitate care delivery in that they are often able to serve the same guests each week offering a routine source of care. Cell phone ownership may be a compelling facilitator of resource delivery among unhoused individuals. In particular, telehealth interventions may serve an extension of no-barrier substance use disorder treatment, behavioral, and mental health services to people experiencing homelessness. Finally, approximately half of all unhoused individuals in this sample had experienced or witnessed an overdose. This suggests that distributing naloxone and training unhoused individuals on naloxone administration could be a high-value harm reduction strategy. To conclude, this multidomain needs assessment provided valuable insight into the health and social needs of unhoused individuals in Houston and may be adapted for use elsewhere.

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