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BackgroundIn the City and County of San Francisco, frequent users of emergent and urgent services across different settings (i.e., medical, mental health (MH), substance use disorder (SUD) services) are referred to as high users of multiple systems (HUMS). While often grouped together, frequent users of the health care system are likely a heterogenous population composed of subgroups with differential management needs.ObjectiveTo identify subgroups within this HUMS population using a cluster analysis.DesignCross-sectional study of HUMS patients for the 2019-2020 fiscal year using the Coordinated Care Management System (CCMS), San Francisco Department of Public Health's integrated data system.ParticipantsWe calculated use scores based on nine types of urgent and emergent medical, MH, and SUD services and identified the top 5% of HUMS patients. Through k-medoids cluster analysis, we identified subgroups of HUMS patients.Main measuresSubgroup-specific demographic, comorbidity, and service use profiles.Key resultsThe top 5% of HUMS patients in the study period included 2657 individuals; 69.7% identified as men and 66.5% identified as non-White. We detected 5 subgroups: subgroup 1 (N = 298, 11.2%) who were relatively younger with prevalent MH and SUD comorbidities, and MH services use; subgroup 2 (N = 478, 18.0%), who were experiencing homelessness, with multiple comorbidities, and frequent use of medical services; subgroup 3 (N = 449, 16.9%), who disproportionately self-identified as Black, with prolonged homelessness, multiple comorbidities, and persistent HUMS status; subgroup 4 (N = 690, 26.0%), who were relatively older, disproportionately self-identified as Black, with prior homelessness, multiple comorbidities, and frequent use of medical services; and subgroup 5 (N=742, 27.9%), who disproportionately self-identified as Latinx, were housed, with medical comorbidities and frequent medical service use.ConclusionsOur study highlights the heterogeneity of HUMS patients. Interventions must be tailored to meet the needs of these diverse patient subgroups.

Increased trade, commerce and business transactions at the international level are placing a substantial demand upon working professionals and college students who must learn English, the lingua franca of international business, in order to thrive in a competitive global workplace. Learning English as a second language (L2) can be a daunting task for many reasons. For instance, how does a student or teacher really know which words or phrases are the most practical to focus upon when learning or teaching? With expanding technology and tech tools (e.g., computer software, apps, etc.) widely available, more modern approaches to learning authentic discourse can increasingly be developed. Lexical chunks, or bundles, i.e., the building blocks of oral discourse, may be analyzed via corpus concordance software and serve as a useful pedagogical tool for teachers and a practical learning tool for students in the L2 classroom. Anyone today can access online corpora, making it an easy resource for L2 teachers and learners to utilize. Teachers may draw content that is suitable for the unique needs of their class, and students can form novel and autonomous linguistic conclusions instead of being spoon fed fixed textbook content. Geared towards L2 educators, this paper more specifically illustrates how corpus-based tools can be utilized to augment second language learning, helping L2 college students achieve communicative competence in their academic and professional lives.

Key PointsQuestion: Did emergency department (ED) use decrease among the top 5% of high users of health care and social services in San Francisco County during the COVID-19 pandemic?Findings: In this cohort study of 8967 individuals, the rate of ED visits decreased by approximately 25% during the pandemic compared with nonpandemic years.Meaning: Factors associated with decreased ED encounters and health outcomes during the COVID-19 pandemic among previously high users are not clear and warrant further investigation.This work has been supported, in part, by the University of California Multicampus Research Programs and Initiatives grants M21PR3278.

ImportanceThe population of homeless older adults is growing and experiences premature mortality. Little is known about factors associated with mortality among homeless older adults.ObjectiveTo identify the prevalence and factors associated with mortality in a cohort of homeless adults 50 years and older.Design, setting, and participantsIn this prospective cohort study (Health Outcomes in People Experiencing Homelessness in Older Middle Age [HOPE HOME]), 450 adults 50 years and older who were homeless at baseline were recruited via venue-based sampling in Oakland, California. Enrollment occurred in 2 phases, from July 2013 to June 2014 and from August 2017 to July 2018, and participants were interviewed at 6-month intervals.ExposuresBaseline and time-varying characteristics, including sociodemographic factors, social support, housing status, incarceration history, chronic medical conditions, substance use, and mental health problems.Main outcomes and measuresMortality through December 31, 2021, based on state and local vital records information from contacts and death certificates. All-cause mortality rates were compared with those in the general population from 2014 to 2019 using age-specific standardized mortality ratios with 95% CIs.ResultsOf the 450 included participants, median (IQR) age at baseline was 58.1 (54.5-61.6) years, 107 (24%) were women, and 360 (80%) were Black. Over a median (IQR) follow-up of 55 (38-93) months, 117 (26%) participants died. Median (IQR) age at death was 64.6 (60.3-67.5) years. In multivariable analyses, characteristics associated with mortality included a first episode of homelessness at 50 years and older (adjusted hazard ratio [aHR], 1.62; 95% CI, 1.13-2.32), homelessness (aHR, 1.82; 95% CI, 1.23-2.68) or institutionalization (aHR, 6.36; 95% CI, 3.42-11.82) at any follow-up compared with being housed, fair or poor self-rated health (aHR, 1.64; 95% CI, 1.13-2.40), and diabetes (aHR, 1.55; 95% CI, 1.06-2.26). Demographic characteristics, substance use problems, and mental health problems were not independently associated. All-cause standardized mortality was 3.5 times higher (95% CI, 2.5-4.4) compared with adults in Oakland. The most common causes of death were heart disease (n = 17 [14.5%]), cancer (n = 17 [14.5%]), and drug overdose (n = 14 [12.0%]).Conclusions and relevanceThe cohort study found that premature mortality was common among homeless older adults and associated factors included late-life homelessness and ongoing homelessness. There is an urgent need for policy approaches to prevent and end homelessness among older adults in the US.