The paper describes the authors’ experiences providing therapy services one day a week at a multidisciplinary clinic embedded within a youth shelter in the southern United States. That single logistical detail—a once-weekly presence rather than a full-time clinic—turns out to be central to nearly every lesson the authors draw. Limited-hour clinicians embedded in multidisciplinary health teams cannot rely on the conventional scaffolding of outpatient practice: scheduled appointments weeks in advance, waiting rooms, administrative staff, and the implicit authority of a dedicated clinic space. Instead, they must work within the rhythms of the shelter itself, where residents arrive and depart unpredictably, crises dominate the daily agenda, and the clinician is a visitor in what is, for the young person, a temporary home.

The authors organize their reflections around several recurring themes: informed consent, rapport building, retention, and the creation of a mothers’ group within the shelter. Each of these may sound like a standard component of any behavioral health service, but the shelter context transforms the calculus. Informed consent, for example, is not simply a form to be signed before the first session. For young people who have frequently had negative experiences with child welfare, legal, and medical institutions, the way a clinician explains rights, confidentiality, and the limits of both becomes an early test of trustworthiness. The authors report that providing clear information on patient rights and confidentiality, and addressing current challenges with humility and compassion, improves the therapeutic relationship and can lead to better retention in care.

That finding aligns with a substantial body of evidence the authors situate their work within. Research on homeless youth consistently documents elevated rates of childhood maltreatment, trauma exposure, and mental health and substance use symptoms, alongside documented reluctance to engage with mainstream services. Systematic reviews of interventions for this population have repeatedly identified engagement and program implementation—not treatment content—as the critical weak points. A meta-synthesis by Curry and colleagues on improving program implementation and client engagement in interventions addressing youth homelessness, and a systematic review by Magwood and colleagues on the acceptability of health and social interventions for people with lived experience of homelessness, both point to trust and personal safety concerns as decisive factors in whether young people use services at all. The Gonynor paper’s emphasis on transparent consent conversations and humility in the face of ongoing crises reads as a practical translation of those larger findings into a shelter hallway.

The technical backbone of the authors’ approach draws on well-established psychotherapy science, reinterpreted for a low-barrier setting. They invoke the therapeutic alliance literature, including the meta-analytic synthesis by Flückiger and colleagues demonstrating that the alliance is among the most reliable predictors of psychotherapy outcome, and the conditions of therapeutic personality change articulated by Carl Rogers in 1957—empathy, genuineness, and unconditional positive regard. In a shelter, where a young person may meet a clinician once and then be gone, the authors suggest that these alliance-building principles cannot wait for a second or third session. Rapport must be initiated in the first contact, often in informal, non-office contexts, and clinicians must accept that engagement may be incremental: a conversation at the shelter, an information sheet, a single session, and only later, if the young person remains, sustained therapy.

Retention is the mirror image of rapport, and the paper treats it as a structural problem rather than a personal failing of clients. Transitional age youth in shelters may lose housing placement, cycle into other systems, or simply have lives too unsettled for weekly appointments. The authors’ guidance for clinicians working limited hours per week, or on multidisciplinary teams serving sheltered youth, is built around flexibility: meeting youth where they are, literally and figuratively, and designing services that tolerate interruption. This echoes longitudinal research by Aubry and colleagues showing that housing stability and mental health functioning are deeply intertwined among shelter users, and work by Padgett connecting homelessness, housing instability, and mental health outcomes. If housing is unstable, mental healthcare must be engineered to survive that instability.

One of the more concrete programmatic lessons is the creation of a mothers’ group within the shelter. Many youth shelters serve young parents, and perinatal mental health needs among homeless mothers are well documented in the literature the authors cite, including Kerker and colleagues’ work adapting a postpartum depression prevention intervention for family homeless shelters and Muzik and colleagues’ evaluation of the Mom Power group intervention for high-risk mothers. A group format allows a once-weekly clinician to reach several parents simultaneously, normalize help-seeking, and address parenting stress in a peer-supported context. The authors also reference widely used parenting resources such as the 1-2-3 Magic discipline framework, indicating that the group blended practical parenting guidance with emotional support—an integration suited to young mothers navigating both early parenthood and homelessness at once.

The multidisciplinary dimension of the clinic deserves particular attention. The authors, all psychologists or psychology-affiliated clinicians based at children’s hospitals and academic medical centers, describe operating within a health team at the shelter rather than as a standalone mental health service. Integrated care models, as described by the American Psychological Association and illustrated in training contexts by Williamson and colleagues’ work on psychology students delivering integrated behavioral health in primary care, position behavioral health providers alongside medical and social service colleagues. For sheltered youth, whose needs span physical health, substance use, housing navigation, and legal or educational issues, this integration is not a luxury but a necessity. Prior studies, including Stergiopoulos and colleagues’ brief interdisciplinary intervention bridging hospital and community care for homeless adults with mental health needs, suggest that coordinated, low-barrier models can improve outcomes for populations that fragmented services routinely fail.

The authors are explicit that their contribution is reflective rather than evaluative: the paper describes experiences and lessons learned, not measured clinical outcomes, and the article’s data availability statement notes that no datasets were generated or analyzed. That honesty matters. The homeless services field has plenty of systematic reviews and meta-analyses; what it lacks, the authors argue, is detailed, practice-level guidance for the many clinicians who staff clinics for only a day a week, or who join multidisciplinary teams in shelters without a roadmap. By documenting specific dilemmas—how to approach consent with a distrustful eighteen-year-old, how to build rapport in a shared living space, how to keep a therapeutic thread alive when a client disappears, how to structure a group for young mothers—the paper fills a gap between the evidence base and the clinic floor.

The broader context gives this work urgency. The United States Department of Housing and Urban Development’s 2024 Annual Homelessness Assessment Report to Congress documents continuing rises in homelessness, and research by van den Bree and colleagues has shown that adolescent factors can predict homelessness in young adulthood years later. Studies of shelter-based clinics, such as Winiarski and colleagues’ work assessing and treating complex mental health needs among homeless youth in a shelter-based clinic, demonstrate that such services can address severe, compounded needs. What the Gonynor, Schueler, and Flint paper adds is the human operational layer: humility, clear communication of rights and confidentiality, compassion toward ongoing challenges, and creative group programming. For a population that systems have repeatedly failed, those may be the interventions that determine whether any formal treatment ever has a chance to work.

Subject of Research: Implementation of multidisciplinary mental healthcare for sheltered transitional age youth experiencing homelessness

Article Title: Reflections on Implementing Multidisciplinary Mental Healthcare with Sheltered Transitional Age Youth

Article References: Gonynor, C., Schueler, J., & Flint, D. (2026). Reflections on Implementing Multidisciplinary Mental Healthcare with Sheltered Transitional Age Youth. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01740-4

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01740-4

Keywords: transitional age youth, homelessness, youth shelter, multidisciplinary care, mental health, therapeutic alliance, informed consent, retention, mothers group, trauma-informed care, community mental health, integrated care

The study, published in Frontiers in Global Women’s Health, used a narrative inquiry design embedded within a larger participatory action research project. Each of the eleven participants took part in two in-depth interviews lasting up to two and a half hours, followed by three sequential focus groups held between February and May 2025. Rather than fragmenting the women’s accounts into codes and categories, the team applied Riessman’s thematic and structural narrative analysis, treating the stories as wholes. They paid attention not only to what was said but to how it was told: the sequencing, repetitions, interruptions, and omissions that revealed how the women made sense of their lives. The researchers then wove the material into composite narratives, first-person accounts built from multiple participants’ verbatim words, a strategy chosen to protect anonymity for women escaping abusive partners or hiding their housing insecurity from their own families.

The health burden the women carried was staggering. Every single participant met the criteria for multimorbidity, meaning two or more co-existing chronic conditions, a profile associated with reduced function, increased health service use, and premature death. Their conditions spanned diabetes, heart failure, cancer, chronic pain, arthritis, memory problems, depression, anxiety, and post-traumatic stress disorder, with many health problems attributed to or worsened by past intimate partner violence, which ten of the eleven women reported. Long-term homelessness is known to accelerate aging, with people experiencing homelessness presenting health profiles comparable to housed individuals ten to twenty years older. That is why age 50 is widely accepted as the threshold for older in homelessness research, and why women aged 55 and older now constitute the majority of visibly homeless women in Canada.

