Homelessness, Health and Human Habitation
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Homelessness is one of the crudest manifestation of poverty, discrimination, and inequality, affecting people of all ages, genders, and backgrounds. Globally, 1.6 billion people worldwide live in inadequate housing conditions, with about 15 million forcefully evicted every year, which is an alarming rise in homelessness in the last 10 years. Eradicating poverty is not only an ethical, but also a social, political, and economic necessity. Placing people at the center of development by ensuring full participation by all, is of utmost importance. Poor physical health is associated with poverty in general but seems to be more pronounced among those who are without homes. Individuals without homes often lack access to healthcare treatment. Chronic health problems and inaccessibility to medical and dental care, can increase school absences and limit employment opportunities. People without home have higher rates of hospitalizations for physical illnesses, mental illness, and substance abuse than other population.
The purpose of this document to explore various existing programs to help homeless population, to prevent homelessness, to expand community-based services for the homeless individuals, and to provide adequate health care for this underserved population. Healthcare providers can help address the needs of homeless individuals by identifying their own patients in the practice who may be homeless or at risk of becoming homeless. Educating these patients about available resources in the community, treating their health problems and offering preventive care should be part of the healthcare.
Each year between 2 - 3 million people in the United States experience an episode of homelessness (HUD-US Departments of Housing and Urban Development; 2018). Homelessness is an issue that can affect anyone. The odds of an individual in the United States becoming homeless in a given year are 1 in 194. The number of homeless individuals was essentially unchanged between 2009 and 2013, showing no improvement. It is estimated 1% of population in developed countries - USA, Canada and EU countries are homeless and 10% of homeless people are under the age of 15.
Over the years the face of homelessness has changed from the adult male alcoholic to an increasingly diverse population with complex medical illnesses. Despite population, the shortage of affordable housing is a major precipitating factor that can render individuals homeless who are not extremely poor. According to US Census, the prevalence of homelessness is high among military veterans, estimated in 2016 to be about 13%.
Families with children are the fastest growing segment of the homeless population (HUD, 2018). The average sheltered family was headed by a female with 2 to 3 members. 34% of the total homeless population composed of families. 50% of children without homes are under age 5. A growing number of families experiencing homelessness have school-age and adolescent children as well. African-American families make up to 43% of homeless families. Lack of education is associated with homelessness, with 53% of homeless mothers lack a high school diploma.
Additionally, the interface between homelessness and child welfare involvement results in many children being separated from parents and are placed in foster care system. These children tend not to be reported in census studies of homelessness. Children without homes have greater numbers of school absences, compromising their academic achievements as well as school adjustment and self-esteem.
Definition of Homelessness
Homeless is defined as the state of "an individual or family who lacks a fixed, regular, and adequate nighttime residence."
Chronic homelessness is defined by the U.S. Department of Housing and Urban Development (HUD), as the state of "an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more or who has had at least four episodes of homelessness in the past three years."
In 2012, HUD has issued the final regulation to implement changes to the definition of homelessness contained in the Homeless Emergency Assistance and Rapid Transition to Housing Act. The definition affects who is eligible for various HUD-funded homeless assistance programs. The new definition includes four broad categories of homelessness:
- People who are living in a place not meant for human habitation, in emergency shelter, in transitional housing, or are exiting an institution where they temporarily resided. The only significant change from existing practice is that people will be considered homeless if they are exiting an institution where they resided for up to 90 days (it was previously 30 days) and were in shelter or a place not meant for human habitation immediately prior to entering that institution.
- People who are losing their primary night-time residence, which may include a motel or hotel or a doubled-up situation, within 14 days and lack resources or support networks to remain in housing. HUD had previously allowed people who are being displaced within 7 days to be considered homeless. The proposed regulation also describes specific documentation requirements for this category.
- Families with children or unaccompanied youth who are unstably housed and likely to continue in that state. This is a new category of homelessness, and it applies to families with children or unaccompanied youth who have not had a lease or ownership interest in a housing unit in the last 60 or more days, have had two or more moves in the last 60 days, and who are likely to continue to be unstably housed because of disability or multiple barriers to employment.
- People who are fleeing or attempting to flee domestic violence, have no other residence, and lack the resources or support networks to obtain other permanent housing. This category is similar to the current practice regarding people who are fleeing domestic violence.
The final regulation on the definition of homelessness went into effect on January 4, 2012. Available @ http://endhomelessness.org/wp-content/uploads/2012/01/changes-in-hud-definition-homeless.pdf
Risks of Homelessness
Although extreme poverty is a characteristic of the homeless population, the shortage of affordable housing is a major precipitating factor that can render individuals homeless who are not extremely poor. Unemployment, job loss, foreclosures, mortgage defaults, personal or family crisis, an increase in rent disproportionate to income, or a reduction in public health benefits all increase the likelihood of loss of a home. Other risk factors include lack of job skills, inadequate social support, problems with alcohol or substance abuse, mental illness, experiences of violence, and previous incarceration. Additionally, the prevalence of homelessness is high among military veterans.
Domestic and sexual violence is the leading cause of the homelessness for women and families, and 20 - 50% of all homeless women and children become homeless as a direct result of fleeing domestic violence. Homeless women are far more likely to experience violence of all sorts compared with women who are not homeless because of a lack of personal security when living outdoors or in shelters. Domestic violence shelter providers are prohibited from reporting client information; therefore, estimates likely undercount the number of homeless women and families seeking shelter as a result of domestic violence.
