by
Marsha McMurray-Avila, M.C.R.P.
Lillian
Gelberg, M.D., M.S.P.H.
William R. Breakey, M.D.
This paper describes special adaptations to clinical practice necessary for addressing the most common health problems of homeless individuals and families. A case is made for the integration of primary care, mental health and substance abuse services as the preferred approach to care for this population, based on the complexity of multiple interrelated health problems that are seen. These problems are examined in a section on the epidemiology of health problems common to people without homes. Homeless people face numerous barriers to access which can be overcome by adaptations to the structure of the delivery system, including extensive outreach, mobile sites and flexibility in policies and procedures. The nature of the homeless condition also calls for special adaptations to clinical practice in the areas of intake and assessment, clinical preventive services, diagnosis, follow-up to assure continuity of care, referrals to specialty care and linkages to other services. Specific adaptations for treatment of physical and mental illnesses are presented, with discussion of primary care, treatment services for substance use disorders, treatment services for serious and persistent mental illnesses, and special services for homeless people with dual diagnoses. The paper concludes with comments on how to address the threats that challenge successful continuation of the unique approach to homeless health care that has evolved, including: inadequate funding to fully implement the integrated approach to homeless health care; impact of market-driven managed care; lack of funding for accessible and appropriate substance abuse treatment; limited cost and outcome data; the disconnect between research and practice; and the scarcity of skilled practitioners willing to serve this population. increased demand for services, decreased capacity and limited resources, the effects of Medicaid managed care, and the need for more qualified practitioners in this field.
After more than a decade of practice, there is considerable agreement as to what constitutes state of the art clinical services for homeless people. Based on research demonstration programs sponsored by public and private funding sources, and experience accumulated by front line workers in the many health care programs across the country, nine general principles have emerged as lessons for practitioners involved in providing care for homeless people:
Physical and mental illnesses are implicated as both causes and consequences of homelessness for many individuals. While the shortage of safe, decent, and affordable housing is the most fundamental cause of homelessness, untreated physical and/or mental health problems create vulnerabilities that can lead to loss of income and home. At the same time, those who experience homelessness are subject to conditions that can result in deterioration of health or exacerbate existing chronic or acute illnesses, leading to rates of illness and injury from two to six times higher than for people who are housed (Wright, 1990). Homelessness also severely complicates the delivery of health services (Institute of Medicine, 1988). Without access to appropriate health care, acute and chronic health problems may go untreated, creating medical complications in multiple co-occurring conditions and ultimately impeding the individual’s ability to overcome homelessness. Failing to provide homeless people with health care of a standard that is available to other people, even when they need elaborate or expensive treatments, constitutes a form of discrimination that should be unacceptable in a democratic society (Bangsberg et al., 1997).
A strong commitment by homeless health care practitioners to respond directly to these complex multiple health care needs of homeless people has resulted in the evolution of an integrated approach to providing clinical services. Primary health care, mental health services and substance abuse treatment need to be made available either from one organization’s comprehensive service system, or if this is not feasible, through linkages with other agencies.
The purpose of this paper is to describe current clinical practice within an integrated system of primary care, mental health and substance abuse services for people without homes. Whenever possible, research has been used to support the discussion. A significant amount of research is available to describe the health problems of homeless people. However, less is found in the research literature related to efficacy of specific clinical practices with this population. Experience in the field and descriptive accounts by practitioners are the basis for many of the special adaptations to clinical practices recommended here for addressing the most common health problems of homeless individuals and families. The discussion is presented in the following sections:
Although there is a major movement to quantify actual outcomes of health care interventions, providers of health care to homeless people have had to adapt their own notions of successful outcome to the realities of the homeless existence. A working group on homeless health outcomes was convened in 1996 by the Health Care for the Homeless (HCH) Branch of the Division of Special Populations/Bureau of Primary Health Care (U.S. Department of Health and Human Services, 1996). This group identified seven systems-level outcomes and seven client-level outcomes that are goals for federally-funded HCH projects. The seven system-level outcomes are interrelated in that HCH projects “provide access for homeless people to a range of comprehensive services. They offer continuity of care within an integrated system to help contain costs and prevent new or recurring problems. Ideally, client involvement is evident in every step of this process.” The seven client-level outcomes are related, but can be measured independently of one another. These include: improved health status; improved level of functioning; improved quality of life; involvement in treatment; disease self-management; client choice; and client satisfaction.
However, the group also noted that “because homeless people are a heterogeneous group with multiple and complex needs, numerous personal and societal factors outside the clinicians’ control may impact the final outcomes for individual patients. Also, their mobility often makes it difficult to track homeless people for follow-up measures” (U.S. Department of Health and Human Services, 1996, p.ii).
A central question in this discussion is determining what qualifies as a “successful outcome”. Health care practitioners working with homeless people are concerned with improving health status, level of functioning and quality of life. Obviously, the most significant change affecting all of these would be acquiring permanent housing. Although this is certainly a recommended goal for health programs, usually undertaken within the framework of case management services, it is not an outcome that can be used to measure the effectiveness of clinical care. This is particularly true given the lack of resources for appropriate affordable housing in most communities, over which the health care practitioner has little control.
The nature of homelessness and the health conditions that accompany it also complicate the determination of “successful outcome.” Homeless people, particularly those with addictions and/or mental illness, go through various stages of change as they move towards the desirable improvements in health status, functioning and quality of life. These stages include: precontemplation; contemplation; action; maintenance; and relapse (Prochaska, DiClemente & Norcross, 1992). This is not a linear process and each individual changes at his or her own rate. Chronic conditions—especially substance abuse and mental illness—are subject to regressions and relapse. This should be expected and needs to be built into program planning, as well as into outcome evaluation methodologies. For example, while recognizing that the incremental steps may occur at different points and may sometimes go backwards, a “hierarchy of objectives” can be constructed for homeless people who are mentally ill, beginning with the most basic to the most sophisticated as follows (Breakey, Susser & Timms, 1992):
Homeless health care practitioners are often limited to measuring change in small increments such as these. New strategies to assess these incremental outcomes are needed, such as the Service Continuum matrix being developed by the HCH Network, a program of the Seattle/King County Department of Public Health, to track clients in their progress towards stability and independence. This assessment matrix is based on incremental change in the areas of relationship, financial resources, health/treatment, social support network and residential status in stages ranging from the initial approach through companionship, partnership and mutuality to stability and independence (HCH Network, 1998).