From the analysis, two storylines emerged. The first, which the researchers named Hurry up and Wait, captures the cruel rhythm of bureaucratic systems that appear to offer help while simultaneously disempowering the people they serve. Women described shelters as unsafe and unstable yet nearly impossible to exit. One woman recounted bed bugs, lice, and the risk of being barred from the shelter entirely if staff suspected she was photographing conditions on her phone. Another described how a case manager required her to phone every two weeks to keep her place on a waitlist for accessible subsidized housing, and how a full voice mailbox could cost her that spot. Mandatory workshops on resume writing and nutrition were repeated regardless of need, and one facilitator’s joking tone during a session on intimate partner violence left participants distressed.

The composite narrative of Marilyn, assembled from several women’s experiences, illustrates how these constraints compound. After a stroke at 54 ended her work and driving, she cycled through an emergency shelter, a hostile relative’s home, and her daughter’s apartment, all while facing rents above $1,200 against income support of less than $1,000 a month. A missing credit history, destroyed by an ex-partner’s fraudulent cards, and mobility limitations that ruled out staircases closed off even the cheapest options. Full disability benefits, which might have changed the math, required yet more medical documentation, expensive taxi rides, and waits of more than a year to see a neurologist. Seniors housing with elevators and lower rents sat just out of reach behind an age-65 eligibility threshold. Her summary was blunt: stuck everywhere.

The second storyline, Making lemonade, documents what the women did inside these constraints. They formed bonds in shelters that outlasted re-housing, talking daily and providing emotional support across the city. They searched for housing together, attended each other’s medical appointments, and exchanged tips on navigating resources. One participant, a recognized artist, offered to teach craftwork in the shelter; another used her computer skills to file housing applications not only for herself but for other residents. Women advocated at building meetings in transitional housing, set boundaries against drug smoke and violence, and used humor strategically, greeting shelter staff behind the glass with a cheerful line that, as one woman recalled, made her smile for the first time.

It is this relational labor that the researchers propose as a previously unrecognized form of social capital. Social capital, in the sociological sense, refers to the resources people derive from their networks and relationships, and it has been mapped in homelessness research across three domains: interpersonal relationships, access to formalized services, and the exchange of emotional, practical, and informational support. The Calgary women built bonding relationships with socially similar peers and bridging relationships with service providers who treated them with dignity. They worked to repair family ties, maintained fierce identities as mothers and grandmothers, and drew on cultural teachings about looking out for one another. In the language of urban geography, they functioned as people as infrastructure, informal networks of cooperation that patched over the fragmentation and under-resourcing of formal systems.

The researchers are careful to note the limits of this finding. Mutual aid, however productive, cannot substitute for housing and healthcare, and other scholars have cautioned that homelessness itself undermines the reciprocity and autonomy that sustain social capital. The structural barriers the study documents are formidable: affordable housing stock that has declined since federal withdrawal from housing provision in the 1980s and 1990s, income supports so low that some women continued working low-wage jobs despite serious illness, and specialist care waits that rippled outward, blocking disability income, transportation passes, and housing waitlists that all demanded medical proof. Age-based eligibility criteria excluding adults under 65 from seniors’ housing left a gap that the study’s participants, most aged 57 to 64, fell straight through.

The study’s methods deserve attention in their own right. The work grew out of the Exchange, a collective of older adults with lived experience of late-life homelessness who co-direct research aimed at improving services. Recruitment used snowball sampling through shelters, transitional housing, and an elder abuse shelter, and the team employed a trauma-informed approach throughout, providing transportation, food, honoraria, and process consent revisited at every encounter. The authors acknowledge limitations: the sample was intentionally small, and Black, Indigenous, and people of color, as well as LGBTQ and Two-Spirit participants, were underrepresented relative to their prevalence in the homeless population, a gap the researchers attribute partly to recruitment pathways that reproduce the same structural barriers the study examines.

The implications reach from clinic to legislature. For health providers, the findings underscore the gendered nature of late-life homelessness and the value of trusting, person-centered primary care relationships, which ten of the eleven women had established. For homelessness organizations, the study argues for relational continuity and manageable caseloads to counter the burnout and turnover that erode the few supportive connections women found. For policymakers, the message is that older women’s lived expertise must inform system design, and that trauma-informed, age- and ability-specific services are likely to yield high returns while preventing the institutionalization the women themselves identified as their greatest fear. Behind the policy language, though, is the study’s central, quietly radical observation: the women it followed were never simply waiting to be helped. They were helping, every day, in ways no system counted.

Subject of Research: Experiences of aging, health, and homelessness among older women and their mutual support networks

Article Title: Help me, and I'll help myself (and others). A narrative inquiry into older women's experiences of health and homelessness

Article References: Nixon, L., Boyling, E., Mierau, E., Hughes, R., Ugburo-Shanomi, J., & Kelly, M. (2026). Help me, and I'll help myself (and others). A narrative inquiry into older women's experiences of health and homelessness. Frontiers in Global Women's Health, 7, Article 1740814. https://doi.org/10.3389/fgwh.2026.1740814

Image Credits: AI Generated

DOI: 10.3389/fgwh.2026.1740814

Keywords: homelessness, older women, aging, social capital, narrative inquiry, health equity, shelters, housing policy, caregiving, structural stigma, participatory research, Canada

The methodological architecture of the review is worth examining because it shapes what the conclusions can and cannot tell us. A systematized review, as the authors define it following the typology of Grant and Booth, applies systematic review principles—structured searches, explicit inclusion criteria, and standardized data extraction—without necessarily the full protocol registration and dual independent review apparatus of a gold-standard systematic review. The team searched across four conceptual domains: young adulthood, interventions, substance use, and traumatic stress, with homelessness terms added and removed to capture both directly relevant studies and the wider evidence base from which adaptable elements might be borrowed. Data were extracted using a structured coding framework organized around three domains: effectiveness, real-world implementation, and intervention characteristics. This tripartite structure reflects a growing recognition in implementation science that an intervention’s clinical efficacy in a controlled trial tells only part of the story; whether it can actually be delivered, sustained, and funded in a community drop-in center or shelter is a separate and equally consequential question.

On the effectiveness front, the headline numbers are encouraging. Over half of the 39 included studies used randomized controlled designs, the most rigorous method for establishing causal effects, and roughly three-quarters reported significant improvements across multiple outcomes, including reductions in substance use, decreases in traumatic stress symptoms, and broader gains in mental health. That such a large proportion of interventions produced measurable benefits suggests the field is not starting from zero. Yet the review’s finer-grained analysis reveals why these findings cannot simply be transplanted to young adults experiencing homelessness. The interventions were most commonly delivered in academic, clinical, or service settings—university counseling centers, primary care clinics, structured research programs—with enormous variation in duration, treatment modality, and theoretical orientation. A web-based alcohol prevention program for college students, a telephone-based intervention for heavy drinking in primary care, a family-based group intervention for HIV and drug risk among homeless families, and home-based telehealth skills training for women veterans all appeared in the evidence base, each built around assumptions about stability, scheduling, and access that homeless young adults often cannot meet.

The co-occurrence problem sits at the heart of the review’s rationale. Epidemiological research has long documented that trauma and substance use are deeply intertwined in this population. Studies cited by the authors, including work by Bender and colleagues on homeless youth in three U.S. cities and by Gwadz and colleagues on gender differences in traumatic events among homeless youth, show elevated rates of posttraumatic stress disorder and multiple victimization both before and after young people leave home. The self-medication hypothesis, articulated by Khantzian, offers one explanatory framework: substances are used to blunt the intrusive memories, hyperarousal, and emotional dysregulation that follow traumatic exposure. Trauma itself is increasingly understood as a transdiagnostic risk factor, elevating risk across a range of mental disorders, and homelessness compounds the problem by exposing young adults to ongoing victimization and instability that perpetuate both the traumatic stress and the substance use. The result is a cycle in which each element exacerbates the others, prolonging homelessness and degrading health outcomes. Yet the review found that interventions addressing both traumatic stress and substance use simultaneously were rare, and none had been built from the ground up for young adults experiencing homelessness.