Many adolescents become homeless after leaving home because of conflicts with parents regarding sexual orientation. Lesbian, gay, bisexual, transgender, or youth questioning their sexual orientation represent 20% of homeless youth. 62% of homeless gay and transgender youth will attempt suicide. Among lesbian, gay, bisexual, and transgender persons who experience domestic violence, 57% became homeless as a result of domestic violence (Domestic Violence Coalition; Jane Doe Inc. 2013).
Lack of access to healthcare is a profound issue for the homeless population, with 73% of homeless individual reporting at least one unmet health need, including medical, surgical, mental health, vision, or dental care or unmet prescription needs. As a result, homeless women lack preventive care such as prenatal care, mammograms, and Pap tests compared with women who are not homeless. In addition, they have higher rates of poor health status, mental illness, and poor birth outcomes.
Types of Interactions between Health and Homelessness: In examining the relationship between homelessness and health, there are three different types of interactions:
- Some health problems precede and casually contribute to homelessness. The most common of these are the major mental illnesses, especially chronic schizophrenia. Another contemporary example of illness leading to homelessness is AIDS. Other health problems contributing to homelessness include alcoholism and drug dependence, disabling conditions that cause a person to become unemployed, or any major illness that results in massive health care expenses.
- Health problems that result from being homeless. Such as diseases of the extremities and skin disorders; it increases possibility of trauma, especially as a result of physical assault or rape. It can also turn a relatively minor health problem into a serious illness. Other health problems that may result from or that are commonly associated with homelessness include malnutrition, parasitic infestations, dental and periodontal disease, degenerative joint diseases, venereal diseases, hepatic cirrhosis secondary to alcoholism, and infectious hepatitis related to intravenous (IV) drug abuse.
- Homelessness as a complicating factor in health care. For even the most routine medical treatment, the state of being homeless makes the provision of care extraordinarily difficult. Even the need for bed rest is complicated, if not impossible, when the patient does not have a bed, or as is the case in many shelters for homeless, must leave the shelter in the early morning.
General Health Problems of Homeless Adults
Although homeless people are susceptible to the same range of diseases that occurs in the general population, the conditions discussed below appear to be especially prevalent among homeless people.
Traumatic Disorders: Contusions, lacerations, sprains, bruises, and superficial burns are more commonly reported in the homeless population. Homeless people are at high risk for traumatic injuries for a number of reasons. They are frequently victims of violent crimes such as rape, assault, and attempted robbery. In addition, primitive living conditions result in unusual risks; for example, the use of open fires for warmth predisposes them to potential burns.
Disorders of Skin and Blood Vessels: Pustular skin lesions secondary to insect bites and other infestations are common among homeless people. In addition, venous stasis of the lower extremities (i.e., poor circulation because of varicose veins) caused by prolonged periods of sitting or sleeping with legs down predisposes homeless people to dependent edema (swelling of the feet and legs), cellulitis, and skin ulcerations. Recurrent dermatitis, which is possibly related to inadequate opportunities to bathe or shower and which is associated with infestations with lice and scabies, is prevalent among the homeless population. This form of dermatitis is frequently confused with bacterial cellulitis, since they both present with red, warm, tender skin lesions. This confusion may lead to inappropriate management. Moreover, homeless people do have an increased frequency of bacterial cellulitis and other pustular skin lesions. Finally, homeless people are at high-risk of developing subcutaneous-collecting abscesses, but this may be related in part to an increased prevalence of needle-stick infections from drug abuse.
Respiratory Illnesses: Acute non-specific respiratory diseases are commonly reported in populations of homeless people in shelters. Living in groups, crowding, environmental stresses, and poor nutrition may predispose homeless people to infections of the upper respiratory tract and lungs. Tuberculosis has become a major health problem among homeless people. Characteristically, this has been a disease associated with exposure poor diet, alcoholism, and other illnesses that can lead to decreased resistance in the host. Substance abusers and the elderly are at high risk for developing tuberculosis. Immigrants from Third World countries also have an increased risk of infection. Whether homelessness alone lead to the high prevalence of tuberculosis or whether multiple other predisposing factors are equally important is not obvious from the studies. However, most studies support the findings that homeless people have a greater prevalence of tuberculosis. Because tuberculosis is spread by personal contact, these infections pose a potential public health problem to occupants of shelters and to the general population.
Chronic Diseases: The proportion of adults seen more than once in the emergency rooms and clinics who suffer from various chronic illnesses (e.g., hypertension, diabetes, and chronic obstructive pulmonary disease) is high in homeless population, as compared with domiciled outpatients. The high prevalence of hypertension can be explained partially by age, race, and alcohol consumption; but homelessness makes the long-term dietary and pharmacological management of hypertension extremely difficult. Similarly, compliance with recommended treatment regimens for cardiovascular and renal diseases, as well as metabolic disorders such as diabetes, is notoriously difficult for homeless people. For these reasons, many homeless people are referred to hospitals for inpatient care for the treatment of disorders that in non-homeless people could be managed on an outpatient basis.
Miscellaneous Health Problems: Foot problems occur with a greater frequency among homeless people. These include superficial fungal infections and calluses, corns, and bunions that are apparently the result of trauma from ill-fitting shoes. Homeless people suffer from many dental problems. Reports of poor oral hygiene, cavities, gingival disease, and extractions with no prosthetic replacements appear to be extremely common among homeless people. These problems are also common among indigent patients in general who have limited or no access to dental care. Finally, various illnesses associated with increased mortality are related to environmental exposure, such as hypothermia and frostbite or hyperthermia. These life-threatening problems are especially prevalent among alcoholic homeless people and those who abuse other drugs.