Other significant work has been initiated to develop appropriate outcome measurements for the homeless health care setting. As a follow-up to the working group on homeless health care outcomes mentioned above, 20 HCH projects were provided federal funding to develop outcomes studies in a variety of areas. It is hoped that the study results and lessons learned will encourage further work in this area by homeless health care projects (U.S. Department of Health and Human Services, 1998b).
As a consequence of the poor nutrition, lack of adequate hygiene, exposure to violence and to the elements, increased contact with communicable diseases, and fatigue that accompany the conditions of homelessness, people without homes suffer from ill health at much higher rates than people living in stable housing. Several studies have found that one-third to one-half of homeless adults have some form of physical illness (Bassuk & Rosenberg ,1988; Burt, 1989; Gelberg & Linn, 1989; Morse & Calsyn, 1986; Roth & Bean, 1986). At least half of homeless children have a physical illness (Wood et al., 1990) and they are twice as likely as housed children to have such illnesses (Wright & Weber, 1987). This lack of health takes its toll by preventing many homeless people from exiting homelessness. For example, one-quarter of homeless adults reported that their poor health prevented them from working or going to school (Robertson & Cousineau, 1986). Even more seriously, rates of mortality are three to four times higher in the homeless population than they are in the general population (Alstrom, Lindelius & Salum, 1975; Hanzlick & Parrish, 1993; Hibbs et al., 1994; Morbidity and Mortality Weekly Report, 1991 and 1992; Wright & Weber, 1987).
The most common physical illnesses among homeless persons include upper respiratory tract infections, trauma, female genitourinary problems, hypertension, skin and ear disorders, gastrointestinal diseases, peripheral vascular disease, musculoskeletal problems, dental problems, and vision problems (Wright & Weber, 1987; Reuler et al., 1986; Miller & Lin, 1988; Wood et al., 1990). Inadequate immunization, while not a physical illness, reflects the lack of preventive health care in this population (Alperstein et al., 1988; Wood et al., 1990; Miller & Lin, 1988). However, the two health conditions most likely to trap people in a state of chronic homelessness are substance abuse disorders and mental illness.
Health problems in these three domains—physical illness, mental illness and substance abuse disorders—are intimately related. For example, surveys of the health status of homeless people demonstrate repeatedly that the single most common disorder is substance abuse. This in turn contributes to a wide range of other health problems resulting from self-neglect and poor hygiene, nutritional deficiencies, trauma, exposure, accidents, victimization, toxic effects of ingested substances (e.g., hepatic cirrhosis due to alcohol) and infections (e.g., bacterial endocarditis, hepatitis and HIV infection due to IV drug use). Studies also demonstrate the poor general health status of severely mentally ill homeless people. They are more prone to neglect personal hygiene and their basic health care needs, and to have poor nutrition. Seriously mentally ill homeless people have been found to be at higher risk for tuberculosis (Sakai et al., 1998) and HIV infections (Susser et al., 1993).
Another example of how many of these problems overlap is in the area of impairment of physical function. Despite their young age (mean age in the mid 30's), half of homeless adults state that they are limited in performing vigorous physical activities (Gelberg, Linn & Mayer-Oakes, 1990). Further, many are limited in moderate physical activities (21 percent), walking several blocks (28 percent), bending, lifting, or stooping (28 percent), type or amount of work (43 percent), or all types of work (29 percent). Functional disability might be due to any acute or chronic physical illness. Just as likely, this impairment might be the result of mental illness. In fact, it is difficult to tease out the differential effects of these two aspects of illness, since they are both multifaceted and both influence one another. For example, if a homeless person experiences physical impairment, this might be due to cardiopulmonary disease, or to the vegetative symptoms of severe depression.
The remainder of this section will address the epidemiology of health problems of people who are homeless. Although there is overlap among the different problems, they will be divided for the sake of clarity into the following categories: acute illnesses; chronic physical conditions; communicable diseases; dental problems; substance abuse disorders; chronic mental illness; and violence. Because of special issues related to gender and age, sections are also included on: women’s health; health of children and teens; and health of the elderly.
About two-thirds of the problems homeless people present to primary health care sites are acute in nature (Wright, 1990). Some of these maladies, especially minor respiratory infections, could easily be self-treated by people in homes, with over-the-counter medications, appropriate nutrition, bedrest and a little bit of medical advice—all of which are inaccessible to those without homes. The three most common acute illnesses that afflict homeless people (Wright, 1990) are usually a direct consequence of the homeless condition:
Exposure to the elements and crowded shelter conditions increases the risk of contracting respiratory infections and the risk of complications. Most of the trauma is directly related to life on the streets. And dermatological problems are frequently due to exposure to the elements, shelter conditions, lack of hygiene facilities, and inappropriate footwear, among other factors. Other acute problems that can also be traced to the homeless condition include infestations (such as lice or scabies), nutritional deficiencies, and acute gastrointestinal disorders.
The other third of the physical health problems of homeless people are chronic problems, such as hypertension, diabetes, gastrointestinal problems, neurological disorders, chronic obstructive pulmonary disease, arthritis and other musculoskeletal problems (Wright, 1990). Many of these illnesses are also common among the housed population, but are made worse by the stress and exposure of homelessness as well as by the lack of access to ongoing treatment. Studies comparing housed and homeless populations have shown that people without homes are more likely to suffer from a chronic health problem (Wright, 1990).
One chronic physical disorder considered to be classically characteristic of the homeless condition is peripheral vascular disease (Scanlan and Brickner, 1990)—venous or arterial deficiencies in the extremities, including such disorders as varicose veins, phlebitis, thrombosis, swollen ankles, cellulitis of the extremities and gangrene. This is primarily due to people being on their feet all day, the lack of opportunities to elevate feet and legs, and often having to sleep in a sitting-up position.
Communicable diseases are of particular concern for two reasons: the potential for rapid spread among people living in crowded shelters or unsanitary conditions; and the health risk to the general public. About one out of every five HCH clients has an infectious or communicable disease (Wright, 1990). Most of these disorders are relatively minor, such as lice or scabies infestations, other skin diseases, etc. However, serious respiratory infections were found in almost four percent, sexually-transmitted disease (STD) in about three percent, and active tuberculosis (TB) infection in about one percent (Wright, 1990). Contagious diseases, such as tuberculosis (Brickner et al., 1985; Wright et al., 1987; Zolopa et al., 1994) and HIV infection (Torres et al., 1990; Zolopa et al., 1994), are more common among homeless people than in the general population.
