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MEDICAL OUTREACH TO HOMELESS SUBSTANCE USERS IN NEW YORK CITY: PRELIMINARY RESULTS*

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MIGRATION, ACCULTURATION, DISPLACEMENT

MEDICAL OUTREACH

TO HOMELESS SUBSTANCE

USERS IN NEW YORK CITY:

PRELIMINARY RESULTS

*

Andrew Rosenblum,Ph.D.,1,y Larry Nuttbrock,Ph.D.,1

Hunter McQuistion,M.D.,2 Steve Magura,Ph.D.,1 and Herman Joseph,Ph.D.3

1

National Development and Research Institutes, Inc., 71 West 23rd Street, 8th floor, NY, NY 10010

2

Project Renewal, Inc., 200 Varick Street, New York, NY 10014

3

New York State Office of Alcohol and Substance Abuse Services, 55 W, 125th St., New York, NY 10027

ABSTRACT

An innovative, experimental, medical out-reach initiative, using a fully-equipped mobile medical van with a staff of 2 part-time physicians, a physician assistant, a social worker, and a driver/medical aid serving the needs of 1048, mostly male, minority group, high-level, homeless New York City substance users with infectious diseases is described. The study sample (N¼250) was divided into experimental S’s who received Intensive case management and a control group who could choose to refer themselves to the SW.

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DOI: 10.1081/JA-120004184 1082-6084 (Print); 1532-2491 (Online)

Copyright&2002 by Marcel Dekker, Inc. www.dekker.com

*Write up of presentation for Towards the Year 2000 Conference, Jerusalem, Israel, July, 1999.

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Biological tests revealed high rates of cocaine use and infec-tious diseases. Preliminary 4-month outcomes (N¼128) showed reductions in drug use, homelessness and health complaints in both groups; experimental subjects compared with controls received more Public Assistance and had fewer emergency room visits.

Key Words: Homelessness; Case management; Substance

use; Medical outreach

INTRODUCTION

Substance use is associated with serious infectious diseases, such as HIV, TB, hepatitis B and C, and syphilis.[1–3]Homeless substance users rep-resent a special concern, since the prevalence of infectious diseases is significantly higher in this population that in the general population.[4] Fur-thermore, homeless substance users are likely to be disaffiliated and suspi-cious of established health care systems.[5]This report presents findings of an ongoing study evaluating a medical outreach initiative, using a fully-equipped mobile medical van, to homeless substance users at various sites in New York City. The van staff include two part-time physicians, a physician’s assistant, a social worker, and a driver/medical aid. The specific aims of the study are to conduct a medical, drug user treatment and social needs assessment survey of homeless visitors to the medical van, and to conduct a process and outcome evaluation of the mobile medical outreach clinic with the addition of intensive case management (ICM) as an experimental enhancement.

VAN POPULATION

In 1997 there were 1709 client visits to the medical van. This repre-sented 1048 persons, since some had multiple visits during this period. The four most frequent presenting complaints and diagnoses were for respira-tory (42%), skin (33%), psychiatric/substance abuse (30%), and cardio-vascular (24%) problems. Mean age is 40, 84% are men, and most are minority (72% African-American, 18% Hispanic).

STUDY SUBJECTS

A total of 250 subjects were inducted into the study. TheNreported below varies due to current availability of test results. Hair assays (N¼184)

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for cocaine and opiates, obtained for research purposes, show subjects to be 78% positive for cocaine (primarily crack-cocaine based on self reports), and 15% positive for opiates. Infectious disease rates (N¼200 to 228) are 13% HIV antibody; 31% hepatitis C antibody; 47% hepatitis B (core anti-body); and 12% syphilis (the syphilis result does not necessarily indicate an active case). All subjects were provided pre- and posttest HIV counseling. Subjects with positive tests results were referred back to the van for medical follow-up.

Experimental subjects are seen by a social worker at the time that they are recruited for the study. The social worker provides intensive case man-agement (ICM), which includes a comprehensive needs assessment, multiple sessions to increase probability of appropriate and completed referrals, and incentives (such as phone cards, public transportation tokens, waist wallets, grooming and sanitary supplies) for service engagement. Clients assigned to the control condition are given the opportunity to see the social worker but they are not directly referred at the time that they visit the van. Thus con-trols are self-referred to the social worker; they are also not given incentives for repeated sessions. Preliminary data with the first 128 subjects enrolled in the study shows that ICM clients compared to controls had more contacts with the social worker (5.8 vs. 1.4) and received (1.29 vs. 0.58) and com-pleted (0.92 vs. 0.36) more referrals. Four-month outcomes (80% follow-up) show that all study subjects, regardless of condition, reported past 30 day reductions in crack use (4.1 vs. 2.2 days), days homeless (13.2 vs. 10.2), and number of health complaints (6.3 vs. 4.8). Effects for ICM, compared with the control conditions, were found for the receipt or maintenance of public assistance (e.g., Medical insurance [Medicaid] and Food Stamps) (72% vs. 50%), and for fewer hospital emergency rooms visits (26% vs. 45%). All above comparisons were statistically significant (p< :05).

