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Homelessness
Dana Sprute, MD, MPH, FAAFP
Lauren Engelmann, MD
image BASICS
DESCRIPTION
“Homeless” or “homeless individual or homeless person” includes the following: (i) an individual who lacks a fixed, regular, and adequate nighttime residence; and (ii) an individual who has a primary nighttime residence that is (a) a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill); (b) an institution that provides a temporary residence for individuals intended to be institutionalized; and (c) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.
EPIDEMIOLOGY
Prevalence
As of January 2014, on any given night there are 578,424 homeless individuals in the United States: 37% are homeless families; 15% are chronically homeless individuals; 48% are not chronically homeless individuals; and 33% are children (1)[A].
  • From 2013 to 2014, overall homelessness decreased by 2.3%; targeted federal assistance has increased. Risk for becoming homeless remains high (1)[A].
  • Although many homeless individuals reside in temporary housing or shelters, 42% live on the streets (1,2)[A].
  • Homelessness continues to decrease due to increases in targeted federal funding for rapid rehousing/permanent housing; 2015 fiscal year $4.5 billion (highest in history to date) (2)[A].
RISK FACTORS
  • Economic factors
    • Poverty
      • 2015 federal poverty definition: $24,250 annual income for 4-person household in the lower 48 states and District of Columbia, slightly higher in Alaska and Hawaii (3)[A].
      • In 2013, 15% of the U.S. population fell below federal poverty definition (4)[A].
    • Unemployment: U.S. rate 5.3% in July 2015 (U.S. Bureau of Labor Statistics, accessed August 4, 2015)
    • Lack of affordable health care: In 2015, 13.2% of people in United States are without health insurance (4)[A].
      • Young adults (ages 19 to 34 years) are disproportionately uninsured (27%) compared with the average for all ages (13%); the uninsured rate for ages 19 to 25 years decreased by 7.4% since between 2009 and 2013, following Affordable Care Act provision allowing individuals in this age group to stay on their parents' insurance plans (4)[A].
      • Access to insurance has markedly improved because of the introduction of the Affordable Care Act; the number of uninsured Americans has dropped 35% since October 2013 (4)[A].
    • Lack of affordable housing: housing is considered affordable if ≤30% of household income
      • Over 6.5 million households are defined by HUD as “severely housing cost burdened” (≥50% of income is spent on housing) (5)[A].
  • At-risk populations: intimate partner violence, victims of violence; youth (particularly those aging out of foster care); veterans; rural; addiction; psychiatric illness; disabled due to chronic medical disease, psychiatric illness, or substance use disorder; reentry after incarceration/prison
    • Intimate partner violence (IPV): 63% of homeless women experience IPV; in many cases, IPV leads directly to homelessness (6)[A].
    • Youth: Each year, 550,000 unaccompanied youths (up to age 24 years) experience an episode of homelessness lasting longer than a week (6)[A].
    • Veterans: 11% of homeless adults; homelessness rate decreased between 2009 and 2014 (1) [A].
    • Addiction disorders: 46% of homeless individuals report alcohol and/or drug use as a major factor contributing to homelessness (6)[A].
    • Psychiatric illness: 45% of homeless report indicators of a mental health issue in the past year; 25% of homeless adults suffer from chronic mental illness (6)[A].
    • Reentry after incarceration: 30-50% of parolees are homeless at any given time (6)[A].
  • Fundamental issues in homelessness and health care that require ongoing consideration (7)[C]:
    • Unstable housing, limited access to nutritious food and water, lack of transportation
    • Higher risk for abuse and violence
    • Physical/cognitive impairments, behavioral health problems
    • Developmental discrepancies for children: speech delay, chronic ear infection, insufficient opportunity to practice gross and fine motor skills
    • Higher risk for communicable disease
    • Lack of health insurance/resources, discontinuous/inaccessible health care, lack of a medical home, barriers to disability assistance
    • Cultural/linguistic barriers: racial and ethnic groups overrepresented in homeless population
    • Limited education/literacy
    • Lack of social supports: Alienation from family and friends precipitates homelessness.
    • Criminalization of homelessness: frequent arrests for loitering, sleeping in public places
GENERAL PREVENTION
  • Policy and funding for community programs that provide emergency/rapid housing, housing stabilization, and case management services to address risk factors.
  • Affordable Care Act (ACA): In 2010, increased Medicaid eligibility for homeless and expanded home- and community-based services and case management for the homeless population (8)[A].