Five factors contribute to a heightened risk for TB among homeless persons (National Health Care for the Homeless Council, 1994):
As a result of this increased risk, the prevalence of TB infection among homeless adults ranges from 32 percent in San Francisco (Zolopa et al., 1994) to 43 percent in New York (McAdam et al., 1990). The rate of active TB among men in a New York shelter clinic was 6 percent (Zolopa et al., 1994). The rate of positive TB skin tests has been found to be related to duration of homelessness (Zolopa et al., 1994; Gelberg et al., 1997), living in crowded shelters or single-room occupancy hotels (SROs) (McAdam, 1990; Zolopa et al., 1994; Gelberg et al., 1997), area of the city (Gelberg et al., 1997), and injection drug use (Zolopa et al., 1994). The general public is also at risk. A homeless person with undiagnosed pulmonary TB who frequented a neighborhood bar infected 42 percent of the regular customers of that bar (Kline et al., 1995). TB is more difficult to treat in a person who is homeless because of the difficulty of screening, following, and maintaining treatment, and because many have multidrug-resistant organisms (Bernardo, 1985; Brudney and Dobkin, 1991).
The prevalence of HIV infection among the homeless population is also higher than in the housed population. Studies reveal an HIV infection rate of 9 percent among San Francisco's homeless adults (Zolopa et al., 1994), 1.3 percent among African American homeless women in Los Angeles (Nyamathi, 1992), 19 percent among homeless psychiatric patients in a New York City men's shelter (Susser, Valencia and Conover, 1993), 62 percent among homeless men who visited a New York City shelter clinic (Torres et al., 1990), and 5 percent among homeless youth in a New York City shelter clinic (Stricof et al., 1991). Recent research (Smereck and Hockman, 1998) has also shown that rates are higher for homeless people living on the street (19 percent of population studied) than those in other living situations such as shelters (11.2 percent of those studied). Rates also differed by gender and race, with exceptionally high HIV+ rates for on-the-street homeless Hispanic males (29 percent) and females (32 percent) and for on-the-street homeless black females (38 percent).
Another recent study (Somlai et al., 1998) found that different factors were associated with HIV risk levels among homeless men and women. In men, high-risk patterns were associated with negative attitudes toward condom use, low levels of intention to use condoms, high perceived risk of AIDS, and low perceived self-efficacy for avoiding risk. Women at high risk of HIV infection had greater life dissatisfaction; were less optimistic and held more fatalistic views about the future; held more negative condom attitudes; perceived themselves to be at risk; and frequently used alcohol, marijuana, and crack cocaine.
Viral hepatitis has become a major concern to clinicians providing care to homeless persons. The hepatitis C virus (HCV) is now the most common chronic blood-borne infection in the United States (CDC, 1998). Although the incidence of HCV infection is declining in the general population, its prevalence remains high in particular subpopulations, especially those involved in high risk behavior of intravenous drug use and unprotected sex. There currently is no significant body of research on HCV specific to the homeless population, but homeless health care clinicians have been seeing a rapid increase in the number of chronic cases, in part because of increased screening. According to these clinicians, the incidence of HCV infection is higher in health care settings serving a larger proportion of injecting-drug users or HIV-infected individuals (HCH Clinicians’ Network, 1999). “Since HCV-infected persons can remain asymptomatic for 20-30 years, many are unaware of their condition, complicating infection control and prevention of ultimately life-threatening sequelae.” (HCH Clinicians’ Network, 1999)
Due to the high prevalence of intravenous drug use and unprotected sex, homeless youth and adults are at also at great risk for hepatitis B. Little has been published on rates of hepatitis B positivity within homeless populations, but the limited literature notes that homeless adolescents are at high risk (Busen and Beech, 1997; Morey and Friedman, 1993; Wang et al., 1991). Experience suggests that all homeless children, youth, and probably most adults should be immunized against hepatitis B and high-risk persons should be tested for hepatitis B and C infection.
People experiencing homelessness are also at risk for hepatitis A, due to overcrowding in shelters as well as eating out of garbage cans, both of which heighten the risk of fecal-oral spread of this disease. In fact, an outbreak of hepatitis A was found in a shelter in Vienna (Kern et al., 1986).
One of the more overt identifiers of poverty in the United States is poor dental health (Gelberg, Linn & Rosenberg, 1988) and it is one of the major health problems reported by homeless individuals (Mowbray et al., 1986). Ten percent of homeless clinic patients have been found to have poor dental health, a rate thirty-one times that found in the general population (Wright and Weber, 1987). Homeless persons living in the community are one-third as likely as domiciled adults to have obtained dental care in the past year, and consequently are twice as likely to have gross dental decay (57 percent versus 23 percent) (Gelberg, Linn & Rosenberg, 1988). More than half of homeless persons have grossly decayed teeth (Gelberg, Linn & Rosenberg, 1988).
Given this high rate of dental disease, dental care should be an integral part of any health care services package developed for homeless people. Unfortunately, dental care is not always given the significance it deserves within the general health care arena. Some may even think dental care for people who are homeless is a luxury. Yet the impact of dental disease and lost teeth goes beyond the general health implications of infection and pain. Nutrition is affected because people without teeth are severely limited in what they can eat, resulting in fatigue and additional health problems. There is also an important link between the condition of the mouth and teeth and an individual’s self-esteem, with the resulting impact on their emotional health and social interactions. This in turn functionally affects their ability to obtain employment. As a formerly edentulous client at one HCH dental clinic commented after getting a full set of dentures, “It’s hard to get a job if you can’t smile" (McMurray-Avila, 1997).
Epidemiological research consistently demonstrates, and service providers can confirm, the major impact of substance use disorders in homeless populations. Based on clinicians’ reports, Wright (1990) estimated that of people seeking primary health care from HCH programs, 38 percent were alcohol abusers and 13 percent abused other drugs. Surveys of homeless people in general suggest higher rates: the Baltimore Homeless Study (Breakey et al., 1989) produced estimates of rates for alcohol use disorders of 67 percent and 26 percent for men and women respectively and rates of 29 percent and 11 percent for men and women for other drug use disorders. Robertson et al.(1997) found lifetime rates of alcohol use disorders of 71 percent in men and 63 percent in women in Alameda County, California. Rates for other drug use disorders were 53 percent and 51 percent. An examination of numerous studies to date (Koegel, Burnam & Baumohl, 1996) concluded that about half of homeless people studied have had a diagnosable substance abuse disorder at some point in their lives, with a history of alcohol abuse occurring in almost half of single adults who are homeless, and a history of drug abuse in approximately one-third.
