Homelessness: A Primer Margot Kushel, MD Professor of Medicine - - PowerPoint PPT Presentation

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Homelessness: A Primer

Margot Kushel, MD Professor of Medicine UCSF/ZSFG

“The place where, when you have to go there, They have to take you in”

Robert Frost

North of Boston

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Definition of Homelessness

• Lacks fixed, regular night time residence (includes emergency

shelter)

• Imminently lose their nighttime residence (within 14 days)
• Fleeing, or attempting to flee, interpersonal violence, stalking,

sexual violence

• (Expanded definition for children/youth)

‒ Homeless Emergency Assistance and Rapid Transition to Housing Act 2009 (HEARTH ACT)

Definition of Chronic Homelessness

Homelessness episode lasting > 12 months OR Four or more episodes in prior three years that total in length > 12 months AND A disabling condition

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HEARTH ACT Definition of Chronic Homelessness 2015

How many people experience homelessness in the United States

• Estimated 2.5 -3.5 million Americans experience homelessness

each year

• Over 600,000 homeless any night
• About ½ are sheltered
• There has been a big focus on reducing chronic homelessness

since 2010 via Housing First Permanent Supportive Housing

• Approximately 80,000 chronically homeless individuals

(nightly)

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Homelessness is not one phenomenon

• Individuals
• Adults
• Not living with minor children when they are homeless (not

necessarily un-partnered, or not parents)

• Men>Women
• 40% to 50+% are now aged 50 or over (and rising)
• Homeless Families
• Parents living with minor children
• Women > Men
• An estimated 25% of all people homeless in US are children living

with parents

• Frequent entrances and exits
• Youth Homelessness
• Unaccompanied youth ages 12-25
• Runaway/”throwaway” children
• Youth exiting child welfare system

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Why does homelessness exist?

• Interplay between structural and individual factors and the

presences or absence of a safety net

• Structural factors
• low cost housing
• jobs for low-skilled workers
• long-term psychiatric care for people with severe mental

health problems

• Burt, M et al. Helping America’s Homeless 2001

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Why does homelessness exist?

• Individual factors
• mental health problems
• alcohol and drug use
• childhood and adult victimization
• low levels of education
• poor or no work history
• Safety net
• social insurance (income support)
• social assistance (housing, food, childcare subsidies)
• social services (mental health services, drug and alcohol

treatment)

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Why does homelessness exist?

• When structural factors and safety net are less forgiving
• Less low income housing
• Fewer well paid jobs
• Less availability of social insurance
• people with fewer individual vulnerabilities become homeless

This is happening now!

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Important Caveats

• African Americans and Native Americans are at dramatically

elevated risk of homelessness

• 3-4 times as likely
• Become homeless with fewer personal vulnerabilities
• Less intergenerational transfer of wealth
• Housing discrimination (and multiple other forms of

discrimination)

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What is current situation?

• Housing affordability crisis
• Difficult to get access to publicly subsidized housing
• Only ¼ families who qualify for housing vouchers get them
• Large proportion of adults 50 and older spending >50% of

household income on rent homelessness

• California has second highest housing costs in nation (behind

Hawaii)

• Evicted Matthew Desmond, 2016

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What are risk factors for homelessness?

• Poverty!
• Adverse Childhood Events
• Interpersonal violence
• Being African American or Native American
• Being LGBTI
• History of incarceration
• History of a mental health or substance use problem
• Being born in second half of baby boom (1955-1964)
• This group comprises approximately 30-40% of homeless

individuals (does not count homeless youth or homeless families)

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What are some common precipitants of homelessness?

• Interpersonal violence
• Job loss
• Relationships ending (death, divorce, break-up)
• Having a child!
• Housing foreclosure
• Eviction (with and without cause)
• Health crisis (of individual or close family member)
• Criminal justice system involvement
• Exiting an institution (hospital, psychiatric treatment facility,

jail/prison)

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Where do homeless people stay?

• People enter and exit homelessness
• Some stay primarily in one type of environment, others move

between them

• Unsheltered (includes vehicles, abandoned buildings,

homeless encampments, doorways)

• Emergency shelters
• Short stay hotels or motels
• Institutions (jails, hospitals, treatment programs)
• Friends or family (couch-surfing)

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Who is unsheltered and what are the special risks?