The implementation findings are particularly revealing about the gap between what works in trials and what survives contact with real-world service systems. The review found strong participant retention across many studies, which is notable given that retention is often the Achilles heel of interventions with mobile, crisis-exposed populations. However, reporting on treatment fidelity—whether the intervention was actually delivered as designed—and on cost was strikingly limited. Fidelity monitoring matters because an intervention that shows effects in a tightly supervised trial may drift or degrade when handed to frontline staff with competing demands; without fidelity data, implementers cannot know which results are reproducible. Cost reporting matters because service agencies operating on thin budgets must make allocation decisions, and an intervention whose resource requirements are unknown cannot be planned for. These reporting gaps, the authors suggest, represent a critical blind spot for anyone hoping to move from the literature to practice.

Among the 39 studies, 16 included samples in which at least half of the participants experienced homelessness or housing instability, and these studies offer the closest available approximations to the target population. They include trials of strength-based outreach interventions linked to shelters or drop-in centers that reduced hard drug use among homeless youth, a randomized controlled trial of a smartphone application plus brief motivational intervention that reduced substance use and sexual risk behaviors among homeless young adults, a brief motivational interviewing-based group intervention showing 24-month effects on alcohol use among emerging adults experiencing homelessness, and a feasibility study of the HOME program combining housing with opioid use disorder prevention. Other work examined housing and supportive services for young mothers experiencing homelessness and intensive addiction and housing case management for homeless veterans. Collectively, these studies demonstrate that young adults experiencing homelessness can be recruited, retained, and helped—but each addressed only part of the problem, typically substance use alone, without an integrated traumatic stress component.

From this mosaic, the review distills a set of design principles for a future integrated intervention. First, delivery should be brief and flexible: long, multi-session protocols that assume reliable attendance are poorly matched to a population whose daily lives are governed by shelter curfews, survival needs, and sudden displacement. Second, harm-reduction approaches should anchor the substance use component. Rather than demanding immediate abstinence as a condition of care, harm reduction meets young people where they are, reducing the risks of use while building trust and engagement—a stance with particular resonance for a population that has often experienced rejection and coercion from institutions. Third, the intervention must be feasible within community-based service settings such as drop-in centers and shelters, which are where homeless young adults already present, rather than requiring referral into academic clinics that many will never reach. The authors frame these components as hypotheses to be tested, not a finished blueprint, and they are explicit that the review is a critical pre-implementation step in a longer development process.

The review also surfaces structural features of the existing literature that constrain its usefulness. The theoretical orientations of included interventions ranged widely, from motivational interviewing and cognitive behavioral approaches to transdiagnostic protocols such as the Unified Protocol, which targets emotional disorders broadly rather than any single diagnosis. Duration varied from single-session brief interventions to multi-month programs. Delivery modalities spanned in-person individual and group formats, family-based sessions, telephone contact, web-based programs, and smartphone applications. This heterogeneity, while a barrier to simple meta-analytic conclusions, is arguably an asset for intervention development: it provides a menu of tested mechanisms and delivery channels from which adaptable elements can be selected and recombined. The authors’ structured coding framework makes that menu explicit, which is precisely what a design team needs when assembling a new intervention rather than evaluating an old one.

What comes next, according to the authors, is direct testing within the population itself. Future research should prioritize intervention trials conducted with young adults experiencing homelessness, to determine which components retain their effectiveness and feasibility when the assumptions of stability and access no longer hold. The stakes are considerable. Homelessness among young adults is associated with elevated rates of mental health and substance use disorders, disrupted education, and long-term trajectories of instability, and the window of emerging adulthood is a developmental period in which effective intervention may alter lifelong outcomes. By systematically cataloguing what has been tried, what worked, how it was delivered, and where the evidence runs out, this review converts a scattered literature into a usable map. It does not offer a cure, and it is candid that none exists yet for this population. What it offers instead is something the field has lacked: a rigorous, transparent account of the raw materials available for building the first integrated traumatic stress and substance use intervention designed specifically for young adults experiencing homelessness, and a clear-eyed statement of the implementation conditions any such intervention must survive.

Subject of Research: Traumatic stress and substance use interventions for young adults experiencing homelessness

Article Title: A Systematized Review of Traumatic Stress and Substance Use Interventions in Young Adults: Implications for Intervention Development with Young Adults Experiencing Homelessness

Article References: Gamoran, J., Bushnell, A., Fragkos, E., Darbro, R., Gueye, A., & Snow-Hill, N. L. (2026). A Systematized Review of Traumatic Stress and Substance Use Interventions in Young Adults: Implications for Intervention Development with Young Adults Experiencing Homelessness. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01734-2

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01734-2

Keywords: homelessness, young adults, traumatic stress, substance use, systematized review, intervention development, harm reduction, mental health, implementation science, PTSD, motivational interviewing, community-based services

The study was conducted at the Institute of Forensic Medicine of Milan, one of Italy’s largest medico-legal centers, where researchers reviewed the entire autopsy database for the eleven-year period. Of the 7,338 autopsies performed overall, 104 involved individuals classified as homeless, defined as people without a stable residence, including those living on the streets, in public spaces, abandoned buildings, or temporary shelters. That figure represents 1.4 percent of total autopsy activity, but the annual trend tells a more troubling story. The number of homeless decedents rose from a low of just two cases in 2015 to sixteen cases in each of 2023 and 2024, with a marked acceleration in judicially ordered autopsies beginning in 2019. Whether this reflects a genuine rise in deaths, greater awareness among investigators, or both, the trajectory aligns with broader European data showing that homelessness has grown by roughly 70 percent since 2008.

The demographic profile of the dead is itself a form of testimony. Men accounted for 87.5 percent of the cohort, and the median age at death was just 53 years, with a range spanning 18 to 88. No minors were identified, but the researchers noted a progressive decrease in age at death over the study period, with the first cases involving individuals younger than 25 appearing only from 2022 onward. Nearly 59 percent of the decedents were non-Italian, with Romanian and Moroccan nationals forming the largest groups, and statistical analysis showed that Italian decedents were significantly older at death than their foreign-born counterparts, a mean of 54.4 years versus 47.8. Deaths clustered in the colder months, with winter accounting for 35.6 percent of cases and January alone contributing nineteen deaths, a seasonal distribution that differed significantly from chance and underscores the lethal role of environmental exposure.

Where these individuals died speaks volumes about the geography of marginalization. The most common discovery sites were indoor public spaces, which accounted for 43.3 percent of cases: abandoned buildings, railway and metro stations, parking lots, warehouses, and even a cemetery. Hospitals were the second most frequent location at 22.1 percent, followed by streets at 16.3 percent and green areas such as parks at 10.6 percent. The circumstances of discovery also revealed profound social isolation. Only about a quarter of the deaths were witnessed. Among the unwitnessed cases, post-mortem intervals varied wildly, from a few hours to several months, and in one case up to four years elapsed between the last known contact with the deceased and the discovery of the body. More than half of the bodies showed putrefactive changes, a finding the authors link to delayed discovery and limited social networks, which in turn degrade the diagnostic quality of the autopsy itself.

Medical histories, when they could be reconstructed, painted a picture of chronic disease left to run unchecked. Anamnestic data were available for just over half of the cohort, and among those 56 individuals, 75 percent had documented chronic conditions. Type 2 diabetes was the most frequently recorded illness, followed by cardiovascular disease and hypertension, with tuberculosis, epilepsy, liver cirrhosis, and hepatitis C infection also appearing repeatedly. Psychiatric or psychosocial information existed for 43 cases, and within that subgroup, substance use involving drugs or alcohol was documented in nearly three-quarters. Yet only four individuals had a formally diagnosed psychiatric disorder, a discrepancy the researchers attribute to fragmented healthcare access, episodic crisis-oriented care, and diagnostic overshadowing, the well-documented tendency of clinicians to attribute physical symptoms to mental illness or substance use rather than investigating underlying organic pathology. In Italy, historical restrictions on general practitioner access for people without a registered residence compounded these gaps.