Mental Illness, Alcoholism and Drug Abuse
Many homeless adults suffer from chronic and severe mental illness. The visibility of mentally ill people has led to the creation of a stereotype for the entire homeless population; the earlier stereotype of the homeless alcoholic has been replaced in recent years with that of the mentally ill homeless person. Not only can homelessness be a consequence of mental illness, but a homeless life may cause and perpetuate emotional problems. To sort out these variables, it is necessary to distinguish among the various categories of psychiatric disorders.
The major mental illness, principally schizophrenia and the affective disorders (bipolar and major depressive disorders), are unlikely to result from the trauma of homelessness. Rather, they cause a level of disability and impaired social functioning in some people that, in the absence of adequate treatment and support, may lead to homelessness, which will then exacerbate these conditions. Personality disorders are not considered ďmajorĒ mental illness because reality awareness is maintained; nevertheless, these disorders are manifested by a personís long-standing inability to deal with the routine demands of living (e.g., as a parent, worker, or independent citizen). Deeply ingrained maladaptive behavior patterns, which begin during childhood or adolescence, interfere with a personís capacity to relate to others, limit a personís potential, and often provoke counterreactions from the environment. Personality disorders should not be seen primarily as a consequence of homelessness. Rather, because they impair a personís ability to cope with the demands of life and the expectations of society, they may contribute to the factors that cause certain people to become homeless.
Other psychiatric illnesses, such as the anxiety and phobic disorders and milder depressive reactions, can either be contributing factors in causing homelessness, or more commonly, result from the stress of homelessness. Becoming homeless is a psychologically traumatic event that commonly is accompanied by symptoms of anxiety and depression, sleeplessness, and loss of appetite. Sometimes, homeless people try to "medicate" these feeling away with alcohol or drugs.
Dementia is a progressive deterioration of mental faculties resulting from degenerative brain disorders, such as Alzheimerís disease; recently, it has been observed among some people with AIDS. It can also be caused by repeated small cerebral hemorrhages or traumas from diseases such as untreated hypertension or controlled epilepsy; it is also a relatively common consequence of chronic alcoholism. Certain types of dementia, therefore, would be expected to occur more commonly in homeless people.
Women who are heads of households and who are homeless with their children represent a segment of the homeless population that is growing both in numbers and in proportion. These women have a markedly different psychiatric profile than individual homeless adult women. In a large study (Institute of Medicine [US] Committee on Health Care for Homeless People, Washington DC, 1988) have examined homeless mothers and their families in approximately two-thirds of the family shelters in Massachusetts. Substance abuse was relatively rare, but this may be an underestimated since the study was limited to shelters and did not include hotels and motels. Of the mothers, 3% were schizophrenic, major affective disorders were found in 10%, and personality disorders were diagnosed in 71%. The children manifested considerable emotional and intellectual impairment. The authors stressed that measures to help such families, if they are stressful, must attend to these psychiatric issues.
Mental disorders are very frequent in homeless populations generally and among homeless people who seek health care. In both groups mental disorders are found that can be considered both a cause and consequence of homelessness.
Clinical Problems in Providing Mental Healthcare for the Homeless Population
The central problem for homeless people with mental illness is the lack of community-based treatment facilities and adequate housing. In addition, the special characteristics of this patient group present particular challenges for treatment. These patients often have already had negative experiences with mental healthcare, often in understaffed, underfunded institutions, and are determined not to accept further treatment. Some have had unpleasant adverse reactions to antipsychotic medications or remember having been abused in the mental health care system; some homeless people lack insight into the reality of their illness and their need for ongoing treatment, but others who are aware of their problems simply do not believe that they will receive appropriate treatment if they accept an offer of care. In most cases, they lack the support of friends or family, are suspicious of authority figures (including providers of treatment) and are slow to develop a trusting therapeutic relationship. As is the case with the homeless in general, their material resources and access to public support programs are extremely limited.
From the perspective of mental health providers, homeless patients are often perceived as less desirable or less rewarding. They may be slow to accept a therapist's sincere efforts to help, but quick to express their negative feelings about the mental health service system. A therapist may be frustrated by failures of homeless patients to keep appointments; and clinics may be unwelcoming to dirty, disheveled, or disorganized patients who frighten away others.
The treatment and rehabilitation of a severely mentally ill homeless person requires the marshaling of major financial and professional resources. Treatment requires enormous patience; considerable clinical skill; and the capacity to mobilize an array of treatment, residential, and rehabilitation resources to meet the needs of a particular patient.
Although ambulatory treatment for mentally ill patients is preferred in most cases, hospital admission may be necessary for treating some patients with severely distressing and disabling symptoms, or for the protection of others if a person is violent. Consent for outpatient or inpatient treatment often can be obtained from a homeless patient relatively easily. For hospital care, voluntary admission is greatly preferred over involuntary commitment and facilitates the development of a constructive doctor-patient relationship. When a patient is unwilling to accept treatment but is clearly dangerous to himself or herself or others, civil commitment procedures are available. However, problems arise when a patient is ill and behaves in a manner that is self-jeopardizing or is offensive, embarrassing, or frightening to others. Because these people are not unequivocally dangerous to themselves or others, they cannot be involuntarily committed.
