Disclosures Homelessness and Health Care of People Experiencing - PDF document

Treating Addiction in the Homeless Population | Barry Zevin, MD Disclosures Homelessness and Health Care of People Experiencing Homelessness Barry Zevin is an employee of the San Francisco Department of Public Health Barry Zevin MD There are no relevant financial or personal relationships that San Francisco Department of Public Health could cause bias in this presentation Whole Person Integrated Care Medical Director Barry Zevin does not accept money, gifts, incentives from the pharmaceutical industry or addiction treatment industry Street Medicine, Shelter Health, Urgent Care barry.zevin@sfdph.org “ The ache for home lives in all of us, the safe Case place where we can go as we are and not be questioned. ” Maya Angelou—All God’s Children Need Traveling Shoes CSAM State of the Art Conference | August 30 – September 1, 2018 | San Francisco

Treating Addiction in the Homeless Population | Barry Zevin, MD • Homelessness is a Result of Poverty Poverty Stigma • Poverty is a Result of Disadvantage, Discrimination, Disability • Homelessness is a Result of Lack of Affordable Survival Shame Housing • Lack of Affordable Housing is a Result of Policy Suffering A Really Brief History of Homelessness in America: Moral Model CSAM State of the Art Conference | August 30 – September 1, 2018 | San Francisco

Treating Addiction in the Homeless Population | Barry Zevin, MD A Really Brief History of Homelessness in America: (Somewhat) Enlightened Contemporary Personal Structural • Lazy, Crazy, & Bad Poverty • • Mental Health • Lack of Affordable Housing – Deinstitutionalization • Substance Use • Lack of Appropriate Housing – Requires treatment voluntary or coerced • Lack of appropriate or – If treatment does not result in cure go back to moral model effective treatment • Disadvantage • Disability Various care coordination and • • Need for Supportive Housing case management models – Housing first, ACT, ICM How Many People Are Experiencing Homelessness In San Francisco? • 8,035 • 9,784 • 17,653 • 151,278 • 567,715 CSAM State of the Art Conference | August 30 – September 1, 2018 | San Francisco

Treating Addiction in the Homeless Population | Barry Zevin, MD People Experiencing Homelessness How Many Homeless People? • 8,035 ‐ 2019 Point in Time Count Fed Definition • 102,968 US Homeless Children single night count • 2,483,539 U.S. Department of Education’s count • 9,784 ‐ 2019 Point in Time Count SF Definition of homeless children in U.S. public schools /2013 • 17,653 – DPH, HSH, registered as homeless U.S. Census data • 151,278 – 2019 California PIT Count • 2.3 million ‐ 3.5 million experience homelessness • 567,715 – 2019 USA PIT Count in a year (old data from before they stopped trying to count) Prevalence of Illness & Disability 70 60 50 40 30 20 10 0 Mental Health Disorder Substance Use Disorder Cognitive Impairments Disability US Population US Homeless Population CSAM State of the Art Conference | August 30 – September 1, 2018 | San Francisco

Treating Addiction in the Homeless Population | Barry Zevin, MD Homelessness and Aging • Homeless Adult Population over 50 – 1990s: 11% – 2003: 37% – 2018: >50% • Mortality 4 ‐ 5X age ‐ standardized general population • 20 ‐ 30 year earlier age of onset of chronic disease National Homeless Deaths Memorial in homeless persons Winter Solstice (December 21) Special Problems • Violence and traumatization • High utilization of medical and other urgent and emergency services – Underutilization of preventative and wellness services • Cognitive Impairment – HL + SUD – >50% acquired brain injury, developmental, etc • Assault of homelessness on individuals integrity and sense of meaning CSAM State of the Art Conference | August 30 – September 1, 2018 | San Francisco