The classification of causes of death exposed the study’s central paradox. Natural deaths accounted for 24 percent of the cohort, led by pneumonia, internal hemorrhages, cardiovascular events, and active tuberculosis, conditions that in housed populations are typically caught and treated long before they become fatal. Non-natural deaths, including suicides, homicides, and accidents, made up 16.4 percent, with blunt trauma and transport-related incidents dominating the injury mechanisms. But the single largest category, 59.6 percent of all cases, was undetermined. These were deaths recorded as acute circulatory insufficiency or asystole, a medico-legal designation applied when no macroscopic autopsy findings can support a specific diagnosis. In 45 of these cases, the autopsy revealed nothing abnormal at all; in 17, abnormalities were present but not acutely lethal. For comparison, undetermined deaths made up only 16.3 percent of autopsies on the non-homeless population at the same institute during the same period, a difference so large that the probability of it arising by chance is vanishingly small.

The reason for this diagnostic gap lies less in pathology than in bureaucracy. In Italy, ancillary post-mortem investigations, including toxicological and histopathological analyses, require explicit authorization from the Public Prosecutor, and resource and procedural constraints mean they are rarely requested. In this cohort, toxicology was performed in only 4.8 percent of cases and histology in just 1.9 percent. Yet when these tests were carried out, their diagnostic yield was remarkable. Toxicological analysis revised the initial diagnosis in three deaths that would otherwise have remained classified as presumed natural: one man had died of acute carbon monoxide poisoning, another of a combined cocaine and methadone overdose, and one woman of acute citalopram intoxication. Histology, likewise, identified a myocardial infarction and a case of pneumonia that macroscopic examination alone had missed. In other words, the few ancillary tests that were performed fundamentally changed the forensic conclusions, suggesting that many of the 62 undetermined deaths conceal identifiable causes that routine laboratory work could have revealed.

One of the study’s most statistically robust findings concerns sex. Although women made up only 12.5 percent of the cohort, they were far more likely than men to die from non-natural causes: 46.2 percent of female decedents died violently, compared with 12.1 percent of men, corresponding to a sixfold increase in odds that reached statistical significance. Among the women whose deaths were classified as non-natural, suicide and homicide together accounted for two-thirds of cases. This pattern echoes international evidence that homeless women face heightened exposure to violence and occupy a particularly vulnerable position within already precarious circumstances. The authors caution that the small number of female decedents limits the precision of the estimate, but the direction of the effect, combined with prior cohort studies of homeless women, reinforces the conclusion that sex-specific risks demand targeted prevention strategies rather than one-size-fits-all interventions.

The researchers are candid about the limitations of their work. Housing status was established from circumstantial information in forensic and police records rather than independent verification, and unidentified decedents who were in fact homeless may have gone unrecognized, meaning the true toll is likely higher than 104. Information on the duration and trajectory of each individual’s homelessness was largely unavailable, preventing analysis of how mortality risk changes over the course of housing loss, a dimension that recent Danish register studies have shown to be critical. Those same large-scale studies contextualize the Milan findings: all-cause mortality rate ratios among homeless individuals exceed six compared with the general population, with mean losses of roughly fifteen life-years in both sexes. Against that backdrop, a median age at death of 53 in the Milan cohort is not an anomaly but a local expression of a global mortality penalty.

What emerges from this decade of forensic observation is a portrait of deaths that are neither random nor, in many cases, inevitable. The authors argue that the patterns they documented, premature natural deaths from treatable infections and cardiovascular disease, violent deaths concentrated among women, and a vast reservoir of undetermined causes, are identifiable and largely preventable. Their prescription runs on two parallel tracks. On the clinical side, they call for proactive outreach models such as street medicine, harm reduction services, and continuity of care that follows individuals beyond the hospital door. On the forensic side, they urge standardized protocols that make toxicological and histological analyses routine in deaths of socially vulnerable individuals, rather than exceptional measures requiring special authorization. Comprehensive post-mortem investigation, they contend, is not merely a technical matter of diagnostic accuracy; it is a matter of equity, judicial accountability, and human dignity, ensuring that the deaths of the most marginalized are counted, understood, and, where possible, prevented.

Subject of Research: Forensic analysis of mortality and post-mortem investigation challenges among homeless individuals in Milan, Italy

Article Title: Forensic insights into mortality and challenges in post-mortem investigations of homeless individuals: a 10-year study (2014–2024) in Milan, Italy

Article References: Tambuzzi, S., Valleriani, D., Carsana, C., Arzenati, P., Mazzarelli, D., & Cattaneo, C. (2026). Forensic insights into mortality and challenges in post-mortem investigations of homeless individuals: a 10-year study (2014–2024) in Milan, Italy. International Journal of Legal Medicine. https://doi.org/10.1007/s00414-026-04037-z

Image Credits: AI Generated

DOI: 10.1007/s00414-026-04037-z

Keywords: homelessness, forensic medicine, autopsy, mortality, cause of death, toxicology, histology, public health, social marginalization, Milan, undetermined deaths, healthcare access

The sheer scale of the dataset gives the findings unusual weight. Most research on homeless health relies on cross-sectional surveys or snapshots of emergency department use, which capture a single moment and can exaggerate the role of crisis care. By contrast, the Hamburg team, led by Daniel Tajdar and colleagues at the University Medical Center Hamburg-Eppendorf, mined ten years of continuous clinical records in which healthcare professionals coded every diagnosis according to ICD-10 criteria. That structure allowed the researchers to compute something rarely available for this population: precise odds ratios linking specific diagnoses to two concrete outcomes, referral to specialist outpatient care and referral to hospital.

The demographic profile of the patient population was striking. The mean age was 44.6 years, with a standard deviation of 13.2, and 83.2 percent of the 5,055 patients were male. This is a population that is aging into chronic disease but remains dominated by working-age men, a group that conventional primary care systems in Germany and across Europe frequently fail to reach. Homelessness has increased substantially across Europe in recent years, and it is well established that people experiencing homelessness carry a high burden of disease and face premature mortality. What has been missing, the authors argue, is longitudinal evidence on the actual spectrum of conditions treated and the patterns of referral that follow.

Mental and behavioral disorders emerged as the single most common diagnostic category, recorded in 1,436 patients, or 28.4 percent of the cohort. Within that group, disorders related to psychoactive substance use affected 817 patients, representing 16.2 percent, while alcohol use disorders accounted for 592 patients, or 11.7 percent. These figures quantify what clinicians in homeless services have long observed anecdotally: psychiatric and substance-related conditions are not incidental features of homeless health but its central axis. The concentration of these diagnoses in a relatively young population underscores how mental health and addiction drive the clinical workload long before the chronic diseases of older age take over.

The referral statistics are where the study delivers its most surprising message. Across all 13,330 consultations, only 10.9 percent resulted in any referral at all, split almost evenly between 5.5 percent referred to specialist outpatient care and 5.4 percent referred onward to hospital. In other words, 89.1 percent of consultations ended with the problem managed entirely within the specialized primary care center. For a population often stereotyped as generating constant emergency admissions, the data show that when accessible, low-threshold primary care is available, it functions as a genuine point of care rather than a mere triage station funneling patients toward hospitals.

That said, the conditions that did trigger hospital referral followed a clear and clinically coherent pattern. Alcohol-related disorders were significantly associated with referral to hospital, with an odds ratio of 1.76 and a 95 percent confidence interval of 1.39 to 2.23. Injuries and poisoning, including drug intoxication, also raised the odds of hospital referral, with an odds ratio of 1.64 and a confidence interval of 1.31 to 2.05. Both findings make intuitive sense: acute intoxication, overdose, and traumatic injury are precisely the situations in which primary care settings lack the equipment and staffing to manage patients safely, and rapid transfer to hospital becomes the only responsible option.

The pathway to specialist outpatient care looked different. Referral to specialists was more likely among older patients, with the odds increasing by a factor of 1.34 for every ten-year increase in age, and among patients presenting with musculoskeletal conditions. This gradient suggests that the specialized centers successfully handled the acute and addiction-related presentations that dominate younger patients, while the accumulating chronic burden of older patients, particularly joint, bone, and muscle disorders shaped by years of rough sleeping and physical labor, required specialist input. It is a reminder that as the homeless population ages across Europe, demand for orthopedic and rheumatological care will likely grow even where addiction services are well established.