• About half of homeless individuals in US are unsheltered
• Men>women
• May stay in encampments, in cars, in doorways

Our study of homeless older adults found that those who were unsheltered had:

• Less social support
• Were less likely to have a case manager or a primary care

provider

• Higher rate of ED use

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Unsheltered: special risks and challenges

• Risk for exposure to elements
• Violence from strangers
• Frequent interactions with police
• Difficult sleep (some sleep during day for safety’s sake and stay

alert at night)

• Subject to frequent moves, loss of all items (confiscation)
• No access to refrigeration, cooking facilities, safe places to store

medications

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Shelters

• Most areas don’t have enough beds for everyone who

wants/needs them

• Most make residents leave each morning and return in evening
• Many charge (i.e. $5 a night)
• Varying lengths of stays
• i.e. 90 days, weekly stay, nightly lottery
• Many have rules of conduct that can be challenging for clients

with substance use disorders or mental health problems

• Most will not let couples stay together
• Most are congregant living facilities, bunk beds or mattresses on

floor; shared bathrooms

• Some clients avoid because of rules, or because of fear of

violence

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Friends or Family

• Staying (unstably) with friends or family common
• Some manage to avoid street or shelter homelessness while

remaining technically homeless, because frequent moves and lack of stability

• Others will go stay occasionally with friends or family

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Living situations vary

Important to remember that many individuals may live with housing instability/informal arrangements

• “couch surfing” w/o leases, guarantees
• Garages/trailers
• Overcrowded housing

And go back and forth between “homeless” and not “homeless”

Homelessness and Health

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Homelessness and Health

• Homelessness associated with poor health
• utcomes
• Homelessness associated with underuse of non-ED

ambulatory care, increased use of acute care (ED use and hospitalization)

• Associated with poor quality of life and increased

mortality

Hwang CMAJ 2001 Baggett JAMA Int Med 2013 Hwang AHRQ 2010

What are barriers to attending medical appointments and adhering to treatment?

• Lack of insurance or financial resources
• Even with expanded Medicaid, may not be signed up/aware
• Copayments (even if small) can be major barrier
• Lack of transportation
• Lack of social support
• No one to remind patient, encourage their adherence
• Depression/shame/feelings of hopelessness
• Irregular access to food
• Limited access to bathrooms
• Many medications cause need for toileting

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Health Care Utilization

• Homelessness associated with high rates of ED use
• Four times expected
• Small proportion of those who are homeless account for majority
• f use of homeless population
• “Frequent Utilizers”
• Reasons for ED use:
• Doesn’t require appointment
• Can’t turn away without insurance
• Ambulance can provide transportation
• Worsened health status may require urgent treatment (cardiopulmonary, GI bleed)
• Injuries, overdose, intoxication

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What are barriers to attending medical appointments and adhering to treatment?

• Needing to prioritize other priorities (safety, place to sleep, finding

food, going to benefits appointments, court dates, not missing work)

• No place to store belonging
• Inability to receive messages; get appointment reminders
• Some have cell phones, mostly month to month service

‒ Biggest barrier to cell phones are cost

• Stigma and shame
• Hygiene, shame of disclosing homelessness, substance use
• Incarcerations

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Clinical barriers to health care/adherence

• High prevalence of early cognitive dysfunction can make

remembering things and following instructions difficult

• Alcohol
• Traumatic brain injury
• Uncontrolled hypertension (high blood pressure)
• Poor functional status and premature development of “geriatric

condition”

• Poor mobility, frequent falls
• Drug use and alcohol use disorders
• Depression and Post-Traumatic Stress Disorder

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Health Care Utilization

• High rates of hospitalization
• Worse health status

‒ Tobacco use, substance use, poor access to chronic disease management, late presentation of illnesses, poor diet, high injury rate,

• Lower admission thresholds

‒ Much harder to manage things as outpatients!

• Longer hospital stays
• Difficult to discharge without home!
• High rates of readmissions
• Poor follow-up, terrible conditions for recovery

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Special needs: Homeless population is aging

• Homeless population is aging
• Those born in second half of baby

boom (1955-1964) have had elevated risk of homelessness throughout their life

• Homeless adults have health

problems similar to those 15-20 years older

• Considered “older” by age 50
• Approximately half of homeless

individuals are now 50 and older

Hahn et al JGIM 2006 Culhane ASAP 2013 Brown et al JGIM 2012 Brown et al Gerontologist 2016

Why is homeless population aging?