Treating Addiction in the Homeless Population | Barry Zevin, MD Homelessness and Resilience • Few homeless individuals are isolated and alone – Street culture community may be essential for survival Homelessness is Traumatizing even if not “healthy” • Strengths based approaches support resilience and coping – Specific daily life skills training – Spiritual support common co ‐ occurring challenges in homeless • Cognitive impairments – > 50% of HL with SUD with significant impairment – Use several forms of communication – Keep It Simple • Mental Health Disorders – Trauma – Get practical about trauma informed approach – Psychiatric Disorders – Substance Use Disorders – Poorly recognized conditions – Complex trauma/Autism Spectrum/ADHD CSAM State of the Art Conference | August 30 – September 1, 2018 | San Francisco

Treating Addiction in the Homeless Population | Barry Zevin, MD Adaptations to Practice Shelter • Ask about Homelessness and housing stability – “What is your Living Situation?” – “Will you be able to stay there? Is that safe?” • Assess Homeless Street Smarts and Survival Skills – How will current illness change persons ability to survive? – How can we scaffold persons success when back in the community Adaptations to Practice Street/Vehicle /Encampment • Most people experiencing homelessness will remain homeless for the foreseeable future • Use Bio ‐ Psycho ‐ Social ‐ Spiritual approach – Multi ‐ disciplinary, integrated, whole person • Explore barriers to care specific to each patient • Develop action plan to overcome specific barriers • What is back up plan? What is back up plan to the back up plan? CSAM State of the Art Conference | August 30 – September 1, 2018 | San Francisco

Treating Addiction in the Homeless Population | Barry Zevin, MD Barriers to Treatment: Barriers to Treatment: Patient challenges Provider Perception of Patients – No insurance/medi ‐ cal – Can’t trust doctors inactive – Feel ashamed due to – “They just don’t care – Poor previous track record – No ID appearance, hygiene, chance of adherence to medical about their health” – No phone of meeting other community plans members – Getting to appointments on – They don’t belong in the – Miss appointments time very difficult – Warrants or other criminal hospital but they don’t justice complications – Can’t / won’t leave stuff / – Safety risk belong on the street pets – Chaotic constant drug use – Poor hygiene – Frequent lost or stolen – Can’t / won’t leave partner – Acute medical issues medication – Disturbing to other – Will lose everything by – “No one cares about my patients – If we are overly kind to entering treatment health” them they’ll keep coming – Time consuming and – 86’d from clinics and services back manipulative Adaptations to Practice Selected Adaptations • Appointments are the enemy of people experiencing • No Insurance: homelessness – Formulary of medications free on site or – Open access – more than just drop in – Offer “meaningful waiting” arrangements with a local pharmacy – CAYA ‐ “Come as you are” – Exceptions to eligibility criteria to assure people • Opportunities to practice in unconventional sites get care – Deliver services where people are – Respite, shelter, navigation center, needle exchange, – Assistance to get on Medicaid (CA medi ‐ cal) residential programs, etc • benefits navigator In locations where HL are – Shelters, clinics, CSAM State of the Art Conference | August 30 – September 1, 2018 | San Francisco

Treating Addiction in the Homeless Population | Barry Zevin, MD Selected Adaptations Selected Adaptations • Trauma histories including bad experience in • Victimization: Lost, Stolen, Destroyed Medications health care and treatment – Short Rx duration –small Rx with refills rather than 1 month supply – Trauma informed approach – Strategies for safe storage – Kind human interaction from first moments of – Shelters may offer daily dispensed encounter • Chaotic substance use and chaotic lives • Cognitive impairments: – Mutual goal setting – Multiple forms of communication – Welcome people back who are intermittent with follow up – Outreach, frequent visits – Creative approaches to intensifying treatment Selected Adaptations Selected Adaptations • Patients leaving “Against Medical Advice” • Usual healthcare quality indicators may not be – Establish this as an “unusual occurrence” or critical relevant for homeless populations marker to initiate quality improvement – Review indicators and eliminate or adapt them – The reason is virtually never “don’t care about my health” – Add new indicators based on risks in population – Ask patients experiencing homelessness as a matter of course early in hospitalization whether there is anything that would interfere with their staying in the hospital until their condition is stabilized CSAM State of the Art Conference | August 30 – September 1, 2018 | San Francisco