Literature Collection

BACKGROUND: The 'Everyone In' national policy initiative launched in England during the COVID- 19 pandemic provided accommodation and health and care support to people who were (or at risk of) sleeping rough. This study aims to understand what worked well and less well in implementing 'Everyone In' for improving physical and mental health outcomes for people experiencing homelessness. METHODS: Between January and October 2023, in-depth interviews/focus groups were conducted across England with those involved in the delivery/implementation of 'Everyone In' and those accommodated. Framework analysis and case study analysis were used for a contextual understanding of the implementation of the policy initiative. RESULTS: Twenty-five people accommodated through 'Everyone In' (28-58 years; 88% males) and 43 service providers (25-62 years; 40% males) were interviewed. Flexibility in funding and resources, 'joining up' services/support, and innovative responsiveness in services across health, care, and housing systems were key positive features of the initiative. In the long term, 'Everyone In' has provided positive learnings for delivering holistic and integrated health and social care. It has also highlighted the importance of accommodating psychosocial needs and addressing the complexities of alcohol and substance use in all homelessness strategies. CONCLUSIONS: Pathways to care for people experiencing homelessness need to be flexible and responsive. Complexities such as substance use need to be approached with compassion while addressing the role of wider determinants in such health behaviours. Innovative approaches and joined-up work improve delivery of interventions and integrated care can reduce barriers to access to support.

The COVID-19 pandemic has placed an unprecedented burden on patients, health care providers, and communities and has been particularly challenging for medically underserved populations impacted by the social determinants of health, as well as people with co-occurring mental health and substance use risks. This case study examines outcomes and lessons learned from a multisite low-threshold medication-assisted treatment (MAT) program at a federally qualified health center in partnership with a large suburban public university in New York to integrate and train Health Resources & Services Administration Behavioral Health Workforce Education and Training-funded graduate student trainees in social work and nursing in screening, brief intervention, and referral to treatment and patient care coordination, including social determinants of health and medical and behavioral comorbidities. The MAT program for the treatment of opioid use disorder has a low threshold for entry that is accessible and affordable, reduces barriers to care, and uses a harm reduction approach. Outcome data showed an average 70% retention rate in the MAT program and reductions in substance use. And, while more than 73% of patients reported being somewhat or definitely impacted by the pandemic, most patients endorsed the effectiveness of telemedicine and telebehavioral health, such that 86% indicated the pandemic did not affect the quality of their health care. The main implementation lessons learned were the importance of increasing the capacity of primary care and health care centers to deliver integrated care, using cross-disciplinary practicum experiences to enhance trainee competencies, and addressing the social determinants of health among populations with social vulnerabilities and chronic medical conditions.

Background Medications for Opioid Use Disorder (MOUD) are associated with important public health benefits. Program changes implemented in response to COVID-19 hold promise as ongoing strategies to improve MOUD treatment. Methods: MOUD patients on buprenorphine or methadone, providers, government regulators, and persons who use drugs not in MOUD were recruited in the Northeast region of the United States between June and October of 2020 via advertisements, fliers, and word of mouth. Semi-structured qualitative interviews were conducted. Interviews were professionally transcribed and thematically coded by two independent coders. Results: We conducted interviews with 13 people currently on buprenorphine, 11 currently on methadone, 3 previously on buprenorphine, 4 previously on methadone, and 6 who used drugs but had never been on MOUD. In addition, we interviewed MOUD providers, clinic staff, and government officials at agencies that regulate MOUD. Most participants found increased take-home doses, home medication delivery, and telehealth implemented during COVID-19 to be favorable, reporting that these program changes reduced travel time to clinics, facilitated retention in care, and reduced stigma associated with clinic attendance. However, some participants reported negative consequences of COVID-19, most notably, decreased access to basic resources, such as food, clothing, and harm reduction materials that had previously been distributed at some MOUD clinics. Conclusion: Access to and retention in MOUD can be lifesaving for persons using drugs. COVID-19-impelled program changes, including increased take-home doses, home medication delivery, and telehealth generally improved participants' experiences with MOUD. Making these permanent could improve retention in care.