Another problems confronting clinicians is a person who is neither offensive not dangerous but who is resistant to treatment because of delusions arising from the mental illness itself. Mental health workers may believe that medication and supportive care could substantially help a mentally ill person cope, but the patient is legally entitled to refuse treatment.
Alcoholism and Alcohol Abuse
In whatever setting homeless adults are studied, alcoholism is the most frequent single disorder diagnosed. Severe and intractable alcohol disorders have historically been thought to be especially prevalent among homeless people. Early accounts often attributed the high frequency of alcohol problems among homeless men to their inherent shiftlessness and failure to obtain gainful employment. 80% of homeless men could be considered alcoholic. Current descriptive studies reveal a population that is younger and more heterogenous than skid row populations. It includes:
- Higher proportions of women and minority group members, such as blacks and Hispanics;
- Alarming numbers of families with young families; and
- An increased proportion of people with mental illnesses and histories of drug abuse.
Detoxification is the indispensable first step in treatment; access to detoxification needs to be widely and readily available. Experience suggests that many people entering detoxification facilities will progress no further, and that a small number of people account for the majority of admissions. It is not always possible, however, to predict who will progress further with treatment; a common clinical experience is that, after multiple short-term admissions, some people elect to continue, and eventually they achieve genuine gains.
In recent years disagreement has risen over the optimal structure of detoxification programs. Traditionally, detoxification has been undertaken in an inpatient medical setting. More recently, non-medical detoxification programs have arisen. The latter have attracted much attention because of their markedly lower cost and reportedly equivalent effectiveness. Ideally, a mixture of both would be available. There is little doubt that many people seeking detoxification can be handled in a non-medical program. However, withdrawal from alcohol in people with serious concurrent medical or psychiatric disorders is best undertaken in a hospital setting; many homeless people fall into this category.
After detoxifications, some people are unable or unwilling to take advantage of the currently available rehabilitation alternatives, which at present require entry into a specialized alcohol treatment system. Some of these difficulties could be resolved if there was in intermediate stage in the treatment process between detoxification and specialized treatment. The goal of such a convalescent stage would be to facilitate complete recovery from the physical and mental ravages of the individual's last period of alcohol intake. A safe setting, perhaps best outside of, but intricately connected to, a medical facility, could provide protection, adequate nutrition, rest, and an opportunity to assess the future realistically. Extended medical and psychiatric evaluations, which are problematic in detoxification settings, could be performed, and consequent therapeutic measures could be proposed.
Specialized treatment and active rehabilitation for alcohol-related problems are complex. Some homeless people with alcohol-related problems may eventually enroll in specialized treatment. However, access to such specialized treatment is far from universal, and the shortage of facilities is serious. Furthermore, there is an extreme shortage of the specialized housing arrangements that are needed to support rehabilitation efforts. Residential opportunities are essential to enable the alcoholic homeless person to get away from the streets, where inducements to resume drinking are ever present.
The Diseases of Addiction: Disorders Relating to Alcohol
Illnesses Associated with Abuse of Drugs other than Alcohol
There are few concrete data describing the extent of drug abuse among homeless individuals. Most studies about the homeless combine alcohol and drug abuse together under the heading of substance abuse. Those that separate the two provide some minimal information about illicit drug use. Estimates of homeless individual adults with drug problems range from a low of 10% reported by users of Johnson-Pew clinics nationwide to 33.5% for individuals living in shelters and on the streets in Boston.
The strongest corelate of drug abuse is age. As with the general domiciled population, rates of illicit drug abuse are highest among younger clients and fall off with increasing age, especially after the age of 50. This is almost the opposite of alcohol abuse, which is found to be least prevalent among younger homeless people.
One of the problems associated with drug abuse is AIDS and AIDS related complex. Whether this is more commonly encountered among homeless people who abuse drugs compared with the remainder of the drug-abusing population is not clear. Nevertheless, as the clinical syndromes associated with AIDS increase in the general population, especially among those who abuse parenteral drug, it will be an increasing problem among the homeless population as well.
Other illnesses more commonly encountered in patients who abuse parenteral drugs are: hepatitis, skin infections, abscesses, thrombophlebitis, bacterial endocarditis, and tuberculosis. Other more exotic infections that are not frequent in the United States are more common among drug abusers, such as malaria, which can be transmitted among patients who share needles.
Finally, a point must be made about the comorbidity caused by mental illness, alcoholism and alcohol abuse, and illicit drug abuse. There is a growing concern among those who work with homeless people about clients with dual and multiple diagnoses (further exacerbated by a higher prevalence of many acute and chronic physical illnesses).
There are two major problems that relate specifically to homeless people with multiple diagnoses. It is repeatedly emphasized that homeless people with dual and multiple diagnoses are among the most difficult to entice into treatment. Second, when outreach efforts are successful, there often are no appropriate programs into which such homeless people can be enrolled. Each separate diagnosis correlates to a specific treatment modality and treatment system. These programs frequently exclude those with secondary and tertiary diagnosis of other illnesses. It is rare to find programs that will address a combination of diagnoses on other than the most episodic of terms.