Methodologically, the study followed the STROBE reporting guidelines for observational research and was approved by the Ethics Committee of the Hamburg Medical Association under file number PV4454. Under German law, specifically paragraph 75 of Book Ten of the Social Code, the evaluation of anonymized routine data is permissible without explicit patient consent, a legal provision that makes studies of this kind feasible without burdening vulnerable patients with research procedures. The work was funded by the Hamburg Social Welfare Authority, though the funder had no role in study design, data collection, analysis, interpretation, or the decision to submit the paper. The authors, spanning the departments of general practice and health services research in Hamburg-Eppendorf, declare no competing interests.

The implications reach well beyond Hamburg. Specialized primary care services for homeless populations exist in various forms across Europe and North America, but evidence about their effectiveness has been thin, and funding often remains precarious. This study provides the strongest longitudinal signal yet that such services can resolve the majority of health problems in-house, reserving hospitals for the acute emergencies that genuinely require them. The authors conclude that strengthening and integrating these services may improve access to care and support continuity of treatment across healthcare settings, a critical point given that fragmented care and lost follow-up are chronic failures in homeless healthcare. Continuity matters doubly here, because the same patients returning over years build the trust that standard clinics often struggle to establish.

The research agenda that follows is equally clear. The authors call for further studies evaluating interventions that specifically target mental health and substance use disorders, which represented the most common health concerns in the cohort. Given that alcohol-related disorders also drove hospital referrals, investments in addiction medicine embedded within homeless primary care could plausibly reduce both suffering and downstream hospital costs. As homelessness continues to rise across European cities, the Hamburg dataset offers a template: ten years of routine clinical data, systematically coded, can transform anecdote into evidence. The message for policymakers is blunt and quantified, with nearly nine out of ten encounters resolved in primary care, the question is no longer whether specialized clinics for people experiencing homelessness work, but how fast they can be scaled.

Subject of Research: Health conditions and healthcare referral patterns among people experiencing homelessness in specialized primary care

Article Title: Health conditions and referral patterns among people experiencing homelessness: a 10-Year longitudinal study of specialized primary care in Hamburg, Germany

Article References: Tajdar, D., Lühmann, D., Paucke, V., Augustin, M., Sommer, R., Stephan, B., Traxler, J., Bobardt-Hartshorn, J. S., Kloppe, T., Scherer, M., van der Leeden, C., & Schäfer, I. (2026). Health conditions and referral patterns among people experiencing homelessness: a 10-Year longitudinal study of specialized primary care in Hamburg, Germany. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03071-y

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03071-y

Keywords: homelessness, primary care, hospital referral, mental health, substance use disorders, alcohol-related disorders, ICD-10, longitudinal study, health equity, Hamburg, Germany, health services research

The research team, led by Sophie Nadia Gaber of Uppsala University and University College London, together with Elisabet Mattsson, Anna Klarare, Jenny Eriksson Lundström, and Penny Rapaport, worked in collaboration with the Women’s Advisory Board for Inclusion Health, a group of women with lived experience of homelessness. This was not a token consultation. Women with lived experience contributed to the study design and recruitment processes, co-produced study materials, supported the analysis and interpretation of the findings, and helped shape the final recommendations. The study was approved by the UCL Research Ethics Committee, with additional approval from the Swedish Ethical Review Authority, and all participants gave written informed consent, with pseudonyms used to protect confidentiality.

Methodologically, the study is notable for its longitudinal, narrative design. Rather than capturing a single snapshot, the researchers gathered data through narrative interviews and participant observations with the nine women over time, allowing them to trace how engagement with digital health shifted as circumstances changed. The data were analysed using a three-phase phenomenological-hermeneutic approach inspired by the narrative and interpretation theory of Paul Ricoeur, a framework that moves from naive surface reading of the women’s accounts toward deeper critical interpretation of what those accounts reveal about structure, power, and exclusion. This approach is well suited to a population whose interactions with institutions are often fragmented, transient, and shaped by trauma.

The participants themselves reflected the complexity of homelessness in England today. The study situates its work within inclusion health, a field dedicated to addressing the extreme health inequities experienced by socially excluded groups, and the researchers used the European Typology of Homelessness and Housing Exclusion, known as ETHOS, to frame the diverse housing situations women navigate. The women’s stories were collected in partnership with a third-sector organisation, underscoring a key finding of the research: for people experiencing homelessness, the boundaries between health care, social care, and charitable support are porous, and digital tools must function across all of these systems, not just within the National Health Service.

From their analysis, the researchers identified three central themes. The first, framed as taking care of my health on my own terms, with or without digital tools, revealed that the women were not digitally helpless. Many used smartphones, searched for health information online, and managed appointments where they could. But they did so on their own terms, prioritising survival, safety, and autonomy. Digital engagement was often contingent on battery access, data credit, stable connectivity, and the emotional bandwidth to navigate clunky systems. When the technology demanded more than their circumstances allowed, the women simply opted out, not from apathy but from rational triage under conditions of scarcity.

The second theme, when digital tools are not enough, I still need support, cuts to the heart of the eHealthism critique. Digital health systems increasingly assume that patients can self-manage: book online, read results on a portal, complete symptom checkers, and follow app-based care plans. The women in this study showed that such self-management presumes a stable life, digital literacy, and relational support that many simply do not have. When a portal password was lost, when a phone was stolen or broken, or when an online form required information they did not have, the digital pathway became a wall rather than a door. What they needed, repeatedly, was a person: someone to help, explain, advocate, and accompany them through systems designed for the digitally fluent and the securely housed.

The third theme, digital health can work, but it’s not the same as seeing someone face-to-face, captures a tension that resonates far beyond this study’s participants. The women acknowledged genuine benefits of digital tools, including flexibility and the ability to reach services without travelling across an unfamiliar and sometimes hostile city. Yet they consistently described remote interactions as thinner, less trusting, and less therapeutic than in-person encounters. For women whose histories often include trauma, the embodied presence of a trusted clinician was not a luxury but a precondition for disclosure and care. A video call could not replicate the safety of a familiar face, and the researchers argue that treating digital contact as equivalent to in-person care risks mistaking convenience for quality.

Building on these themes, the study’s most significant theoretical contribution is a three-layer conceptual framework of exclusion mechanisms in eHealthism. The individual layer encompasses the personal capacities, resources, and circumstances that shape whether someone can engage with digital health at all. The relational layer captures the interpersonal dynamics of trust, support, and continuity that determine whether digital tools are used well or abandoned. The contextual layer refers to the structural conditions, housing instability, poverty, violence, and institutional fragmentation, that constrain every other layer. Together, the researchers argue, these layers challenge two dominant assumptions of digital health policy: that health is primarily an individual responsibility, and that digital access universally empowers. eHealthism, in this framing, describes how digital health can moralise health behaviour and blame individuals for non-engagement while the systems themselves remain blind to exclusion.

The practical implications are concrete. The researchers propose recommendations for inclusion health that centre on meaningful choice in hybrid care, meaning that patients must be able to choose between digital and face-to-face pathways rather than being forced into whichever option the system prefers to offer. They also call for ongoing, trauma-informed relational support, recognising that a one-off digital skills session is insufficient for people whose lives are marked by instability and whose trust in institutions must be rebuilt repeatedly. For the National Health Service and third-sector organisations alike, the message is that digital inclusion is not achieved by handing someone a device or a login; it requires sustained relationships, flexible service design, and honest acknowledgement that for some patients, the digital route will never be the right one.

The study arrives at a moment when digital health expansion is accelerating globally, from NHS app-first strategies to telehealth booms elsewhere, and its findings speak to a much broader population than the nine women who shared their stories. Refugees, people with severe mental illness, older adults with dementia and related conditions, and anyone else at risk of social exclusion face overlapping versions of the same barriers. By grounding its analysis in the lived narratives of women experiencing homelessness, and by co-producing both the research and its recommendations with a Women’s Advisory Board for Inclusion Health, the study models the very relational, choice-based approach it advocates. Its central warning is stark but constructive: if digital health is to advance health equity rather than deepen disparity, policymakers must abandon the fantasy of universal digital empowerment and design hybrid systems that meet people where they actually are, with or without a smartphone in hand.