• People born in latter half of baby-boom (1954-1964) have had

lifetime elevated risk of homelessness

• Among homeless people aged 50 and older, 44% never

homeless prior to age 50

• Nationwide 1/3 renters aged 50+ are “housing cost burdened”

paying >30% household income in rent

• Increasing numbers “severely cost burdened” paying >50%

in rent

• Worse in high cost areas

‒ Hawaii and California with highest housing costs nationwide

Culhane ASAP 2013 Harvard Joint Center for Housing Studies 2014

Older Homeless Adults

• Leading cause of death cardiovascular and cancer
• 15-20 years earlier than general population
• High prevalence of geriatric conditions
• 20 years earlier than general population
• Increased likelihood of progression to skilled nursing

facility (SNF)

• Concerned about mortality, but few discussed advance

care planning (ACP) with healthcare providers

Baggett JAMA Int Med 2013 Brown Gerontologist 2016 Song JGIM 2008

What is role of healthcare providers/teams in safety net settings?

• Screen for risk of homelessness and homelessness
• Refer at-risk for prevention efforts
• Adapt care for those who are homeless
• Collect multiple contacts
• Consider loosening targets avoid iatrogenesis
• Screen (and treat/refer) for mental health and substance use problems,

geriatric conditions

• Advance care planning/End of Life issues
• Know local resources and refer
• Permanent Supportive Housing
• Medical Respite
• Rapid Rehousing

No validated screening tool for homelessness or risk of homelessness

Screen for homelessness

• Recommend against using “Are you homeless?”
• Normalize homelessness “Many of our patients are

finding it difficult to have a regular place to stay.”

• Ask: Have you been without a regular place to stay in

the past month? Have you stayed in a shelter/outdoors/car?

• If staying with friends/family ask:
• Can you stay there as long as you would like? Do you

stay the same place every day?

Screen for risk of homelessness

• Do you have difficulty paying rent, mortgage or utilities?
• Have you fallen behind in your rent?
• What proportion of your total household income is going

towards housing? (>50% high risk)

• Are you worried you will be evicted/asked to leave?
• Are you worried that someone else who helps you pay for

your rent won’t be able to pay?

• Is your name on the lease?

Screen for risk of homelessness

• Be aware of high risk periods
• Death of household member
• Job loss (patient or household member)
• Illness/injury (patient or household member)

Why ask?

• Even if you can’t “do anything,” it will help you understand your

patient and build trust

• Be aware of stigma and stigmatizing language
• Refer to appropriate programs
• Recognize that not all will want to go to shelter settings even if

available

• Most shelters require residents to leave during day
• Gather contact information
• Where do you stay?
• Is there anyone who may be in touch with you?
• Is there any place you attend regularly where I could leave

messages? (church, senior center, food program)

Tips on finding people

• Get extensive contact information
• Ask who might know where you are if we are having trouble

finding you?

• Is it ok if I contact them?
• Ask: Tell me about where you spend your time? Where might I

find you?

• Particular markers (under x overpass, on this street)
• Places: fast food restaurants, libraries, clinics, food programs,

shelters, churches

• If you are allowed—ask: may I take your picture? Is it ok if I show

it to others who might be in the places you have told me about

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Key referrals for those at-risk of losing housing

• Homelessness/eviction prevention
• Short and medium term rental subsidies, utility deposits

and payments, legal services

• Case management
• Housing search and placement
• Credit repair
• Legal resources
• Seniors and people with disabilities may have extra

protections beyond general tenancy protections

Strategies to help with medical care

• Cell phones
• Cost is biggest barrier
• May get lost, but for many, phones can help with coordinating

care, staying in touch with family, care providers

• Transportation
• Easy to overlook, but major barrier
• Safe storage for belongings
• Ask about barriers!

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There are ICD10 codes for homelessness

• Housing Circumstance Affecting Care Z59.9
• Homelessness Z59.0
• Make sure all members of the healthcare team know

about the patient’s housing status!

