Health Care for the Homeless
Comprehensive Services to Meet Complex Needs
Health Care for the Homeless
Comprehensive Services to Meet Complex Needs
Serious personal health problems and flaws in health
care systems are major contributors to contemporary
homelessness. Some health problems — drug
addiction, serious mental illness, and physical
disabilities — are distressingly obvious, particularly
in persons living in public spaces. Other problems are
less visible but equally insidious, undermining
capacity to maintain stable housing and function
independently. In far too many cases, a fragmented
health care delivery system has not responded
adequately to the multiple needs of homeless persons,
who are indigent and typically uninsured.
Soon after the dramatic increase of homelessness in
the 1980s, health care professionals, shelter providers,
advocates, government agencies and homeless people
themselves recognized that a concerted health care
response was required. A successful, 4-year Health
Care for the Homeless demonstration program,
THE EXTENT OF HOMELESSNESS
Number of Homeless Persons Annually: 3.5 million
Number of Homeless Persons Nightly: 842,000
—National Law Center on Homelessness
& Poverty1
operated in 19 cities with financial support from the
Robert Wood Johnson Foundation and the Pew
Charitable Trust, was replicated in the Stewart B.
McKinney Homeless Assistance Act of 1987. The
Health Resources and Services Administration, which
administers the federal Health Care for the Homeless
(HCH) Program authorized by this legislation, began
funding homeless health projects in 1988.
By 2001, HCH projects existed in every state, the
District of Columbia, and Puerto Rico. HCH
projects are created and operated by the communities
they serve, are widely heralded as a smart and
effective approach to homelessness, and continue to
emerge in additional communities as the
Consolidated Health Center Program of which they
are part continues to expand.
This brochure briefly describes the connection
between homelessness and poor health, and explains
how HCH projects are responding. Health and social
service providers who are working to end homelessness
in their own communities, those who seek to improve
the delivery of health care in the United States, and
those who are interested in learning about one of the
major social problems of our time will find in Health
Care for the Homeless a rich history, a wealth of
knowledge, and colleagues dedicated to ending
homelessness in our country. n
Homelessness and Poor Health
Research over the last 20 years has demonstrated that homelessness and poor health are strongly correlated in
three ways2:
• Health Problems Cause Homelessness Half of all
personal bankruptcies in the United States result
from health problems,3 it is a short downhill slide
from bankruptcy to eviction to homelessness.
Moreover, some health problems that are more
prevalent among homeless than housed people —
including infectious diseases, substance use
disorders, and mental illnesses — are known to
undermine the family and social supports that
provide a bulwark against homelessness for many
vulnerable people.
• Homelessness Causes Health Problems People
without homes are mercilessly exposed to
the elements, to violence, to communicable
diseases and parasitic infestations. Circulatory,
dermatological, and musculoskeletal problems are
common results of excessive walking, standing, and
sleeping sitting up. Homelessness and malnutrition
go hand-in-hand, increasing vulnerability to acute
and chronic illnesses. Stresses associated with
homelessness also reduce resistance to disease,
account for the emergence of some mental illnesses,
and enhance the false promises of relief offered by
alcohol and drugs. Homeless people experience
illnesses at three to six times the rates experienced
by housed people.4
• Homelessness Complicates Efforts to Treat
Health Problems The health care delivery system
is not well attuned to the realities of living without
stable housing. Health care facilities often are
located far from where homeless people stay, public
transportation systems are insufficient or
nonexistent in many places, and most homeless
people don’t have cars. Clinic appointment systems
are not easily negotiated by people without
telephones, for whom other survival needs (finding
food and shelter) may take priority. Standard
treatment plans often require resources not
available to homeless persons, such as places to
obtain bedrest, refrigeration for medications,
proper nutrition or clean bandages.5
These three correlations, noted by the Institute of
Medicine nearly two decades ago, still obtain today.