Subject of Research: Digital health engagement and exclusion among women experiencing homelessness

Article Title: eHealthism in inclusion health: a qualitative longitudinal study with women experiencing homelessness

Article References: Gaber, S. N., Mattsson, E., Klarare, A., Lundström, J. E., Rapaport, P., & in collaboration with the Women’s Advisory Board for Inclusion Health (2026). eHealthism in inclusion health: a qualitative longitudinal study with women experiencing homelessness. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03061-0

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03061-0

Keywords: eHealthism, digital health, homelessness, inclusion health, health equity, women's health, qualitative research, narrative interviews, hybrid care, trauma-informed care, eHealth, social exclusion

The study, published in PLOS Medicine by a research team led by Kanna Hayashi of Simon Fraser University and colleagues including Thomas Kerr, drew on two harmonized prospective cohort studies of people who use drugs in Vancouver. Participants were followed through semi-annual interviews between December 1, 2021 and May 31, 2025, a window that captured a period of intense municipal enforcement activity in the city. The researchers focused on a specific and measurable question: among people who were homeless at a given study visit, did those who reported that municipal authorities had confiscated their belongings become less likely to report that they were no longer homeless six months later?

The analytical approach was deliberately rigorous. Because people who experience sweeps differ systematically from those who do not—in drug use patterns, health status, and exposure to other social and structural risks—the researchers used proportional hazard marginal structural modeling, a statistical framework designed to handle time-varying confounders that are themselves affected by prior exposure. This method allowed the team to adjust for a wide range of shifting factors, including demographic characteristics, evolving drug use patterns, health conditions, and other social and structural exposures, thereby isolating the association between enforcement actions and housing transitions more credibly than a naive comparison would permit.

The numbers themselves tell a striking story. Among 235 participants who were unhoused at baseline, 59, or 25.1 percent, reported that authorities had confiscated their belongings. Over the course of follow-up, 128 participants, or 54.5 percent, stopped reporting homelessness, corresponding to an incidence rate of 55.6 cases per 100 person-years, with a 95 percent confidence interval of 46.4 to 66.1. In other words, in this cohort, roughly half of unhoused people who use drugs did manage to exit homelessness within the observation period—making the divergence between those who experienced sweeps and those who did not all the more consequential.

When the statistical models were applied, the association was unambiguous. Experiencing confiscation of belongings was negatively associated with transitioning out of homelessness, with an adjusted hazard ratio of 0.35 and a 95 percent confidence interval of 0.13 to 0.94, a result that reached statistical significance at p equals 0.036. In practical terms, people whose possessions were seized by municipal authorities were about two-thirds less likely to stop being homeless during follow-up than comparable people who did not report such confiscation, after accounting for the full battery of time-varying confounders.

The researchers also conducted a secondary analysis that broadened the exposure beyond confiscation. Between June 1, 2023 and May 31, 2025, they examined municipal government-enforced forced displacement, which may or may not have involved the seizure of belongings. Among 154 participants in this analysis, 50, or 32.5 percent, reported forced displacement at baseline, and 62, or 40.3 percent, stopped reporting homelessness during follow-up. The association here was even stronger: forced displacement carried an adjusted hazard ratio of 0.07, with a 95 percent confidence interval of 0.02 to 0.20 and a p value below 0.001. People who were forcibly displaced were, in this model, more than ninety percent less likely to exit homelessness during the follow-up period than those who were not.

The mechanism behind such a powerful association is not difficult to reconstruct, and the study’s authors point to the ways in which sweeps can undermine the fragile pathways that lead from the street to housing. Identification documents, medications, contact information for housing workers, shelter referrals, and the basic equipment of daily survival are all routinely lost when belongings are confiscated. Each lost item can stall a housing application, sever a connection to a case manager, or force a person back into survival mode that consumes the time and energy needed to navigate bureaucratic systems. Displacement also disrupts the geographic stability that outreach workers rely on to find and support clients, meaning that the very services designed to end homelessness may lose contact with the people they are meant to help.

The findings arrive amid a broader North American trend in which encampment clearings have intensified, often accompanied by legal battles over the rights of unhoused people and by public debate over whether enforcement or services should dominate municipal responses. Prior research has already documented a range of health-related harms associated with sweeps, including increased overdose risk, loss of harm reduction supplies, and deterioration in physical and mental health. What this study adds is a direct estimate of the impact on the central outcome that housing policy ostensibly pursues: whether people actually stop being homeless. The answer, in this Vancouver cohort, is that enforcement appears to push that outcome further away.

The authors are careful to acknowledge the limitations inherent in observational research. The study design cannot establish causation with the certainty of a randomized trial, and the researchers note that the rates of transitioning from homelessness may have been overestimated in their sample. Residual confounding remains possible despite the sophistication of the marginal structural models, and the cohort’s focus on people who use drugs means the findings may not generalize to all unhoused populations. Still, the consistency and magnitude of the associations, particularly for forced displacement, are difficult to dismiss as statistical noise, and the prospective design with repeated interviews substantially strengthens the evidence relative to cross-sectional studies.

The policy implications are pointed. The authors conclude that the confiscation of personal belongings and forced displacement might undermine pathways to housing, and they call for approaches that prioritize access to dignified and affordable housing rather than practices that perpetuate homelessness. They also flag an important direction for future research: assessing the quality of the housing that unhoused people are eventually placed in, and examining how that quality relates to returns to homelessness. As cities continue to grapple with visible encampments and mounting political pressure, this study offers a quantitative warning that the broom may be a more powerful obstacle to housing than the tent itself.

Subject of Research: The relationship between municipal encampment sweeps and persistent homelessness among unhoused people who use drugs in Vancouver

Article Title: Encampment sweeps and persistent homelessness among unhoused people who use drugs in Vancouver, Canada: A prospective cohort study

Article References: Hayashi, K., Sayre, E. C., McDermid, J., Marsh, S., Shane, C., Milloy, M.-J. S., P.O.W.E.R., & Kerr, T. (2026). Encampment sweeps and persistent homelessness among unhoused people who use drugs in Vancouver, Canada: A prospective cohort study. PLOS Medicine, 23(9), e1005033. https://doi.org/10.1371/journal.pmed.1005033

Image Credits: AI Generated

DOI: 10.1371/journal.pmed.1005033

Keywords: homelessness, encampment sweeps, forced displacement, housing policy, Vancouver, people who use drugs, prospective cohort study, marginal structural modeling, public health, PLOS Medicine, harm reduction, social determinants of health

The research, published in the Journal of General Internal Medicine, analyzed an extraordinary dataset: 1.6 million Veterans who made at least one emergency department visit between October 2022 and September 2023, generating 3.2 million individual visits. Of those Veterans, 185,392 were women, accounting for 362,347 emergency visits. The investigators, led by Dr. Jessica Faiz of the VA Greater Los Angeles Healthcare System and UCLA, drew on VA administrative records, community care claims data, and enrollment files to reconstruct where every visit occurred and why. Their central finding is deceptively simple: about 60 percent of women Veterans’ emergency visits took place in VA emergency departments, while the remaining 40 percent occurred in community settings paid for through VA Community Care, the program expanded by the MISSION Act of 2018 that allows Veterans to receive care outside the VA system.

That 60-40 split matters because the two populations flowing through each door are strikingly different. Women Veterans who used VA emergency departments were, on average, younger than their male counterparts, with a mean age of 50.2 years compared with 62.9 years for men. They were also more likely to be Black, representing 33 percent of women emergency users compared with 20.9 percent of men, more likely to be Hispanic, more likely to live in urban areas, and more likely to carry a service-connected disability, at 65.5 percent versus 50.1 percent. Most striking of all, 42.1 percent of women Veterans presenting to emergency departments had a serious mental illness, nearly double the 23.4 percent prevalence among men. The picture that emerges is of a high-need population whose emergencies are intertwined with mental health, housing instability, and the long shadow of military service.

To untangle why some women end up in VA emergency departments and others in community ones, the team deployed logistic regression with generalized estimating equations, a statistical technique that accounts for the fact that the same patient may appear many times in the dataset across repeated visits. The models adjusted for age, race, ethnicity, rurality, comorbidity burden measured by the Elixhauser index across 31 chronic conditions, serious mental illness, housing instability, combat exposure, military service branch, VA enrollment priority group, driving time to the nearest VA emergency department or urgent care clinic, and the frequency of primary care contact in the preceding year. The result is one of the most comprehensive adjusted portraits of emergency care navigation ever assembled for this population.