| The intoxicants used by homeless people vary from place to place and time to time, following the trends in the wider society. Thus, as the cocaine abuse epidemic increased through the 1980s and 1990s, the amount of cocaine use and abuse in the homeless population increased also. However, in nearly every report, alcohol is still the principal drug of abuse in most places. The drugs of greatest concern in homeless people, from a public health standpoint, are alcohol, heroin and cocaine. Alcohol abuse and dependence are associated with a wide range of health complications involving the liver, the nervous system and the heart. This is in addition to the social deterioration, loss of economic productivity, vulnerability to accidents and victimization that are common outcomes. Heroin dependence, in addition to its social, legal and economic effects on the person, in most cases involves intravenous administration, with the hazards of infections such as bacterial endocarditis, hepatitis and HIV disease which have a major impact on an individual's health and pose major challenges for health care services. Cocaine, when it is administered intravenously, poses similar risks, in addition to the social and mental consequences of its use. |
In the mid-1980s there were several well-designed prevalence studies using standardized diagnostic methods to determine rates of mental illness in homeless populations of major American cities (Institute of Medicine, 1988; Fischer and Breakey, 1991). Research indicates that prevalence rates of specific psychiatric disorders vary in different subgroups of homeless people and from place to place, but a broad consensus emerged that of homeless people residing in shelters, about one third had significant mental illnesses (Koegel, Burnam & Farr, 1988; Breakey et al., 1989; Susser, Struening & Conover, 1989; Smith, North & Spitznagel, 1992, 1993).
Data from the Baltimore Homeless Study (Breakey et al., 1989) are typical: approximately 35 percent of men and 48 percent of women were found to have a major mental illness. Schizophrenia was diagnosed in 9 percent of men and 16 percent of women, and major mood disorders in 17 percent of men and 25 percent of women. Note that these mentally ill people varied in their degree of disability, as do mentally ill people in general. If criteria of extensive histories of inpatient admissions and significant functional impairment are applied, the number who are “severely and persistently” mentally ill is many fewer. It is this group who present the greatest needs for treatment and rehabilitation. They were estimated to represent between 20 and 25 percent of homeless people by Koegel, Burnam & Baumohl (1996). In the Baltimore sample, they comprised 17 percent of men and 24 percent of women (Breakey et al., 1989).
Violence in the lives of homeless persons is a major factor for understanding critical pathways from childhood and adulthood into homelessness (Bassuk, Melnick and Browne, 1998; Kipke et al., 1997; Link et al., 1995; North, Smith and Spitznagel, 1994; Toro et al., 1995). Such violence experienced during childhood and adolescence often continues once individuals become homeless as a result of their lack of protection and personal security. These experiences lead to both acute and chronic health conditions (Gelberg, Linn and Mayer-Oakes, 1990) and potentially affect trust building and subsequent adherence with preventive and ongoing health care (Goodman et al., 1997).
Health services for homeless women are severely lacking (Institute of Medicine, 1988), and yet pregnancy and recent births are risk factors for becoming homeless (Weitzman, 1989). Ninety-five percent of homeless women are sexually active (Nyamathi, 1993), and yet 72 percent do not use birth control (Gelberg & Linn, 1985). Less than 10 percent use condoms, despite lifestyles that place them at great risk for HIV/AIDS and other sexually transmitted diseases (Gelberg & Linn, 1985; Shuler et al., 1995; Brickner et al., 1990). This is evidenced by the fact that 60 percent of homeless family planning clinic users had a history of a sexually transmitted disease (STD), and 28 percent had a history of pelvic inflammatory disease (PID) (Shuler et al., 1995). In addition, more than one-fifth have not had a Pap smear in the past five years (Gelberg & Linn, 1985) compared to less than 9 percent of women in the general population (Hayward et al., 1988). This is alarming given that 23 percent of homeless family planning clinic users had an abnormal Pap smear (Shuler, 1991).
If the homeless condition is unhealthy for people in general, clearly it is even more dangerous for a pregnant woman. Homelessness brings high risks for complications during pregnancy due to lack of prenatal care, poor nutrition, stress and exposure to violence. Normal physiological changes of pregnancy often become pathological, signs of potential complications go unnoticed or unattended, and the minor discomforts of pregnancy are exacerbated by the homeless environment (Killion, 1995). These complications become even more pronounced when the woman is a substance abuser, is mentally ill or is HIV+. Based on studies of women's obstetrical history, 74 percent have had children (Burnam & Koegel, 1989; Shuler et al., 1995) and 54 percent are currently at risk for unintended pregnancy (Shuler et al., 1995). Homeless women are more likely to be pregnant (11 percent of homeless women age 20 and over, and 24 percent of 16- to 19-year-old homeless youth) than their poor but housed peers (five percent) (Chavkin et al., 1987). In addition, they are more likely to receive inadequate prenatal care than poor but housed women (56 percent versus 15 percent) (Chavkin et al., 1987).
It follows that homeless women are more likely than impoverished housed women to have poor birth outcomes (Paterson and Roderick, 1990; Shuler et al., 1995; Weitzman, 1989; Wright and Weber, 1987), with one study showing a difference in low birth weight newborns of 16 percent for homeless mothers versus seven percent for non-homeless mothers (Chavkin et al., 1987). In New York City, infant mortality was highest among homeless women (24.9 per 1,000 live births) as compared to poor housed women (16.6 per 1,000 live births), and non-poor housed women (12.0 per 1,000 live births) (Chavkin et al., 1987). In Great Britain, while homeless women had higher rates of premature births (11 percent vs. seven percent of the general population), their rates of infant mortality were the same as those of housed women (Paterson & Roderick, 1990).
Homelessness puts women at risk for trauma due to violence, often echoing abuse suffered earlier in life. Physical and sexual abuse in family and other interpersonal relationships have been identified as both a cause and a consequence of homelessness in the lives of women (Hagen, 1987; Stoner, 1983). In one study of homeless and poor housed women, 67 percent reported severe physical violence by a childhood caretaker, 43 percent reported childhood sexual molestation, and 63 percent reported severe violence by a male partner (Browne & Bassuk, 1997). Women on the streets are often victims of assault, both physical and sexual. Those who are mentally ill or under the influence of drugs or alcohol are even more vulnerable to attack, and less likely or able to seek help afterwards (Burroughs et al., 1990). Unfortunately, even being in a shelter does not always protect women from violence, especially in large public shelters that also house men. And homeless women who are in relationships are just as likely as housed women to be battered by their partner, becoming victims of domestic violence without the benefit of the “domestic” dwelling (Burroughs et al., 1990).