  • Department of Housing and Urban Development (HUD): increasing permanent supportive housing units, increasing services for veterans and those with disabilities (8)[A]
  • Social Justice Policy Recommendations: permanent affordable housing, foreclosure and homelessness prevention, increased funds for HUD McKinney-Vento programs (emergency, transitional, and permanent housing), rural homeless assistance, universal health care, universal livable income, employment/workforce services, prevention of hate crimes against the homeless, decriminalization of homelessness
COMMONLY ASSOCIATED CONDITIONS
  • Hunger
  • Medical conditions
    • Worsening of chronic conditions: lack of healthy food, places to store medications, or medical equipment; inability to get restful sleep; decreased health literacy (7)[C]
    • Infectious diseases
      • Tuberculosis (TB), HIV/AIDS, STI (7)[C]
      • Skin/nail infections and infestation (lice and scabies)
      • Liver disease (e.g., hepatitis B or C, or alcohol-related)
  • Cognitive impairment: traumatic brain injury (TBI), cerebrovascular accident (CVA), substance use
  • Dental problems
  • Exposure-related conditions (frostbite, heatstroke)
  • Psychiatric illness (7)[C]
  • Trauma: increased risk of assault, victims of hate crimes
image DIAGNOSIS
PHYSICAL EXAM
  • Comprehensive exam: height/weight, BMI, especially: liver, dermatologic, oral, feet, neurologic, mental status
  • P.493

  • Focused exams: for patients uncomfortable with full-body, unclothed exam at first visit
  • Dental assessment: age-appropriate teeth, obvious caries, dental/referred pain, diabetes, CVD
DIAGNOSTIC TESTS & INTERPRETATION
  • Mental health: Patient Health Questionnaire (PHQ-9, PHQ-2), MHS-III, MDQ
  • Cognitive assessment: Mini-Mental Status Exam (MMSE), Traumatic Brain Injury Questionnaire (TBIQ), Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
  • Developmental assessment: Ages & Stages Questionnaires, Parents' Evaluation of Developmental Status (PEDS), Denver II, or other standard screening tool
  • Interpersonal violence: IPV, sexual assault, TBI
  • Forensic evaluation: if indicated by history
  • Baseline labs: as needed to address suspected medical concerns
  • TB screening: PPD
  • STI screening: HIV, chlamydia, gonorrhea, syphilis, hepatitis B, hepatitis C, trichomonas, bacterial vaginosis, monilia
  • Substance abuse: SSI-AOD (Simple Screening Instrument for Alcohol and Other Drugs), urine drug screen
Follow-Up Tests & Special Considerations
  • Reproductive health care and STIs: Obtain detailed sexual history (sexual identity, orientation, behaviors/sexual practices, number of partners). Consider possible exploitation of patient, especially if mental illness/developmental disability suspected. Communicate willingness to initiate contraception first visit without exam. Genital exam recommended, but be sensitive to patient needs, if possible sexual abuse history. If pelvic exam is refused, consider empiric treatment for STI (and possibility of multiple orifice infection). Dispense medications on site; ask if partner needs treatment.
  • Pediatric care: complete exam every visit, use each visit to identify/address problems and provide vaccinations as homeless families may not see a medical provider unless child is sick. Vision and hearing screening at every visit and refer for abnormalities.
image TREATMENT
  • Establish rapport: sensitivity to prior negative health care experiences
  • Enlist resources: mental health and substance abuse programs, free clinics, case management
  • Health care maintenance: vaccinations (hepatitis A and B, Pneumovax, TdaP, influenza) cancer and chronic disease screening for adults; Early Periodic Screening, Diagnosis, and Treatment Program (EPSDT) screening and vaccinations for children
  • Care plan
    • Basic needs: Food, clothing and housing may be higher priorities than health care.
    • Patient goals and priorities: immediate/long-term health needs. Address patient wants first.
    • Action plan: simple language, portable pocket card
    • After hours: extended clinic hours
    • Safety plan: for violence and abuse suspected; mandatory reporting requirements
    • Emergency plan: location of nearest emergency department (ED), preparation for evacuation
    • Adherence plan: Use of interpreter; identification of potential barriers.
MEDICATION
  • Simple regimen: low pill count, once-daily dosing
  • Dispensing: small amounts on-site to promote follow-up, decrease loss/theft/misuse risk. Determine resources for written prescriptions.