Criminalization of Homelessness
Some cities have criminalized homelessness itself, as well as activities often related to homelessness, such as sleeping in public, begging in public, and camping in public. Increasingly, local governments are using criminal laws to address the presence of homeless people in public places. Others are using rarely enforced laws, such as prohibitions on vagrancy and loitering, to conduct "sweeps" aimed at homeless people. Restrictions on providers of aid to homeless people are also prevalent. Constitutional challenges to such laws and practices have been filed in courts across the USA. City actions have been invalidated as unconstitutional in some areas. They have been upheld in others as legitimate efforts to regulate public space. One leading court decision ordered the city to create "safe zones" for homeless people, in effect invalidating city actions as unconstitutional in only part of the city. In analyzing the constitutional issues raised, courts have adopted a variety of sometimes conflicting approaches.
The proactive response seeks to address the causes of homelessness and to provide solutions. To the extent the focus of this effort is emergency aid, such as, providing more shelter, it will be of limited effectiveness, although clearly less destructive than arresting people or herding them into remote "zones". To the extent focusing on providing affordable housing, adequate income, job training and placement, and social services, it has the potential to be both humane and effective. Instead of dividing the citizens, cities should work at forging the consensus to support such solutions. Establishing community councils that bring together business groups, homeless people, and service providers can create dialogue and help forge political consensus.
Making Social Inclusion a Reality
The Copenhagen Declaration on Social Development and its Programme of Action have guided multilateral action on social development since 1995. The Declaration emphasized the eradication of poverty as an ethical, social, political, and economic imperative. (Details below in Suggested Reading)
In 2020, it will be 25 years since the Copenhagen Declaration set out a list of ten commitments to drive social development and social progress globally at the international and national levels. The United Nations Department of Economic and Social Affairs (UN DESA) will reaffirm the need for a people-centered approach to development and for its urgent and concrete implementation through coordinated and coherent efforts by the international community. DESA will remind all stakeholders that the social pillar of sustainable development is critical to achieve the objectives of the 2030 Agenda, as the economic growth is necessary but not sufficient to reduce poverty, and that social policy plays an important role to achieve inclusive development for all.
Strategies to Reduce Homelessness at Community and Societal Levels
There are several strategies to reduce homelessness and associated negative health outcomes, falling into three primary categories:
- Health and healthcare strategies;
- Workforce strategies; and
- Housing strategies.
Each of these types of strategies are discussed in more details below./p>
Health and Healthcare Strategies
As described above, homeless individuals often become ill or their existing illnesses are exacerbated because of being homeless. A strategy to improve the health outcomes of these individuals, including substance abuse disorders, chronic disease, and mental health outcomes, must include the delivery of health care services in a stable living environment. Additionally, healthcare providers need to be aware and sensitive to the living conditions homeless individuals and adapt chronic disease management accordingly.
Offering medical respite care services is one health care strategy starting to occur in communities throughout the United States. Medical respite care provides a transition for those exiting the hospital who have no permanent residence and are not well enough to return to the street. In addition to meeting the health care needs of these individuals, a respite care program also works to connect individuals to community-based resources, including permanent housing. HUD defines the continuum of care as a local coalition that promotes community commitment to ending homelessness, funding for efforts to rehouse people without homes, and access to mainstream programs.
Continuum of Care (CoC) Program: Designed to promote communitywide commitment to the goal of ending homelessness; provides funding for efforts by non-profit providers, and State local governments to quickly rehouse homeless individuals and families while minimizing the trauma and dislocation caused to homeless individuals, families, and communities by homelessness; promotes access to and effects utilization of mainstream programs by homeless individuals and families; and optimizes self-sufficiency among individuals and families experiencing homelessness. Available @ https://www.hudexchange.info/programs/coc/
Respite care: Barbara McInnis House (BMIH), Boston, Massachusetts (USA), provides up to 104 beds, is the first and the largest medical respite program for homeless people in the USA. The multidisciplinary staff provides medical, recuperative, rehabilitative, palliative, and hospice care for 2,000 people annually. The program at BMIH is also the primary referral source for Boston Hospitals when they discharge homeless people who need long-term care. The intended result will be fewer readmissions after staying at BMIH.
Colorado Case Study: The Colorado Coalition for the Homeless opened and integrated-care health center to serve Denverís homeless residents. The center deploys a single intake system to coordinate the provision of physical and mental health services in one location and during one visit. The center is located within a mixed-use building that also provides 60 units of permanent supportive housing for the chronically homeless, allowing for a homeless individual to be housed while receiving health care and other case management services. More than 13,000 patients were treated at the health center in 2018, resulting in approximately $1,263 in annual public sector health cost savings per health center patient.
Being out of work is known to have negative impacts on health and well-being. Re-employment leads to improved self-esteem, improved general and mental health, and reduced psychological distress and minor psychiatric morbidity. Work has been shown to be therapeutic and rehabilitative for vulnerable populations, such as those who are sick or disabled, which leads to better health outcomes, reduces poverty, and improves quality of life and well-being. While there is limited research on the benefits of work to homeless individuals, applying research findings suggests that if homeless are given the opportunity for long-term employment, they will receive similar benefits. The role that stable housing has in these outcomes is substantial though and must be a significant factor in what other supports homeless individuals need to sustain their employment.
Thus, while employment and training programs targeting homeless individuals have proven to be effective connecting individuals to work, successful completion of an employment program by a homeless individual does not necessarily end their homelessness if they are not concurrently offered a place to live. Workforce strategies must be complimented by housing strategies. Therefore, transitional housing programs such as Sound Families in Seattle, are important models to consider as they work to connect homeless individuals and families to stable employment along with stable housing and other supportive services. In Colorado, the city of Denver is implementing a pilot program with the goal of getting homeless individuals to work for more than one day.