Homeless children are more likely to suffer from acute health problems, than from chronic conditions. The most common illnesses in children seen by HCH projects are, in approximate order of frequency: minor upper respiratory infections; minor skin infections; ear infections; gastrointestinal problems; trauma; eye disorders; and lice infestations (Wright, 1990). As might be expected in families that move frequently, homeless children are often behind in their immunizations (Wood, 1992). And without easy access to health care services, chronic illnesses such as anemia, asthma and recurrent otitis media often go undiagnosed and untreated. Poverty has been seen to have a significant impact upon children’s health, achievement, and behavior (Brooks-Gunn and Duncan, 1997). The effects of homelessness on normal childhood development have been documented to include academic difficulty (due to missing school) (Eddins, 1993) and behavior problems (Wood, 1992), as well as growth delay (Fierman et al, 1991), developmental delay, anxiety, depression and learning difficulties (Aber et al., 1997; Bassuk, Rubin & Lauriat, 1986; Eddins, 1993).
Homelessness among adolescents is more frequent than is generally realized (Ringwalt et al., 1998). Homeless youth, sometimes known as runaways, throwaways or simply “street kids,” suffer from illnesses directly related to a lifestyle on the streets that is characterized by violence and deprivation (Kennedy et al., 1990; Robertson, 1996). Street youth have often been victims of physical and sexual abuse and family chaos, and have been found to have a greater number of psychological and physical problems than the general adolescent population (Sherman, 1992). Many engage in “survival sex,” exchanging sexual favors for food, clothing or shelter, making them vulnerable to sexually-transmitted diseases, including HIV, as well as unintended pregnancies (Rew, 1996). Health problems most commonly seen by clinics serving this population include (in approximate order of frequency): violent and traumatic injury; substance abuse; sexually-transmitted diseases, including hepatitis and HIV/AIDS; psychiatric disturbances; skin infestations; ignored pregnancies; “unwell” babies; and common chronic illnesses that have been exacerbated by the lack of simple care (Kennedy et al., 1990).
A study of homeless and poor housed youths found that approximately 32 percent had a current mental disorder accompanied by impairment in function, but use of mental health services was low (Buckner and Bassuk, 1997). Psychiatric disorders are likely to be ignored, covered up or denied by adolescents. Their frequent past histories of abuse and neglect, their involvement in antisocial lifestyles and neglect of their education have grave implications for their personality development and maturation into adulthood.
Relatively few homeless people over age 65 are seen in health care sites serving homeless people—only 2.7 percent in 1996 (U.S. Department of Health and Human Services, 1998a). This could be due either to early mortality or to the additional benefits and assistance available once a person reaches 65 (allowing for access to income, housing and health care). Although their numbers are few, “the aged homeless are of special concern because of their vulnerability to victimization while on the streets and in shelters, their frailty due to poor physical health, and the reluctance of community senior centers to accept them as participants” (Ladner, 1992). As would be expected, many of their health problems are chronic conditions associated with aging, such as COPD, PVD, hypertension and heart disease (Blakeney, 1991; Gelberg, Linn & Mayer-Oakes, 1990; O’Connell, Summerfield and Kellogg, 1990 ). The majority suffer from alcoholism, but mental illness is somewhat less common than in the general homeless population (Blakeney, 1991).
Compounding the increased risk for illness or injury, there is evidence that homeless people encounter major obstacles to obtaining needed medical and psychiatric services. The majority of homeless adults state that they did not obtain needed medical care in the previous year (Gelberg and Linn, 1988; Robertson and Cousineau, 1986). Even among those with a chronic medical condition, half had not seen a doctor within the previous year (Robertson, Ropers and Boyer, 1985). Organizations providing services to homeless people have described numerous difficulties in accessing substance abuse treatment for their clients (Williams, 1992).
Since the mid-1980’s, significant advances have been made in the development of effective delivery systems for health services to people who are homeless. The support of several agencies of the U.S. Department of Health and Human Services—often through programs authorized by the Stewart B. McKinney Homeless Assistance Act of 1987—has been instrumental in these advances. The Bureau of Primary Health Care’s Health Care for the Homeless (HCH) program has assisted more than 130 communities in providing comprehensive health services to people who are homeless, with a special focus on developing systems that directly address the barriers to access homeless people face.
Some of these barriers to access are related to external factors such as lack of transportation (Robertson & Cousineau, 1986). Others are internal, for example, denial of existence of a health problem, lack of awareness of available services, or active avoidance due to fear or distrust of large institutions. Because an exhibition of toughness is necessary in order to survive on the streets, homeless persons may at times deny that they have health problems in an attempt to maintain a sense of their own endurance. People with substance abuse disorders or mental illness may deny having a problem or be unaware of the severity of it.
Even when aware of their problem and of available services, many homeless people are distrustful of any offers of help due to previous negative experiences with the health care and social services systems. They may be too embarrassed to have medical professionals see them in a condition of poor personal hygiene. Or they may avoid seeking health care because of the fear of having their meager financial resources taken away to pay for the services they receive, or fear of authority figures (Stark, 1992), including Immigration and Naturalization authorities, child protective service workers (by runaway teenagers and homeless women with children), and police (by drug abusers or ex-convicts) (Jahiel, 1992).
In order to overcome these barriers, health care projects serving homeless people have developed adaptations related to locations of service delivery, with options ranging from mobile to fixed-site services. Mobile approaches—both street outreach and use of mobile units—respond especially well to the barriers mentioned above, finding and engaging people who would otherwise not receive health services. Fixed-site locations include: shelter-based services; community health center or hospital-based clinics with special accommodations for homeless people; and free-standing HCH facilities such as clinics, respite units, drop-in centers or residential programs. Current federally-funded HCH projects tend to use more than one approach, frequently combining street outreach with fixed-site locations in shelters or free-standing clinics (Cousineau et al., 1995).
Another significant obstacle to access relates to times when services are offered. Mainstream services depend on scheduled appointments, which are often hard for homeless people to keep, due to competing priorities for survival, such as finding day labor, a free meal or a shelter bed for the night (Gelberg, Gallagher, Andersen & Koegel, 1997). People who are homeless also lack access to telephones to make appointments or change them if necessary. For this reason, scheduling of services needs to coincide with the most convenient times for the population being targeted, and should not conflict with those times when homeless people are normally searching for a meal or shelter. Many HCH projects set aside certain times for walk-in clinics, while other times are designated for scheduled follow-up appointments with clients who have an established history of care. Outreach schedules need to be even more flexible, often taking place during early morning or evening hours, depending on the population and the setting (McMurray-Avila, 1997).