Avoid Iatrogenesis

• High fall risk and lack of regular access to food
• Consider loosening control of blood pressure, diabetes
• Lack of toileting, bathing and cooking facilities
• Diuretics, medications that cause diarrhea
• Feet and skin care
• Avoid medications that require refrigeration
• If use opioids: Small quantities with frequent refills and NALOXONE
• Prior to sending screening tests, ask
• Do you have follow-up for abnormal results?
• Will patient be able to do follow-up test (i.e. FITcolonoscopy)

Mental Health and Substance Use Problems

• High prevalence of mental health and substance use problems
• Screen for
• Depression, post traumatic stress disorder

‒ PHQ 9 or Geriatric Depression Screening Tool ‒ Primary Care PTSD Screener

• Alcohol and Substance Use Disorder

‒ WHO AUDIT and WHO ASSIST ‒ Screening tools for alcohol and drug use problems ‒ Available on line

• Tobacco use

‒ 5As (Ask, Advice, Assess, Assist, Arrange)

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Geriatric Conditions

• Cognitive Impairment
• ADL and IADL impairments
• Mobility impairments, Falls
• Urinary incontinence
• Depression
• Vision and hearing impairments

Geriatric Conditions

• Common
• Severe
• Onset much earlier than general population

Screen, starting at 50

• Cognitive Impairment
• Mini Cog, MOCA
• ADL and IADL impairments
• Katz ADL, BIFS (adapted IADL)
• Mobility impairments/Falls
• Do you have difficulty walking across a room
• Have you fallen in the prior six months?
• Timed Get Up and Go Test
• Urinary Incontinence
• Screen, recognize role of environment!
• Hearing and vision

Life threatening conditions and mortality

• Homeless adults are worried about dying
• High prevalence of personal experience of death
• Close family member, witnessing death
• Worries include:
• No one will find them
• Wishes won’t be followed
• Won’t be remembered or memorialized
• Concerns about what will happen to their bodies after death

Song JGIM 2007

Advance Care Planning and End of Life Care

• Don’t assume estrangement from family, but if patient expresses

reluctance or resistance, respect that

• Homeless individuals can be engaged in ACP
• Issues include documentation and communication of wishes
• Make effort to do and to be thoughtful about how decisions

relayed to treating facilities

• Recognize that “home hospice” is not option if someone is living
• n streets
• Consider: Respite Care, PSH, hospice within SNF

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Housing First Permanent Supportive Housing

• Subsidized housing with on-site or closely linked supportive

services

• Low barrier to entry: no requirements of sobriety or

adherence to mental health plans prior to housing

• Tenant has tenancy rights
• For veterans, called HUD-VASH

‒ https://www.hudexchange.info/resources/documents/Housing-First- Permanent-Supportive-Housing-Brief.pdf ‒ http://portal.hud.gov/hudportal/HUD?src=/program_offices/public_i ndian_housing/programs/hcv/vash

Medical Respite

• Acute and post-acute care for homeless individuals too ill to

be on street, but not meeting requirement for hospitalization

• Variety of settings
• Shelters, freestanding facilities, SNF, transitional housing
• National Health Care for the Homeless Council
• https://www.nhchc.org/resources/clinical/medical-

respite/

Rapid Rehousing

• For people who meet Federal criteria for homelessness
• Temporary financial assistance and services to return people

experiencing homelessness to permanent housing ‒ http://www.endhomelessness.org/pages/rapid-re- housing

Summary

• Median age of homeless population is increasing
• Median age >50
• Almost half of older homeless newly homeless in older age
• Screen and refer to services for both homelessness and risk of

homelessness

• Think about homelessness risk and refer for prevention efforts!
• Homelessness associated with poor health outcomes
• Adapt care as appropriate
• Collect contacts
• Loosen targets
• Consider medication side effect profile
• Think before sending screening tests!

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Summary

• Mental health, substance use problems and geriatric conditions

prevalent and start early

• Screen for them and treat as possible
• Address concerns about dying, end of life care
• Discuss fears openly
• Engage in advance care planning
• Recognize challenging in EOL care
• Know key interventions
• Housing First Permanent Supportive Housing
• Medical Respite
• Rapid Rehousing

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