Sound Families in Seattle, Washington: The Sound Families Initiative launched in 2000, $40 million investment to triple the number of service-enriched housing units for homeless families in Pierce, King and Snohomish Counties in the state of Washington. Over the life the initiative 1,445 units were funded, the majority of which implemented a transitional housing model. A significant majority of the homeless families participated in Sound Families were able to make strides, sometimes large, sometimes small, toward stability, economic independence, and improved quality of life. At the core of this work were four cornerstones of success:
- Transitional housing more seamlessly linked to permanent housing provided much needed stable housing for families to address other issues related to their becoming homeless.
- Supportive case management and other services available through the transitional program helped families to move towards equilibrium while maintaining their housing. Low turnover in case managers and solid training and supervision ensured a high-level of support to families.
- For most families, there was a good fit between the level of a family's needs and the service capacity of the transition program. Ensuring this match required adequate and quality up-front assessment of each family's needs.
- Partnerships between service providers and housing owners allowed housing to be linked to services to secure permanent housing upon exit.
The project emphasizes housing of mothers with children and working families earning $16,000 or less a year. The program is unique because funding also supports the coordination of services, such as child care and job training. In this program, employment rate was 50% shoeing that employment outcomes may be primarily effected by housing.
Work Programs for the Homeless: The Denver Day Works Pilot Program is an effort by the City of Denver to provide a work experience opportunity for people who are experiencing homelessness throughout the city. There is a specific focus toward engaging those not already connected to other supportive day services. The goal of the program is to have at least 70% participants engage in more than one day of work through the program, at least 49 participants gain permanent employment, and 30 of those participants stay employed for at least 90 days. The City of Denver also intends to have 20 of the permanent jobs to be with city agencies. To date, the City of Denver reports that 109 people have been given work opportunities, 49 participants have found permanent employment, and 5 of these are with the City and County of Denver.
Urban Peak, Denver, and Colorado Springs: Homelessness for young people ages 15 to 24 can be particularly difficult. According to the 2015 homeless point in time study, 1 in 5 youth in Metro Denver area who are homeless were living on the streets, while the rest were living in shelters or other transitional housing programs. Urban Peak was founded in 1988 and it is the only non-profit organization in Denver offering a complete spectrum of services for youth who are experiencing homelessness or at imminent risk of becoming homeless. The organization, which operates today in both Denver and Colorado Springs, works to support young people through "real life challenges" to become self-sufficient adults. Services are provided at little or no cost (youth in housing do pay a minimal rent each month).
Of the youth served by Urban Peak in 2015, 49 reported past involvement with child welfare. Many of the youth served also engage in high-risk behaviors such as having unprotected sex, having multiple sex partners, and participating in intravenous drug use, making them much more likely to remain homeless and be more resistant to change. According to research conducted by Urban Peak, the costs to taxpayers of incarcerating a young person because of these behaviors would be approximately $8,629; conversely, through Urban Peak, this same young person can receive supports and services that may help them succeed at a cost of $972 to $2,200. Details available at: https://www.urbanpeak.org/denver/about-us/about-urban-peak/about-urban-peak/
In addition to housing services, Urban Peak offers youth education and employment services, including individual and small group instruction to obtain a GED or re-enroll or engage in high school to complete remaining coursework needed to graduate, as well as assistance in applying for post-secondary educational courses. Employment services include a Job Readiness Training Course. In 2016, Urban Peak served 1,814 unduplicated clients.
Supportive Housing - Housing First Model: Supportive housing strategies target the most vulnerable people who need housing and service supports to remain stably housed and live healthy lives. Supportive housing, also often referred to as service enriched housing, provides an essential platform for the delivery of services, including community-based social, mental health, substance abuse, and primary/specialty medical care services, that lead to improved health and stability.
Housing First: It is an evidence-based, permanent, supportive housing intervention for chronically homeless individuals that has the potential to improve health outcomes and reduce costs to health care and other public safety net programs. The model offers housing to individuals prior to any engagement or commitment to supportive and health services. Studies of the model found that it dramatically reduced levels of alcohol and drug addiction as well as shrank health related costs by half. "Adults who have experienced chronic homelessness may be successfully housed and can maintain their housing" - these analyses confirm similar findings from more than 30 studies nationwide that show how supportive housing, by addressing critical social determinants of health for the most vulnerable populations, can significantly reduce costs while simultaneously improving health and other quality of life outcomes.
One specific Housing First model in Massachusetts - The Home and Healthy for Good (HHG) Program - is run by the Massachusetts Housing and Shelter Alliance and is funded by the Commonwealth of Massachusetts. The HHG has provided chronically homeless adults with housing and supportive services, in accordance with the Housing First Model, since 2006. As of February 2017, HHG has served 960 homeless individuals. An evaluation of the program indicates that six months prior to housing, participants accumulated 1,812 emergency department visits, 3,163 overnight hospital stays, 847 ambulance rides and 2,494 detox stays. The estimated total cost per person for measured services - including Medicaid ($26,124), shelter (5,723), and incarceration ($1,343) - amounted to $ 33,190 per year. After one year in the program, the total per person costs of these same services fell to $8,603.