Lack of financial resources or health insurance and lack of documentation constitute additional access barriers that affect how services need to be structured and delivered. One-fifth of homeless adults who had not obtained needed medical care stated that this was due to inability to pay for medical services (Cohen, Teresi & Holmes, 1988; Robertson & Cousineau, 1986). Only one-sixth (Bassuk, Rubin & Lauriat, 1984; Farr, Koegel & Burnam, 1986; Robertson, Ropers & Boyer, 1985) to one-third (Fischer, Shapiro & Breakey, 1986; Miller & Lin, 1988) of people who are homeless have any form of health insurance, and most have no cash resources at all (Koegel & Gelberg, 1992). One decade after most of these studies were performed, HCH projects still report that over 70 percent of the clients they see have no financial resources for health care (U.S. Department of Health and Human Services, 1998a). Homeless people frequently lack identification or other documentation to prove indigent status in order to qualify for free or reduced services in mainstream health care settings. They often have had their identification documents lost or stolen, or are living in the streets and shelters of the U.S. without legal documentation.
Health care programs for homeless people must therefore tap into every available funding source to eliminate this access barrier. Public funds, through Medicaid and other funding streams, have supported health care for poor and homeless people. As public programs exert pressure to conform to models first developed for managed care in the private sector, effective HCH projects must continue to give priority to responding to the special needs and realities of their clients. At the same time they must strive to address the increased needs for detailed intake, authorization and billing procedures, despite the drain on resources of staff and time. These conflicting priorities may be a source of considerable stress to clinicians and to program administrators. Strict adherence to a business mentality will create frustration for staff and alienation for clients.
Access to services is also affected by language and cultural barriers and by attitudes of providers of care. While a positive, open attitude of being culturally sensitive is necessary, it only becomes cultural competence when it is put into practice. Practicing cultural competence involves a combination of attitude, knowledge and skills (CASSP). An attitude of respect is essential when working with people who are homeless, as well as maintaining an acceptance of cultural differences among people. People from all cultural backgrounds become homeless, so practitioners need to be willing to work with clients of different ethnic minority groups and cultures. Knowledge of the history, traditions, values, and family systems of these cultures is important, especially an understanding of the effects of particular cultures on the help-seeking behaviors of people who are homeless, as well as the specific health beliefs and healing practices of the cultures involved.
In addition to the obvious skill of language competency, skill is also needed to adjust clinical practice to accommodate certain health beliefs and healing practices of different cultures. Cultural beliefs affect attitudes toward disease and health, as well as offering explanations for causes of ill health, including mental illness and substance abuse. What may be labeled “non-compliance” by a health care provider could in reality be due to cultural differences in interpreting the diagnosis and/or treatment.
An additional barrier to access is created when homeless people with histories of disruptive behavior are actually barred from services. Homeless health care providers continually have to assess the nature of disruptive behavior—is the person acting out due to a mental illness beyond his or her control, or is the behavior intentional and meant to do harm? Again a delicate balance must be maintained between flexibility—particularly with regard to examining and changing rules or policies that may be inappropriate for the population in question—and the safety of the client, other clients and the staff. What may sometimes be labeled a shortcoming of the client in terms of being “non-compliant” may actually be a shortcoming of the system of services—non-compliance with the approaches needed to effectively serve the clients.
One final adaptation to service delivery that health care providers must make when working with homeless people relates back to the concept of integrated services discussed in the introduction. Most mainstream health care organizations are primarily single-focused. They either provide medical care, mental health services or substance abuse treatment. Few are organized to deal with the multiple issues that are part of being homeless. When people are treated only for the “presenting problem,” the underlying cause of that problem may not be addressed. Clinical interventions with homeless people are most effective when carried out by multidisciplinary teams (Burness Gleicher et al., 1990). The practice of clinicians from different disciplines working together offers more chance of arriving at appropriate diagnosis and treatment conclusions.
Providers of health care must be aware of all of these potential barriers, making adaptations as necessary and paying special attention to the characteristics of the population they are serving. Designing health services for homeless youths provides a good example of this. Adolescents who are homeless and apart from their families present significant problems for health care because of the difficulty in engaging them, but also because of their frequent reluctance to acknowledge their need. Their status as minors, issues of consent and confidentiality and their distrust of adults provide additional barriers to care (Robertson, 1996) Clinicians working with this group should be well-versed in the usual health needs of adolescents, but particularly prepared to deal with the physical and emotional effects of violence, common and exotic sexually transmitted diseases, pregnancy and mental illness. Kennedy et al. (1990) describe a number of principles in delivery of health care to “street kids.” These include outreach to places where adolescents congregate; immediacy, the ability to respond without delay, because a teenager may not wait or come back again, having once expressed willingness to accept treatment; networking, to provide the needed linkages into a range of helping services; and sanctuary, in terms of privacy and protection. Services should be available in youth shelters, but also on the street, through outreach, because many homeless adolescents do not use shelters (New York State Council on Children and Families, 1984; Robertson, 1996). Health promotion, disease prevention and harm reduction strategies focused on this group are essential.
Based on the broad scope of health problems described above, it is clear that a full array of services must be made available and accessible for people who are homeless. Otherwise, the care can easily revert into “Band-Aid medicine” and miss underlying or co-occurring conditions. The following discussion covers elements of health care encounters common to medical, mental health or substance abuse services, including: intake and assessment; clinical preventive services; diagnosis; referrals for specialty and inpatient care; linkages to non-health services; and follow-up to ensure continuity of care. It is important to remember that the elements may not necessarily occur in this order, or be provided in a typical clinical setting.
A system that features multiple points of entry is termed the “no wrong door” approach. In such a system, a homeless person is offered the opportunity to link with all needed services through the initial contact—whether through a medical or dental program, street outreach, or any point in the continuum of substance abuse or mental health services. To identify needed services, an adequate assessment of health and social problems is necessary, including housing status and access to basic needs (food, clothing, etc.).
In addition to the standard clinical history questions, the intake procedure should pay special attention to the client’s living situation, including questions related to sleeping location, sources of food, support systems (friends or family), history of mental illness, use of alcohol or street drugs, exposure to violence or abuse, cause of homelessness, and plans for getting out of the homeless situation (Usatine et al., 1994). Answers to these questions will help determine the appropriate course of action, regardless of whether the initial encounter involves medical or dental services, mental health or substance abuse problems. Providers of care to homeless people also need to be alert for any possible underlying conditions that could affect the diagnosis, proposed treatment or eventual outcome of each client’s case. It is important to note, however, that the need for a comprehensive assessment must always be weighed against the possibility of alienating or intimidating the person being assessed.