The diagnosis a woman carries through the door turns out to be one of the strongest predictors of where she will be treated. Women with low-acuity conditions, things like upper respiratory infections, sinusitis, low back pain, and skin disorders, had 62 percent higher odds of being treated in a VA emergency department than in the community. Behavioral health-related visits also tilted toward VA settings, with 10 percent higher odds. The pattern likely reflects the financial predictability of VA care: for non-urgent problems, Veterans may reasonably prefer a system where copays are transparent and coverage is guaranteed, rather than risk surprise bills or gaps in Community Care authorization. In contrast, women presenting with emergency care-sensitive conditions, the time-critical diagnoses such as myocardial infarction and stroke where rapid, high-quality treatment demonstrably reduces death and disability, had 39 percent lower odds of receiving care at a VA facility. Chest pain was the single most common diagnosis among women treated in community emergency departments, while musculoskeletal pain topped the list at VA sites.

Geography exerts an equally powerful force. Women who lived farther from a VA emergency department were substantially more likely to seek care in the community, a finding that aligns precisely with the intent of the MISSION Act, which was designed to relieve Veterans facing geographic barriers to VA facilities. Distance also appears to shape the behavior of women experiencing homelessness, who had 10 percent lower odds of using VA emergency care. The authors suggest that fragmented care and lost continuity with VA services, chronic challenges for homeless-experienced Veterans, may push this group toward whatever emergency department is closest, regardless of affiliation. Notably, women with pregnancy-related diagnoses had the lowest odds of any group of presenting to a VA emergency department, consistent with the fact that most women Veterans receive obstetric care outside the VA system entirely.

Perhaps the most socially consequential finding concerns race and trust. Women Veterans from racially and ethnically minoritized groups had consistently higher odds of using VA emergency departments than White women, even after adjusting for clinical and geographic factors. The researchers offer two non-exclusive explanations: this may signal genuine trust in VA providers, a phenomenon documented in prior studies of women Veterans’ healthcare experiences, or it may reflect structural barriers, cost, insurance status, provider availability, that make community care harder to reach. Either way, the pattern echoes earlier national data showing that minoritized Veterans rely more heavily on VA-provided care across the board. It also raises the stakes for equity in emergency settings, where split-second clinical decisions intersect with providers who, as the broader literature on implicit bias in emergency medicine shows, are not immune to the cognitive shortcuts that can shape outcomes.

Combat exposure emerged as another unexpected predictor. Women Veterans with a history of military combat had 20 percent higher odds of seeking emergency care at VA facilities. The authors speculate that this may reflect the comprehensive post-combat care the VA offers, a stronger institutional connection among combat Veterans, or the higher rates of service-connected disability that qualify them for lower copays. Whatever the mechanism, the finding reinforces a theme running through the entire study: the VA emergency department functions not merely as a treatment site but as an anchor of institutional identity and trust for a subset of women whose needs span trauma, mental health, and physical medicine simultaneously.

The study’s technical rigor is matched by candid acknowledgment of its limits. Administrative data cannot capture clinical nuance, urgency, or patient preference, all of which influence where someone chooses, or is able, to seek care. The researchers could not distinguish ambulance arrivals from walk-ins, a crucial gap because community emergency department use for chest pain or stroke may reflect emergency medical services routing protocols rather than any deliberate choice. The analysis also captured only VA-paid visits, missing care covered by private insurance or Medicare. Missing race and ethnicity data, affecting 8.2 percent of women, were handled through multiple imputation by chained equations, and multicollinearity among predictors was formally assessed using variance inflation factors, all of which fell below 1.7 after collinear variables were removed.

The implications reach far beyond the VA. Because two in five women Veterans’ emergency visits now occur in community settings, and because those community visits are disproportionately the high-acuity, high-admission encounters most likely to require follow-up, the authors argue that care coordination between systems is no longer optional. They call for efficient exchange of emergency records, medication changes, and diagnostic results between community emergency departments and VA primary and specialty care; routine ascertainment of Veteran status at community registration desks; and automated notifications to VA care teams when a Veteran presents in the community. Within the VA itself, they point to the need for expanded behavioral health capacity, round-the-clock ultrasound and gynecologic consultation, and same-day services for lower-acuity concerns. As the population of women using VA healthcare has nearly doubled over the past decade, the study makes clear that the question is no longer whether women Veterans will receive emergency care in both systems, but whether both systems will be ready for them.

Subject of Research: Emergency department utilization patterns among women Veterans across VA and community care settings

Article Title: Where Women Veterans Seek Emergency Care: Patterns and Predictors of VA and Community Emergency Department Use

Article References: Faiz, J., Carvalho, C. J., Urech, T., Wu, S., Breland, J. Y., Frayne, S. M., Washington, D. L., Cordasco, K. M., & Vashi, A. A. (2026). Where Women Veterans Seek Emergency Care: Patterns and Predictors of VA and Community Emergency Department Use. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10847-z

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10847-z

Keywords: women Veterans, emergency department, Veterans Health Administration, VA Community Care, MISSION Act, behavioral health, health equity, care coordination, geographic access, homelessness, mental health, health services research

The review arrives at a politically charged moment. The authors explicitly note that rapid policy shifts in several jurisdictions have favored treatment-focused approaches to addressing homelessness, often framing addiction treatment as a gateway to housing. Against that backdrop, the team set out to determine what the published evidence actually says about the key components and outcomes of housing-based support models. Their answer, drawn from more than 13,000 screened records, is nuanced but firm: the strongest and most consistent evidence favors low-barrier Housing First models, while evidence for treatment-first models remains more limited and heterogeneous.

Methodologically, the review was designed for speed without sacrificing rigor. The researchers searched five major databases — CINAHL, Embase, Medline, APA PsycInfo, and Web of Science — for peer-reviewed studies published between January 1, 2000 and April 30, 2025. After screening 13,393 records, they included 57 studies: eight randomized controlled trials, thirty quasi-experimental studies, six qualitative studies, five mixed-methods studies, and eight other designs. Study quality was appraised using Joanna Briggs Institute tools, and the team extracted data on intervention characteristics, model features, comparison conditions, and outcomes spanning housing stability, substance use, mental health, and service utilization. That breadth of study designs, from gold-standard randomized trials to real-world quasi-experiments, strengthens the ecological validity of the findings while also revealing where the evidence base thins out.

From this body of work, four distinct program types emerged. Scattered-site models place participants in independent apartments dispersed across a community, with support services delivered where people live. Single-site models concentrate housing and on-site services within one building, offering concentrated support but sometimes recreating institutional environments. Transitional housing provides time-limited accommodation intended as a bridge toward permanent housing. Finally, outreach support-to-housing programs begin with street-level engagement and gradually connect individuals to housing. Each architecture carries different assumptions about what people experiencing homelessness need first — and each produces different patterns of outcomes in the literature.

On the headline question of housing stability, the verdict was unambiguous. Housing First models consistently improved housing stability compared with treatment-first, linear treatment-contingent models, or treatment-as-usual conditions. This finding held across randomized trials and observational studies alike, reinforcing what has become a robust international evidence pattern: when the immediate goal is ending homelessness, removing preconditions works. The mechanism is conceptually straightforward. Requiring people to demonstrate sobriety or complete treatment before accessing housing creates a barrier that many with active substance use disorders cannot clear, leaving them cycling through shelters, hospitals, and the street. Housing First inverts that sequence, treating stable housing as the platform from which health improvements become possible.

The picture grows more complicated when the review turns to substance use outcomes. Effects of Housing First on substance use were heterogeneous across studies, with alcohol-related outcomes improving more consistently than illicit drug use. Some trials found meaningful reductions in alcohol consumption and alcohol-related harms among participants in scattered-site Housing First, while effects on illicit drug use varied widely, with some studies showing no significant differences compared with control conditions. This heterogeneity matters for policy. It suggests that housing alone, while transformative for stability, does not automatically resolve the full spectrum of substance use health needs — particularly for stimulant and opioid use, where the evidence for spontaneous improvement in the absence of integrated treatment is weakest.

Mental health outcomes followed a similarly mixed pattern. Some studies reported no differences between Housing First and comparison conditions on measures of psychiatric symptoms, while others documented improvements in psychological distress. The reviewers caution against reading these mixed results as evidence of failure. Mental health trajectories among this population are shaped by many factors beyond housing, including trauma history, physical health, social connection, and access to psychiatric care. What the data do support is that Housing First does not worsen mental health outcomes — a persistent concern among critics — and in several studies actively reduces distress, all while delivering far superior housing outcomes.