Homeward Pikes Peak (HPP), Colorado Spring: HPP provides recovery and housing services to individuals who struggle with addiction and homelessness. There are three programs:
- Housing First - focuses on homeless individuals and their families by providing vouchers for apartments and case-management and substance abuse or mental health services for veterans for individuals with severe mental illness.
- Harbor House Residential - is a "sober living" program for homeless individuals struggling with alcohol or drugs with enough space to house 30 individuals.
- Harbor House Clinic provides outpatient substance abuse treatment specializing in pregnant women and women with dependent children.
HPP estimates to have saved taxpayers over $2 million per year just in the housing programs by reducing Emergency Room visits, 911 calls, detox stays, and psychiatric hospitalizations.
Rapid Re-Housing Program: It provides short-term rental assistance and services. The goals are to help people obtain housing quickly, increase self-sufficiency, and stay housed. It is offered without precondition such as employment, income, absence of criminal record, or sobriety) and the resources and services provided are typically tailored to the needs of the person. It has been demonstrated to be effective in getting people experiencing homelessness into permanent housing and keeping them there. By connecting people with a home, they are in a better position to address other challenges that may have led to their homelessness, such as obtaining employment or addressing substance abuse issues. The intervention has also been effective for people traditionally perceived to be more difficult to serve, including people with limited or no income and survivors of domestic violence. Research demonstrates that those who receive rapid re-housing assistance are homeless for shorter periods of time than those assisted with shelter or transitional housing. Rapid re-housing is also less expensive than other homeless interventions, such as shelter or transitional housing.
Tiny House Appendix Q: An Affordable Solution for homeless: the adoption of the 2018 IRC Appendix Q into state building code means each owner can use this appendix, along with section R104.11 to work with their building department and/or engineer to create a foundation system that meets the intent of the code and does not require the complete removal of the trailer tires. Tiny houses provides building safety standards for houses on foundations that are 400 sq. ft. and under. However, the appendix doesn't mean you can build a tiny house on a foundation wherever you want in Massachusetts; or other States in USA; you will still have to adhere to your municipalityís zoning codes.
Now that the tiny house Appendix Q has gone through the rigorous vetting process from the International Code Council (ICC), it is up to each state/jurisdiction to decide whether to adopt it or not. Currently, our efforts are towards that end. Since the approval in December 2017, it has already been implemented in numerous states/building jurisdiction (Idaho, Maine, Georgia) with many more in line (Oregon, Massachusetts, Texas, Colorado, New Mexico to name just the one that we know about. Tiny House Appendix Q has been adopted in Massachusetts, effective January 1, 2020.
Supported Housing and Residential Continuum Models
The question of whether safe and affordable housing is sufficient to remediate homelessness has special significance for people with comorbid substance abuse and other mental and physical disorders. This question forms the basis for the evolution of two philosophically unique housing paradigms:
- Housing first, also called supported housing or rapid-rehousing (for immediate housing of families for shelters).
- Treatment first, also referred to as linear, contingent, continuum-based, or residential continuum approaches.
These approaches has been described - treatment first, as a range of housing options coupled with required service participation through which an individual's transition to independence is achieved over time. This is in contrast to housing first, which simply offers voluntary services to those receiving housing first. Such programs couple housing in the community with supportive services, usually for addiction and/or other mental disorders, but they differ in their requirements to obtain and keep housing benefits. Whether housing is contingent on compliance with such services forms the basis of the difference.
Housing-first and treatment-first programs may actually be conceptualized as two different entities that are not easily compared. In housing-first, there are no contingencies or barriers to receiving housing. In treatment first, housing is either contingent on treatment compliance or completion of a part of the treatment program itself. Housing-first is a way to implement a housing-first strategy for people who need intensive services or are non-responsive to contingency-based housing entry paradigms. Services in housing-first are voluntary, but residents have the opportunity to see a case manager regularly depending on their health status and stability. Within a housing-first philosophy, there are models that have intensive case-management services available. Typically, housing-first models measure housing stability and only recently have started to evaluate health status and so forth.
Conversely, criticism of the contingency-based or treatment-first, housing model is that people who are chronically homeless may find it difficult to engage in treatment without being housed first. They may be unable to meet or commit to the demands related to housing readiness (e.g., sobriety, basic living skills, personal hygiene, and commitment to engage in treatment) and ineligible for these types of housing resources. Thus, regarding housing-first and treatment-first programs, one is not necessarily better than the other. It may be that the two programs are not comparable, as they are designed to target different outcomes, and that matching the program to the needs of the person may be the best approach. The majority of people with serious mental illness who are engaged in housing with supports available are less likely to experience hospitalization and more likely to have improved quality of life.
The Homelessness Prevention and Rapid Re-Housing Program has been the most effective plan for reducing homelessness. The National Alliance to End Homelessness has identified The Ten Essentials, a guide to help communities identify effective permanent solutions to homelessness:
- Emergency prevention;
- Systems prevention;
- Shorten homelessness;
- Rapid re-housing;
- Permanent housing; and
The Womenís Health and Education Center (WHEC) encourages healthcare providers to advocate for improved healthcare for homeless individuals, and to take steps to end homelessness.
Global Efforts of Womenís Health and Education Center (WHEC)
Homelessness should not be seen as a personal failure, but a societal one. The characteristics of homeless populations have become increasingly diverse in many countries. They include groups overrepresented among homeless in the past, such as single adult men, members of indigenous populations and people leaving institutional care, as well as older persons, youth, families with children, and migrants. Unaccompanied migrant adolescents experiencing homeless are a growing concern, as their precarious living situations as asylum seekers often lead to homelessness and housing exclusion. In addition, a large proportion of homeless people in many European Union (EU) countries have had experience living in childrenís institutions.