Prevention activities fall into several categories:
Screening. Without overwhelming clients with probing questions unrelated to the stated purpose of their visit, screening for both physical and mental chronic conditions should be included whenever possible, even in acute care visits. Practitioners working with homeless people constantly have to balance the importance of preventive activities (whether screening or promoting behavior change) with the mental or emotional state of their clients, as well as sensitivity to their past experiences with the “system.” In order to engage homeless people in ongoing care it is necessary to avoid alienating them and to focus on establishing trust (Cousineau et al., 1995). However, screening procedures are welcomed by many homeless people (Long et al., 1998) and should be a part of each clinical encounter within a clinical program. Some health care programs for homeless for people have also performed screenings in shelters, soup kitchens and other locations, to identify potentially treatable conditions in people who otherwise might not get clinical care.
Blood pressure screening for hypertension is routine with any physical exam. Homeless people should also be offered TB skin testing (CDC, 1995), while recognizing the likelihood of false negatives with people who are HIV+ (Morrow et al., 1997); routine testing for STDs, including HIV/AIDS; breast, cervical, skin, prostate and colon examinations; screening for glaucoma; and testing for cholesterol levels (Weinreb, 1992). In addition to screening for physical illness, primary care providers also need to be alert for signs of substance abuse and mental illness (Usatine et al., 1994). The CAGE is a simple but effective screening tool for alcoholism (Ewing, 1984). Health care providers must also be trained in routine screening of patients for victimization histories, as well as in the recognition of the physical and mental symptoms and signs of violence among their patients (e.g., injuries and post traumatic stress disorder) (Harris & Landis, 1997; Lam & Rosenheck, 1998; Moy & Sanchez, 1992; North & Smith, 1992; Padgett & Struening, 1992).
Well-Child Exams. Like any other children, homeless children require regular examinations and immunizations. Working with homeless families who have children raises additional screening issues. According to Wood, “Homeless families often cite benign acute problems as the reason for a clinic visit. Each encounter, however, should include a history of preventive health care, developmental problems, school problems, medical problems and past child abuse" (Wood, 1992). Because homeless families experience many problems that could lead to child abuse—including extreme family stress, exposure of the child to multiple caretakers, family violence, and drug or alcohol abuse—clinicians should screen for child abuse (neglect, physical and sexual) in the history and physical examination of every child (Wood, 1992).
All homeless children should receive a PPD skin test for TB annually. Homeless children who are African American should receive a sickle cell screening test. And children with a history of pica or anemia should be screened for lead exposure (Wood, 1992).
Immunizations. Immunizations to prevent diphtheria, tetanus, influenza, pneumococcal pneumonia and hepatitis A and B should be made available to all homeless adults (Weinreb, 1992). Rubella vaccination should be offered to homeless women of childbearing age who are not pregnant and who are antibody negative, and who have no other contraindications for vaccination (Weinreb, 1992). Homeless children should receive the HIB (Haemophilus Influenza B), DPT (Diptheria, Pertussis, Tetanus), OPV (Oral Polio Vaccine), and MMR (Measles, Mumps and Rubella) vaccines according to the routine guidelines of the American Academy of Pediatrics Committee on Infectious Disease (Wood, 1992).
Women’s Health. The importance of preventive care for homeless women (gynecological exams, family planning and perinatal care) is made obvious by the research cited above. McNally and Wood (1992) recommend a comprehensive approach to providing perinatal care and family planning for homeless women, with special emphasis on awareness of potential complications, screening for alcohol/drug use, HIV/AIDS and other STDs, and use of multidisciplinary teams to include outreach and case management, as well as clinical care (McNally & Wood, 1992).
Health Education/Health Promotion. Health education and health promotion to prevent communicable diseases is especially vital in the homeless population, given the increased risk factors, yet the characteristics and lack of resources of homeless people present an unusual challenge to health educators. Many homeless people are preoccupied with their current difficulties and by temperament are not future-oriented. They may find it difficult to make a short term sacrifice for a long term benefit. It is clearly unrealistic to expect people who are homeless to make changes in behavior based only on the knowledge that it’s “bad for their health.” For example, an over-reliance on distribution of printed materials would not be effective with this population. However, provision of resources (such as condoms, bleach kits or syringes) will facilitate the changes of behavior necessary to prevent HIV/AIDS or other STDs.
Self-help approaches, such as those used in mental health self-help agencies (Segal et al., 1998) or12-step programs, are one way to reach people and provide ongoing support for behavior changes. Activities that involve one-to-one personal interaction or group interaction, such as support groups, can be successful, given the isolation many homeless people feel and the need for meaningful human contact (Tsemberis, 1996). The use of “peer educators” in drug abuse prevention with homeless youth (Fors & Jarvis, 1995) and “peer health advisors” to improve compliance with initial clinic visits for homeless adults newly tested positive for TB or HIV (Peterson et al., 1993) are examples of successful and innovative health education approaches that involve the target population directly.
Another avenue to health promotion is through education of other service providers. For example, teaching shelter and meal providers about preparation of healthy meals will probably have more impact on the nutrition of homeless people than giving them brochures on the important food groups. Surveillance of health and safety conditions in shelters and other service sites will help avoid potential accidents and injuries, as well as preventing communicable diseases, such as tuberculosis (Mayo et al., 1996). Health care or shelter staff who work with families also need to be aware of potential child abuse and neglect, armed with strategies from education to incident reporting.
In the practice of diagnosis, three specific accommodations will be mentioned here related to: 1) the clinical exam; 2) recognizing multiple diagnoses; and 3) availability of diagnostic tools such as laboratory testing and radiology.
Clinical Exam. Medical care providers need to be especially sensitive to issues of hygiene when involved in physical exams with people who are homeless. Although some clients, particularly those with severe mental illness, may be oblivious to their unwashed condition, many are quite embarrassed. A high tolerance and understanding on the part of the provider, combined with availability of shower facilities (as well as clean socks and other clothing), will go a long way towards developing an environment in which homeless people can feel comfortable and welcome. This issue continues to stand as a major barrier for homeless people attempting to receive care in mainstream settings.
During the clinical exam, the provider will need to be alert for those conditions which commonly occur as a result of homelessness—upper respiratory tract infections, trauma, skin disorders, musculoskeletal problems and dental disease—regardless of what was presented as the chief complaint. In addition, providers should be on the look-out for common chronic conditions such as hypertension, gastrointestinal and neurological problems, peripheral vascular disease and obstetric/gynecologic conditions (Usatine et al., 1994). Because homeless people frequently have lost glasses or had them broken or stolen, vision should also be checked. Serious vision problems have been reported by nearly one-quarter of people who are homeless (Gelberg & Linn, 1989).
