2023 HSR&D/QUERI National Conference

4151 — Primary Care Engagement Among Individuals with Experiences of Homelessness and Serious Mental Illness: An Evidence Map

Lead/Presenter: Megan Shepherd-Banigan,  COIN - Durham
All Authors: Shepherd-Banigan M (Durham VA), Connor Drake (Durham VA) Jessica R. Dietch (School of Psychological Science Oregon State University) Abigail Shapiro (Durham VA) Amir Alishahi Tabriz (Department of Oncological Sciences University of South Florida) Elizabeth E. Van Voorhees (Durham VA) Diya M. Uthappa (Duke School of Medicine) Tsai-Wei Wang (Duke School of Medicine) Jay B. Lusk (Duke School of Medicine) Stephanie Salcedo Rossitch (Durham VA) Jessica Fulton (Durham VA) Adelaide Gordon (Durham VA) Belinda Ear (Durham VA) Sarah Cantrell (Duke School of Medicine) Jennifer M. Gierisch (Durham VA) John W. Williams Jr. (Durham VA) Karen M. Goldstein (Durham VA)

Homelessness and serious mental illness (SMI) amplify barriers to engaging in primary care. The complexity of co-occurring social needs and barriers to health care complicates efforts to serve this at-risk population. We conducted an evidence map to identify interventions designed to promote primary care for this at-risk population.

An evidence map is a systematic synthesis of a broad field to identify gaps in knowledge and establish future research needs. We searched MEDLINE (via Ovid), Embase (via Elsevier), and PsycINFO (via Ovid) from database inception to May 15 2020. We identified interventions and strategies that promoted primary care engagement for a homeless population with SMI. Strategies were categorized by the level of intended action (e.g., patient, clinic, system) and domain (e.g., education/training, communication, outreach, data sharing infrastructure). Finally, we applied the Complexity Assessment Tool for Systematic Reviews (i_CAT) to characterize the complexity of included interventions.

We screened 4,650 manuscripts and included 22 studies reporting on 15 unique interventions. Study designs varied widely from randomized controlled trials and cohort studies to single-site program evaluations. We identified and categorized intervention components, including 22 at the patient-level (e.g., health education, assertive outreach, material support), 4 at the clinic-level (e.g., specialist team members, training), and 5 at the system-level (e.g., data sharing infrastructure, interagency collaboration). Interventions displayed notable complexity around number of intervention components, interaction between intervention components, and extent to which interventions were tailored to specific patient populations.

The literature applied low quality study designs, including non-comparative, one-armed evaluations. The methodological rigor of studies for this population needs to be improved while also focusing on translating results more quickly into community settings. In addition to employing rigorous designs, stepped wedge pragmatic trials or adaptive studies that test multiple intervention strategies are novel designs to evaluate and translate future interventions.

We identified and categorized elements used in various combinations to address the primary care needs of individuals with experiences of homeless and SMI. Practitioners and policymakers can use these findings to design and adapt interventions for adults experiencing homelessness and SMI.