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.
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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)
N | % | |
Probable mental Illness or major psychiatric distress | 428 | 71 |
Lifetime moderate- or high-risk alcohol or illicit drug use | 357 | 59 |
At least 1 chronic medical condition | 537 | 89 |
Tri-Morbidity (All of the above) | 233 | 39 |
Table 2
Bivariate Comparisons of Characteristics by Tri-morbid Status (% and Means) (N = 601)
Tri-morbid | Not Tri-Morbid | |
|---|---|---|
Primary Care Experience and Social Support | ||
Primary care provider experience (PCQ-H mean) | 3.13 | 3.16 |
Social support (“strong ties” scale mean) | 9.16 | 10.64* |
Live-in partner (%) | 10 | 10 |
Socioeconomic Status (%) | ||
Housed | 54 | 68* |
Working full- or part-time | 13 | 22* |
Hard to pay for basics | 75 | 64* |
Patient at VA Primary Care Site (%) | 63 | 70 |
Demographics | ||
Gender (% male) | 84 | 86 |
Minority (% non-white) | 70 | 69 |
Average age | 51.5 | 54.1* |
*p < .05 |
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.
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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.
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.