CONCLUSION

The van operates with a clientele with high levels of homelessness, substance use, and infectious diseases. Reductions in drug use, homeless-ness, and physical symptoms may represent the benefit from the medical encounter all subjects received on the van. The incorporation of ICM, which included the immediate availability of on-site case management services in conjunction with the ongoing van operation, appears to provide an added benefit of engaging highly impaired individuals and helping them to acquire and maintain publicassistance benefits. The mobile medical outreach appears to provide a good opportunity for identifying serious communic-able diseases, HIV counseling, and primary care treatment.

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ACKNOWLEDGMENT

Study funded by NIDA RO1 DA10431.

REFERENCES

1. Edlin, B.R.; Irwin, K.L.; Faruque, S.; McCoy, C.B.; Word, C.; Serrano, Y.; Inciardi, J.A.; Bowser, B.P.; Schilling, R.F.; Holmberg, S.D. The Multicenter Crack Cocaine and HIV Infection Study Team. Intersecting Epidemics—Crack Cocaine Use and HIV Infection Among Inner-City Young Adults. N. Engl. J. Med.1994,331(21), 1422–1427. 2. Novick, D.; Joseph, H. et al. Absence of HIV Antibodies in Rehabilitated Methadone Patients. Arch. Internal Med. 1990, 150, 97–98.

3. Centers for Disease Control (CDC). Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-related ChronicDisease. MMWR1998,47(Suppl.), 1–39.

4. Wright, J.D. The Health of Homeless People: Evidence from the National Health Care for the Homeless Program. In Under the Safety Net; Brickner, P.W., Scharer, K.L., Conanan, B.A., Savarese, M., Scanlan, B.C., Eds.; W.W. Norton: New York, 1990.

5. Brickner, P.W.; McAdam, J.M.; Torres, R.A.; Vicic, W.J.; Conanan, B.A.; Detrano, T.; Piantieri, O.; Scanlan, B.; Scharer, L.K. Providing Health Services for the Homeless: A Stitch in Time. N.Y. Acad. Med.

1993,70(3): 146–170.

THE AUTHORS

Andrew Rosenblum, Ph.D., is the Deputy Executive Director of the National Development and Research Institutes, Inc. He has served as principle inves-tigator, co-investigator and project director on several research projects on substance use, including innovative interventions for the treatment of cocaine dependence, outreach to homeless populations, and an evaluation of a treatment linkage model for street-based sex workers.

Larry Nuttbrock is currently a Project Director with the National Development and Research Institutes (NDRI). His recent work includes an evaluation of alternative treatment modalities for homeless mentally-ill chemical abusers, an assessment of mobile medical outreach to homeless

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people, and an analysis of the association between cocaine use and HIV infection among soup kitchen attendees in New York City.

Hunter L. McQuistion, M.D., is Medical Director of Project Renewal, Inc., New York City’s leading nonprofit organization serving disabled adult homeless people. He teaches and publishes widely, and is an Associate Clinical Professor of Psychiatry at the Mount Sinai School of Medicine. Dr. McQuistion sub-specializes in community psychiatry, and has special interests in techniques of engaging difficult to reach clinical populations and in accessing indigent communities to integrated systems of health and social services. He is also Treasurer of the American Association of Community Psychiatrists and is a Fellow of the American Psychiatric Association.

Stephen Magura, Ph.D., C.S.W., is Director of the Institute for Treatment and Services Researches at National Development and Research Institutes, Inc. He has designed and directed clinical trials, treatment outcome studies, health services research, social epidemiology studies, HIV prevention research, and policy analysis, as related to drug dependency. He has pub-lished over 100 articles and authored/edited several books and special jour-nal issues on outcome evaluation and clinical trials, including Experimental Therapeutics in Addiction Medicine.

Herman Joseph, Ph.D., is a Senior Research Scientist at the New York State Office of Alcohol and Substance Abuse Services (OASAS). He has played a pivotal role in substance abuse treatment research in New York City. Along with Dr. Vincent Dole, he conducted one of the first follow-up studies that documented the benefits of methadone maintenance for the treatment of opiate dependence. He is founder and chairperson of the Chemical Dependency Research Working Group and is founder and executive chair of the International Substance Abuse and Pain Conference. His seminal publications have addressed AIDS and hepatitis C among homeless IV drug users, treatment of IVDUs in the criminal justice system, and metha-done medical maintenance.

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References

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