  • Storage of medications: If no access to refrigeration, avoid medications requiring it.
  • Patient assistance: free/low-cost drugs if readily available for continuous use; seek local options for assistance
  • Aids to adherence: harm reduction, outreach/case management, directly observed therapy
  • Side effects: primary reason for nonadherence (diarrhea, polyuria, nausea, disorientation)
  • Analgesia/symptomatic treatment: Consider pain contract, single provider for pain medication refills.
  • Dietary supplements: multivitamins with minerals, nutritional supplements
  • Managed care: generics, if possible; assistance getting prescription filled
  • Lab monitoring: Monitor patients on antipsychotic medications for metabolic disorders.
ADDITIONAL THERAPIES
  • Associated problems/complications
    • Fragmented care: multiple providers. Use electronic medical record (EMR); list prescribed medication on wallet-sized card.
    • Masked symptoms/misdiagnosis: for example, weight loss, dementia, edema, lactic acidosis
    • Focus on immediate concerns, not possible future consequences
    • Integrated treatment for concurrent mental illness/substance use disorders
    • Support for parent of child abused by others and for abused parent
  • Follow-up
    • Reliable phone/e-mail contact for patient/friend/family/case manager
    • Frequent follow-up, incentives, nonjudgmental care regardless of adherence
    • Anticipate/accommodate unscheduled clinic visits.
    • Provide car fare, tokens, and help with transportation services.
    • Monitor school attendance and address health/developmental problems with family/school.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Homeless likely to benefit from admission if living conditions are suboptimal to treat medical, psychiatric, and substance use disorders.
Discharge Criteria
  • Bed rest, extended periods of elevation, rest, or icing are not feasible in most instances.
  • Plans requiring multiple return visits likely to fail if no transportation.
  • Admission to inpatient rehabilitation if appropriate and possible
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Patients with a history of nonadherence need additional support (e.g., case manager, outreach) to succeed in ongoing care after hospital discharge.
  • Limited access to telephones to schedule appointments; may be unable to receive telephone messages with test results or rescheduled appointment times.
  • Arrange appointments prior to discharge.
  • Document the best way to contact the individual.
  • Refer to health care agency designed to address needs of people who are homeless with integrated physical/mental health services and substance use treatment.
PROGNOSIS
Mortality rates for homeless adults are 3 to 4 times higher compared with general U.S. population (9)[C].
REFERENCES
1. U.S. Department of Housing and Urban Development, Office of Community Planning and Development. The 2014 point-in-time annual homeless assessment report to congress. https://www.hudexchange.info/resources/documents/2014-AHAR-Part1.pdf. Accessed August 22, 2015.
2. National Alliance to End Homelessness. The state of homelessness in America, 2015. http://www.endhomelessness.org/page/files/State_of_Homelessness_2015_FINAL_online.pdf. Accessed August 22, 2015.
3. U.S. Department of Health and Human Services. 2015 poverty guidelines. http://aspe.hhs.gov/2015-poverty-guidelines. Accessed August 22, 2015.
4. U.S. Department of Health and Human Services. Health Insurance Coverage and the Affordable Care Act. http://www.hhs.gov/healthcare. Accessed August 22, 2015.
5. U.S. Department of Housing and Urban Development. Affordable Housing. http://portal.hud.gov/hudportal/HUD?src=/program_offices/comm_planning/affordablehousing. Accessed August 22, 2015.
6. National Alliance to End Homelessness. www.endhomelessness.org. Accessed August 22, 2015.
7. Bonin E, Brehove T, Carlson T, et al. Adapting Your Practice: General Recommendations for the Care of Homeless Patients. Nashville, TN: Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2010.
8. United States Interagency Council on Homelessness. Opening doors: federal strategic plan to prevent and end homelessness, update 2013. http://usich.gov/opening_doors/annual-update-2013. Accessed August 22, 2015.
9. Maness DL, Khan M. Care of the homeless: an overview. Am Fam Physician. 2014;89(8):634-640.
Codes
&NA;
ICD10
  • Z59.0 Homelessness
  • Z59.1 Inadequate housing
  • Z59.8 Other problems related to housing and economic circumstances
Clinical Pearls
&NA;
  • Ending homelessness requires permanent housing, supportive services, and implementing policies to prevent chronic homelessness.
  • Assistance in gaining access to benefits or meeting basic needs may decrease stress, improve therapeutic relationship, and allow individuals to direct attention to physical health.