Addressing homelessness requires comprehensive, inter-sectoral policy frameworks and rights-based housing-and health-strategies, in alignment with the 2030 Agenda for Sustainable Development. The structural causes of homelessness should be effectively addressed through legal and policy responses at all levels. Appropriate types of policy interventions should be made for each category of homelessness and by distinguishing between chronic and transitional homelessness. Please visit UN Document E/CN.5/2020/NGO/60, regarding our initiatives for achieving Universal Health Coverage, published by 58th session of Commission for Social Development. Available at: http://www.womenshealthsection.com/content/documents/CSocD_2020_Written_Statement.pdf
Recommendations for Healthcare Providers and Policy-makers:
- Identify patients within the practice who may be homeless or at risk of becoming homeless (i.e., ask about living conditions, nutrition, mental health issues, substance abuse, domestic violence).
- Provide healthcare for the homeless women, children and men without bias, including preventive care, and do not withhold treatment based on concerns about lack of adherence.
- Improved coordination between community programs and specific healthcare services, such as, prenatal care, cervical cancer screening, immunizations, mental health, substance abuse, and treatment for sexually transmitted infections and tuberculosis.
- Donations of medications from pharmaceutical companies for use in homeless clinics and shelters, being mindful of influences on prescribing behavior.
- Become familiar with an inform patients who are (or at risk of becoming) homeless about appropriate community resources, including local substance abuse programs, domestic violence services, and social care visits.
- Simplify medical regimens and address barriers, including transportation needs, for follow-up healthcare visits.
- Modified residency and medical student curricula to increase awareness of healthcare issues of homeless individuals and promote involvement in direct care.
- Advocate for initiatives to address homelessness such as increased funding for housing, case management services, substance abuse treatment, mental health services, domestic violence programs, and primary and preventive care for homeless individuals.
- Volunteer to provide healthcare services at homeless shelters and other facilities that serve homeless individuals.
- Increase access to long-acting reversible contraception.
- Indexing the minimum wage locally to the cost of housing.
- Adequate disability benefits for those who are unable to work.
- Increased funding for comprehensive programs, such as the Health Care for the Homeless program, and research directed to the prevention of homelessness.
- Professional liability protection for physicians who volunteer their services to homeless individuals.
Homeless people experience a wide range of illnesses and injuries to an extent that is much greater than that experienced by the population as a whole. First of all, health problems themselves, directly or indirectly, may cause or contribute to a personís becoming or remaining homeless. The leading example is major mental illness, especially schizophrenia, in the absence of treatment facilities and supportive housing arrangements. Second, the condition of homelessness and the exigencies of life of a homeless person may cause and exacerbate a wide range of health problems. Just as ill health can cause homelessness, so can homelessness cause ill health. Examples of this include skin disorders and the sequelae of a traumatic injury. Finally the state of being homeless makes the treatment and management of most illnesses more difficult even if services are available. Examples of this can be found for alcoholism and nearly any chronic illness, such as diabetes or hypertension. As with all aspects of the problems of homeless, data on their health problems and healthcare needs are partial, fragmentary, and incomplete. Still, enough is known about the health problems of homeless people to provide basic descriptive information and draw inferences for the purposes of programmatic intervention.
Criminalization responses to homelessness are inhumane, do not solve the problem, and are subject to constitutional challenge. Where constitutional violations are present, courts can and should step in to invalidate city laws and policies. Judicial interventional is especially important given the difficulty of using the political process to oppose them. Cities have the power to avoid such intervention by rejecting criminalization responses, and they should do so. Such responses foster divisiveness, waste resources, and divert effort from more positive responses. They are also unlikely to be effective, particularly as they become more widespread: people who are homeless ultimately must live somewhere. Rather than penalizing their homeless residents, cities should work constructively to address the problem of homelessness. By taking this approach, cities can constitutionally and responsibly address the common interest of those who are homeless and those who are not. Ending Homelessness.
Established in 2001, the Women's Health and Education Center (WHEC) was granted special consultative status with the Economic and Social Council of the United Nations, in 2008. WHEC has been actively working to advance the causes of peace, health, and development with the United Nations since its inception. It has a vision to build infrastructure in developing countries and to create meaningful opportunities for girls and women to participate in global philanthropy.
The organization embraces the tremendous diversity of people, religions, and cultures around the world. In support of this belief, the organization has established an academic and cultural focus at important institutions around the globe, to nurture common interests and potential. By supporting reproductive health and research, open dialogue, and objective analysis, WHEC has laid the ground work for mutual understanding among countries.
Preparing the next generation of healthcare providers in the international arena, deepening their knowledge, and improving the skill set for a career in global health and global governance is urgently needed. Programmes are needed for healthcare providers to provide them with academic training and practical knowledge to assist them in providing national and international healthcare.
Building the capacity to care.
- United Nations: 58th Session of Commission for Social Development (CSocD)
Affordable housing and social protection Systems for all to address homelessness
- Housing: An Important Determinant of Health
- The United States Interagency Council on Homelessness
Coordinates the federal response to homelessness
- U.S. Departments of Housing and Urban Development (HUD)
Learn about Affordable Housing
Dedicated to Women's and Children's Well-being and Health Care Worldwide