The mainstream health care system often is not
prepared to contend with the psychosocial challenges
and multiple co-morbidities commonly experienced
by homeless people, and is unwelcoming toward those
with behavioral health issues who may appear unclean
or threatening, cannot pay for services, and typically
lack health insurance. Consequently, many
individuals who are homeless have had bad prior
experiences with the health care delivery system and
avoid mainstream providers. n
THE DEFINITION
OF HOMELESSNESS
The term “homeless individual” means an
individual who lacks housing (without regard
to whether the individual is a member of
a family), including an individual whose
primary residence during the night is a
supervised public or private facility that
provides temporary living accommodations
and an individual who is a resident in
transitional housing.
—Public Service Health Act,
Section 330(h)(5)(A)
A homeless person is an individual without
permanent housing who may live on the
streets; stay in a shelter, mission, single
room occupancy facilities, abandoned
building or vehicle; or in any other unstable
or non-permanent situation. A recognition
of the instability of an individual’s living
arrangements is critical to the definition of
homelessness.
—Bureau of Primary Health Care, HRSA
HCH Principles of Practice, Program
Assistance Letter 99-12
De-linking Poor Health and Homelessness
In communities nationwide, projects providing
primary care to homeless people seek to disrupt the
terrible nexus between poor health and homelessness.
As of July 1, 2008, 202 HCH grantees of the Health
Resources and Services Administration (HRSA) were
providing health and social services to more than
740,000 clients per year.6 These projects typically
operate as part of Community and Migrant Health
Centers, hospitals, or Departments of Public Health,
or as freestanding agencies. Most combine HRSA
funding with other revenue and grants to provide a
broad range of services.
At a minimum, each project provides a prescribed set of
required services, including primary health care and
substance abuse services, emergency care and referrals,
outreach and assistance in qualifying for entitlement
programs and housing. Many HCH projects go well
beyond these basic services, offering dental care, mental
health treatment, medical respite services, supportive
housing, and other services needed to resolve their
clients’ homelessness.
LIFE EXPECTANCY
U.S. Population: .............................
Homeless in Boston: .....................
Homeless in Atlanta: .....................
Homeless in San Francisco: .........
78
47
44
41
years7
years8
years8
years8
To engage homeless persons and to provide effective
care, HCH projects utilize a number of approaches
that accommodate the realities of homelessness.
These include:
• Outreach HCH physicians, nurses, social workers
and others skilled at making connections with
homeless people (often including persons who have
experienced homelessness themselves) seek out and
bring care to homeless people wherever they are —
in encampments, under bridges, on the streets, in
jails, at soup kitchens and other service sites.
• Service locations HCH clinics are located in or
near shelters and other places where homeless
people congregate.
• Service hours Many HCH projects operate during
extended hours to accommodate the schedules of
clients who work or must be elsewhere at certain
times to secure food or shelter.
• Transportation HCH projects frequently provide
transportation to and from clinics, specialty providers,
social security or food stamp offices, and shelters.
• Elimination of financial barriers HCH projects
assure that inability to pay even a small fee does not
impede access to health services.
• Sensitivity HCH staff endeavor to understand the
unique circumstances and stresses associated with
homelessness. They understand that the process of
engaging individuals who are homeless often
involves overcoming significant fear and suspicion,
and that a patient, nonjudgmental, persistent
approach is often required.
• Comprehensive services HCH providers understand
that health care and other basic needs are interrelated
and strive to address each client’s needs holistically
through the use of multidisciplinary clinical teams.
Integration of primary care with the treatment of
mental health and substance use disorders is a
hallmark of HCH practice, and efforts to secure
housing, entitlements, and jobs are intrinsic to
this approach.
• Case management Coordination of a wide range
of on-site and referral resources receives particular
attention in the HCH approach to care.
THE HOUSING SHORTAGE
9 million low-income renter households
nationwide pay more than half of their income
for housing.
In no community in the U.S. today can
someone who gets a fulltime job at the
minimum wage reasonably expect to find a
modest rental unit he or she can afford.
—National Low Income Housing Coalition9
• Clinical adaptations To promote favorable clinical
outcomes, HCH providers have developed
techniques such as prescribing simple medical
regimens with few side effects, or screening for
common problems during the first encounter
with a client.
Male:...................... 57%
Female: ................ 43%
• Advocacy HCH staff engage in advocacy to secure
client services, to protect clients’ rights, to affect the
local service delivery systems so that it better meets
the needs of their clients, and to change policies
that cause, exacerbate, or create obstacles to
resolving homelessness.
