LAUSR

Importance Eye health in the homeless population is important, yet follow-up to referral appointments in this population remains low. Objective To investigate the association of health coaching and transportation vouchers with follow-up rates at a free ophthalmology homeless shelter clinic. Design, Setting, and Participants A prospective cohort study was conducted from January 9, 2019, to March 4, 2020, among all 71 patients evaluated at a free ophthalmology clinic at a single homeless shelter in San Francisco, California. Exposures If indicated, patients were referred for advanced ophthalmologic care at a county hospital and free eyeglasses from a nonprofit organization. Main Outcomes and Measures The primary outcome was follow-up rates to referral appointments. The secondary outcomes were prespecified baseline variables hypothesized to be associated with follow-up. The intervention began September 4, 2019. Follow-up rates were compared between the preintervention (n = 37) and postintervention (n = 34) groups. The hypothesis was formulated before data collection. Results Among the 71 patients, 50 (70.4%) were men, and the mean (SD) age was 51.9 (12.4) years. A total of 28 patients (39.4%) were referred for free eyeglasses, 14 (19.7%) to the county hospital for advanced care, and 7 (9.9%) to both. Of those referred, the difference in follow-up from the postintervention to preintervention groups was 53.8% (95% CI, 39.8%-67.9%; P < .001). Compared with patients who did not follow up, those who did had a mean difference of 59 more days at the shelter (95% CI, 39-80 days; P = .003). Among patients with a visual acuity of 20/40 or worse in the better-seeing eye, the mean difference between those who did not follow up and those who did was 61% (95% CI, 44%-78%; P = .003). The mean difference in follow-up between patients who were born in the US and patients not born in the US was 89% (95% CI, 79%-98%; P = .02). Of those in the postintervention group, the difference in presentation to follow-up for patients with a high school diploma compared with those without was 59% (95% CI, 37%-81%; P = .001). Conclusions and Relevance This study suggests that a health coaching and bus token intervention improved follow-up rates at a free ophthalmology homeless shelter clinic by at least 39.8%; this improvement supports considering implementation of this intervention when developing public assistance programs if independent corroboration is provided. Barriers to follow-up included a shorter duration of stay at the homeless shelter, visual acuity better than 20/40, not being born in the US, and lower educational level, although the size of this study does not permit determining if some or all of these are associated with one another.