Beyond housing and behavioral health, the review examined acute healthcare utilization and costs. Evidence for reductions in psychiatric hospitalization and overall costs was described as promising but less definitive than the housing stability findings. Several studies suggested that Housing First participants spend fewer days in hospitals and emergency departments, generating offsets that partially or fully compensate for the cost of housing and support services. However, the reviewers found this evidence less consistent across studies, likely reflecting differences in health system contexts, measurement approaches, and follow-up durations. For policymakers weighing fiscal arguments, the review suggests the cost case is plausible but not yet ironclad — an area where longer-term, more rigorous economic evaluations are needed.

The authors’ conclusions translate directly into policy recommendations. They call for scaling up low-barrier Housing First programs while integrating expanded voluntary substance use treatment, mental health care, harm reduction services, and wraparound supports within housing. The emphasis on voluntariness is significant: the evidence does not support coercive treatment mandates as a condition of housing, but it does support making comprehensive, choice-based services readily available to tenants who want them. The four program types identified in the review offer a menu rather than a single prescription — scattered-site models may suit people seeking independence, while single-site and transitional models may serve others — but the common thread is that housing comes first, not last.

The review also candidly maps the gaps that remain. While some treatment-first models reported positive outcomes, the evidence base for them was more limited and heterogeneous than for Housing First, making head-to-head comparisons difficult. The authors highlight the need for further comparative research and, critically, more robust longer-term studies to identify which specific program components best support substance use health among this high-needs population. As jurisdictions worldwide grapple with visible homelessness crises and intensifying debates over housing versus treatment paradigms, this review offers a rare commodity: a rigorously synthesized evidence base. Its message is neither that housing solves everything nor that treatment is irrelevant, but that the sequence matters — and the science says house people first, then wrap every effective service around them.

Subject of Research: Housing-based support models for adults experiencing homelessness with substance use and mental health needs

Article Title: Housing-based support models for individuals experiencing homelessness, substance use and mental health needs: a rapid review

Article References: Somefun, O. D., Kerman, N., Corace, K., Taha, S., Buckley, L., & Stergiopoulos, V. (2026). Housing-based support models for individuals experiencing homelessness, substance use and mental health needs: a rapid review. Addiction Science & Clinical Practice. https://doi.org/10.1186/s13722-026-00716-9

Image Credits: AI Generated

DOI: 10.1186/s13722-026-00716-9

Keywords: homelessness, Housing First, substance use, mental health, harm reduction, treatment-first models, housing stability, rapid review, addiction science, psychiatric hospitalization, supportive housing, public health policy

The review, conducted according to the PRISMA-ScR reporting guideline for scoping reviews, set out to map how alternative first response programs are defined, studied, and evaluated in the academic literature. The inclusion criteria were deliberately broad but precise: eligible studies had to describe non-law-enforcement teams dispatched to calls for service involving mental or behavioral health crises. The team searched PubMed using a comprehensive set of keywords, supplemented by author-curated sources and backward searches through reference lists. That exhaustive strategy yielded only sixteen studies, a number that surprised even the investigators given the prominence of these programs in public discourse and municipal budgeting.

One of the review’s most consequential findings concerns language. Terminology across the sixteen studies varied substantially, with the phrases alternative first response and mobile crisis teams appearing most frequently. This lexical fragmentation is not merely cosmetic. When programs are labeled inconsistently, systematic comparison becomes difficult, funding applications describe different things under the same name, and policymakers struggle to know which evidence applies to which intervention. The authors found that programs were typically defined in contrast to police response rather than on their own operational terms, and were staffed by multidisciplinary teams that might include medics, social workers, peer support specialists, and counselors.

The scope of the programs studied was also revealing. Most of the existing research focused on mental health crisis response, often overlapping with homelessness and substance use, reflecting the reality that these problems are deeply intertwined on city streets. The programs emphasized three core functions: de-escalation of acute crises, linkage to services such as housing and treatment, and diversion away from the criminal legal system and emergency departments. In effect, alternative first response sits at the intersection of public health, social welfare, and public safety, attempting to resolve with clinical and social tools what has historically been handled with badges and handcuffs.

The timing of the literature is itself a data point. Every included study appeared after 2019, and the majority after 2022, which coincides with the national reckoning over policing that followed 2020. Municipalities seeking visible, concrete reforms turned to crisis response models as a politically feasible intervention, and programs proliferated faster than journals could evaluate them. The review’s authors note that this creates a peculiar situation in which cities are making multi-million-dollar staffing and dispatch decisions with limited rigorous evidence about outcomes, cost, and unintended consequences.

The gaps the review identified are as informative as the studies it found. Client experiences received limited attention, particularly among marginalized populations, the very people these programs most often serve. Only a small number of studies, such as qualitative work documenting the experiences of unhoused community members with Portland Street Response, have centered the voices of those receiving the service. Longitudinal research tracking outcomes over time is nearly absent, experimental designs are rare, and cost-effectiveness analyses, which are essential for justifying sustained municipal funding, are lacking altogether. Without such evidence, it remains difficult to answer basic questions about whether alternative response reduces arrests, emergency department use, or hospitalizations over the long term.

Some early quantitative signals from outside the review’s sixteen studies suggest the models hold promise. An analysis published in Science Advances in 2022 found that a community response approach to mental health and substance use crises in Eugene was associated with reduced crime, and subsequent work has attempted to quantify CAHOOTS’s impact on police workload through call diversion and prevention. A pragmatic randomized effectiveness trial published in Social Science & Medicine in 2024 compared police-mental health co-response with police-as-usual response to behavioral health emergencies, illustrating the kind of rigorous design the field will need more of. But the review’s authors caution that such studies remain exceptions, and that co-response models involving police are methodologically distinct from fully civilian teams.

The review also highlights structural dependencies that complicate the alternative response vision. Related research cited in the paper has documented that mobile crisis teams frequently rely on law enforcement for multiple key functions, from scene security to transportation, meaning that even civilian programs often operate within a police-centered ecosystem. National surveys have further shown that simply reaching a mobile crisis team can be difficult, with access varying widely across jurisdictions, and that new Medicaid funding opportunities are shaping implementation in ways that researchers are only beginning to track. Rural areas face additional capacity challenges, raising questions about whether models developed in dense urban settings can translate to communities without a deep bench of behavioral health professionals.

For the researchers behind the review, the path forward is clear even if the road is long. They call for more rigorous, longitudinal, and client-focused research to assess program impacts and inform implementation, policy, and funding decisions. That means randomized or quasi-experimental designs where feasible, consistent terminology and program definitions that allow cross-site comparison, deliberate inclusion of marginalized participants in studies of client experience, and economic evaluations that quantify what these programs save or cost relative to the status quo. It also means studying the full chain of response, from how calls are routed at dispatch to what happens to individuals after the crisis team leaves the scene.

The stakes of closing this evidence gap extend well beyond academic housekeeping. Alternative first response has become one of the most prominent and politically charged reforms in American public safety, embraced by advocates as a way to reduce police violence and criminalization of mental illness and homelessness, and scrutinized by skeptics worried about responder safety and accountability. Whether the model fulfills its promise will ultimately be an empirical question, not an ideological one. This scoping review provides the field’s first comprehensive map of what is known, and, more importantly, a candid inventory of what is not. Sixteen studies, all less than a decade old, is a starting point, not a foundation, and the authors’ message to funders and policymakers is unambiguous: the experiments are running, but the measurements have yet to catch up.

Subject of Research: Peer-reviewed evidence on non-police alternative first response programs for mental health crisis and homelessness

Article Title: A Scoping Review of the Peer-Reviewed Research on Alternative First Response for Mental and Behavioral Health Crisis and Homelessness

Article References: Leickly, E., Porter, C., & Kriegel, L. (2026). A Scoping Review of the Peer-Reviewed Research on Alternative First Response for Mental and Behavioral Health Crisis and Homelessness. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01730-6

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01730-6

Keywords: alternative first response, mobile crisis teams, mental health crisis, homelessness, scoping review, police diversion, de-escalation, behavioral health, CAHOOTS, crisis intervention, criminal legal diversion, public health