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

Partner Logo 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 2 Presentation Title and/or Sub Brand Name Here 3/2/2017

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 HEARTH ACT Definition of Chronic Homelessness 2015 4 3/2/2017

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) 5 3/2/2017

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 6 3/2/2017

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 7 3/2/2017

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) 8 3/2/2017

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! 9 3/2/2017

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) 10 3/2/2017

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 11 3/2/2017

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) 12 3/2/2017

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) 13 3/2/2017

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) 14 3/2/2017

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 15 3/2/2017

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 16 3/2/2017

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 17 3/2/2017 violence

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 18 3/2/2017

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 20 3/2/2017

Homelessness and Health  Homelessness associated with poor health outcomes  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 22 3/2/2017

Health Care Utilization  Homelessness associated with high rates of ED use • Four times expected • Small proportion of those who are homeless account for majority of 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 23 3/2/2017

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 24 3/2/2017

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 25 3/2/2017