Age 14 and
under: ................ 12%
Age 15 to 19:.......... 5%
Age 20 to 44: ...... 47%
Age 45 to 64: ...... 34%
Age 65 and up: ...... 3%
• Client involvement HCH projects are careful to
involve their clients in developing realistic treatment
plans, in the governance of their agencies,
in evaluating the efficacy of homeless services, and
in advocating for service improvements and
policy change.
HEALTH CARE FOR THE HOMELESS
CLIENT RESOURCES
Uninsured: ......... 70%
Medicaid: ........... 22%
Medicare: ............. 4%
Other Public
Insurance: ......... 3%
Private
Insurance:............. 2%
At or Below Federal
Poverty Level: .... 91%
—Bureau of Primary Health Care, HRSA
2007 Uniform Data System6
HEALTH CARE FOR THE HOMELESS
CLIENT DEMOGRAPHICS
African
American:.......... 41%
Caucasian: ............ 31%
Hispanic: .............. 22%
Asian/Pacific
Islander: .............. 2%
Native American/
Alaskan Native:....2%
—Bureau of Primary Health Care, HRSA
2007 Uniform Data System6
The Health Care for the Homeless Program employs a
model of care that is appropriate for everyone, but is
particularly well adapted to the circumstances of those
most in need. By creating numerous new service
delivery sites and modalities, the HCH Program has
contributed importantly to the development of the
health care infrastructure in the United States. In that
respect, HCH is far more than a safety net.
Yet for those whose personal circumstances have
reduced them to homelessness and for whom all other
systems have failed, HCH remains the final safety net.
The quality of care available through Health Care for
the Homeless improves the health and well-being of
displaced people and models for all service providers a
high standard of care. n
More resources regarding Health Care for
the Homeless are available from:
The National Health Care for the Homeless Council
Health Care for the Homeless Clinicians’ Network
P.O. Box 60427 • Nashville,TN 37206-0427 • 615/226-2292
[email protected] • [email protected] • www.nhchc.org
Sources:
1. National Law Center on Homelessness & Poverty. 2007 Annual
Report, July 2008.
2. Institute of Medicine, Committee on Health Care for Homeless
People. Homelessness, Health, and Human Needs. Washington, D.C.:
National Academy Press, 1988:
http://www.nap.edu/openbook/0309038324/html/
3. Himmelstein, D.U., Warren E., Thorne D., and Woolhandler S.,
Physicians for a National Health Plan. Illness and Injury as
Contributors to Bankruptcy. Journal of Health Affairs Web
Exclusive, February 2005:
http://www.pnhp.org/news/2005/february/bankruptcy_study_hig.php
4. Wright, J.D., Poor People, Poor Health: The health status of the
homeless. In: Brickner PW, Scharer LK, Conanan BA, Savarese M,
Scanlan BC. Under the Safety Net: The Health and Social Welfare of
the Homeless in the United States. New York: WW Norton & Co.,
1990: 15–31.
5. Montauk SL. The Homeless in America: Adapting Your Practice.
Am Fam Physician 2006;74:1132–8.
http://www.aafp.org/afp/20061001/1132.pdf
6. Health Resources and Services Administration, U.S. Department of
Health and Human Services. The Health Center Program: 2007
National Aggregate UDS Data.
http://www.bphc.hrsa.gov/uds/2007data/National/homeless/Nation
alTable3Aho.htm
7. National Low-Income Housing Corporation. Out of Reach:
2007–2008. http://www.nlihc.org/oor/oor2008/
8. U.S. Census Bureau. The 2008 Statistical Abstract: The National
Data Book, Table 98. Expectation of Life at Birth, 1970 to 2004, and
Projections.
http://www.census.gov/compendia/statab/tables/08s0098.pdf
9. O’Connell JJ. Premature Mortality in Homeless Populations: A
Review of the Literature. National Health Care for the Homeless
Council, 2005. http://www.nhchc.org/PrematureMortalityFinal.pdf
Cover photo by Rick Friedman • Photo this page by James J. O’Connell, MD
This publication was developed with support from the
Health Resources and Services Administration,
U.S. Department of Health and Human Services.