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©2002 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.
SUBSTANCE USE & MISUSE
Vol. 37, Nos. 8–10, pp. 1269–1273, 2002
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 (N ¼ 250) was divided into experimental S’s
who received Intensive case management and a control
group who could choose to refer themselves to the SW.
*Write up of presentation for Towards the Year 2000 Conference, Jerusalem, Israel,
July, 1999.
y
Corresponding author. E-mail: andrew.rosenblum@ndri.org
1269
DOI: 10.1081/JA-120004184
Copyright & 2002 by Marcel Dekker, Inc.
1082-6084 (Print); 1532-2491 (Online)
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MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016
©2002 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.
1270
ROSENBLUM ET AL.
Biological tests revealed high rates of cocaine use and infectious diseases. Preliminary 4-month outcomes (N ¼ 128)
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 represent a special concern, since the prevalence of infectious diseases is
significantly higher in this population that in the general population.[4] Furthermore, homeless substance users are likely to be disaffiliated and suspicious 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 represented 1048 persons, since some had multiple visits during this period. The
four most frequent presenting complaints and diagnoses were for respiratory (42%), skin (33%), psychiatric/substance abuse (30%), and cardiovascular (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. The N reported
below varies due to current availability of test results. Hair assays (N ¼ 184)
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©2002 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.
OUTREACH TO HOMELESS SUBSTANCE USERS
1271
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 (N ¼ 200 to 228) are
13% HIV antibody; 31% hepatitis C antibody; 47% hepatitis B (core antibody); 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 management (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 controls 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 completed (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, homelessness, 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 public assistance benefits. The mobile medical outreach
appears to provide a good opportunity for identifying serious communicable diseases, HIV counseling, and primary care treatment.
MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016
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1272
ROSENBLUM ET AL.
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
Chronic Disease. MMWR 1998, 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 investigator, 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
MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016
©2002 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.
OUTREACH TO HOMELESS SUBSTANCE USERS
1273
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 published over 100 articles and authored/edited several books and special journal 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 methadone medical maintenance.
MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016
©2002 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.