Evaluating Psychiatric Symptoms Requires Sensitivity To Each Person’s Special Situation. There may be a risk of either over-diagnosing or under-diagnosing treatable conditions. For example, suspiciousness in a homeless person does not necessarily indicate paranoia, but may be an understandable consequence of living on the streets. Conversely, low mood and disturbed sleep should not readily be dismissed as normal reactions to bad circumstances; they may be symptoms of a treatable depressive illness.
Recognizing Multiple Diagnoses. Primary care practitioners need to pay special attention to identifying multiple diagnoses, avoiding isolated diagnoses that may miss co-occurring or underlying issues. This is true whether the co-occurring diagnoses are all physical in nature or combine physical, mental health and/or substance abuse diagnoses.
Availability of Diagnostic Tools. Accurate diagnosis often depends on the availability of laboratory testing and radiology. Making these services easily accessible is essential when working with homeless people. In some cases this may include providing transportation to a site where the testing can be performed or x-rays taken.
Successful outcome when working with homeless people depends on more than just accurate diagnosis and quality treatment. Frequently, success hinges on the client’s ability to follow through with the recommended treatment. Care providers face numerous obstacles in supporting this ability and establishing continuity of care. In addition to barriers already listed, additional complicating factors include:
Competing Needs and Priorities. People who are homeless may place a greater priority on fulfilling their basic needs for food, shelter, hygiene, and income than on obtaining needed health services or following through with a prescribed treatment plan (Ball & Havassy, 1984; Gelberg & Linn, 1988; Gelberg, Gallagher, Andersen & Koegel, 1997; Robertson & Cousineau, 1986; Sacks, Phillips & Cappelletty, 1987). Keeping follow-up appointments necessary for continuous, comprehensive care is also difficult for homeless people due to their competing needs and different time orientation (Koegel & Gelberg, 1992). Although we typically think of homeless people as having an inordinate amount of time on their hands, often they must deal with the varied schedules and locations of several service facilities to ensure that all their needs are met (Koegel & Gelberg, 1992).
Mobility. While many homeless persons are long-term residents of their communities, others are quite mobile within or between cities or states in their search for subsistence resources. This mobility makes continuity of care difficult (Brickner et al., 1984; Koegel & Gelberg, 1992).
Difficulty Keeping and Storing Medication/Food.The conditions of street life affect compliance with medical care. There is usually a lack of proper sanitation (Baxter & Hopper, 1981); lack of a stable place to keep medications safe, intact, and refrigerated (Brickner et al., 1984; Wright & Weber, 1987); and an inability to obtain the proper food for a medically indicated diet to deal with conditions such as diabetes mellitus or hypertension (Brickner et al., 1984; Wright & Weber, 1985).
Discharge Planning. Homeless people who have been hospitalized are often discharged directly from the hospital to the streets with inadequate discharge planning to assure conditions for safe recuperation. Even homeless mothers are discharged to the streets with their newborn infants soon after childbirth. Readmission of homeless patients to hospitals is not uncommon (Stark, 1992).
Attitudes of Health Care Providers. People who are homeless may sense from the medical profession a reluctance to treat them due to their poor hygiene or mental illness, or because of assumptions that they come to hospitals for shelter and not for a medical problem (Baxter & Hopper, 1981). Being treated with a lack of respect does not encourage follow-up care or compliance with care.
Respite Care. One of the most valuable activities for promoting continuity of care is the availability of respite care facilities for homeless persons who are not considered sick enough to be hospitalized, but are too sick to stay on the streets. Shelters and streets are often the sites to which homeless patients are discharged from hospitals (Goetcheus et al., 1990; Stark, 1992). Since shelters are usually open only at night, where do ill homeless persons go for rest, nutrition and simple basic care? Convalescent facilities are needed so that homeless persons, after being provided medical, surgical or obstetrical care are not discharged from outpatient settings or hospitals to the streets when their recuperation requires running water, a bed, refrigeration, or proper nutrition (Stark, 1992). Respite care ensures that homeless persons receive care that most others, with homes and families, receive routinely (Goetcheus et al., 1990).
Referrals for Specialty Care and Inpatient Care. Although the focus here has mostly been on primary care and the importance of early intervention, the realities of homelessness often result in illnesses or injuries being left untreated, resulting in numerous complications requiring more specialized attention. Homeless people need easy access to specialty care and hospitalization to deal with these situations. Homeless health care providers work hard to establish relationships with public and private health care institutions to obtain this access. However, providers in those institutions who are not familiar with the homeless population may need support, advice or training from homeless health care providers. In some cases, client advocates from a homeless health care project may need to accompany clients when they are referred to those institutions, to assure appropriate care.
Linkages to Other Services. The comprehensive assessment mentioned earlier provides the foundation for determining what linkages are needed. Establishment of referral relationships with other service providers, and a system of case management to coordinate those services, help assure the effectiveness of care given for physical or mental health problems. Given the negative impact that homelessness has on health and health care outcomes, clearly the most significant difference between treating homeless people and the general population is the need to include elimination of homeless conditions as part of any treatment plan. For this reason, linkages to other services—including transitional or permanent housing—is an essential element of care. (The sections below on services for substance abuse and mental illness will deal with this in more detail.)
In the sections that follow, primary care (medical and dental), treatment for substance use disorders, treatment of serious and persistent mental illnesses and treatment of patients with co-existing mental illness and substance use disorders (the “dually diagnosed”) will be considered in turn.
Clinical protocols for primary care treatment of specific physical illnesses or injuries are frequently the same for homeless people as for the general population. Variations from standard protocol are most often related to improving the possibility of compliance with treatment by taking into consideration complications of the patient’s living situation or co-occurring diagnoses, including multiple physical illnesses, substance abuse or mental illness.
One of the most common changes in treatment is found in prescribing practices that are adjusted to accommodate the homeless environment. For example, medications that can be given in larger doses over a shorter period of time may be more effective (e.g., injections vs. oral medications). People without homes usually have to carry their belongings with them at all times and supplies of medication that must be taken over a long period of time may be lost or stolen. Another alternative is to consider giving the patient just enough medication to last until the next scheduled visit. The promise of receiving medications at a future visit may be an incentive for the patient to return. When possible, once-daily dosing is best (Usatine et al., 1994). Medical and dental providers also need to be sensitive to possible substance abuse issues when prescribing medications. Collaboration with substance abuse staff is essential in order to avoid prescribing narcotics or other medications inappropriately, while still assuring adequate pain management.
The importance of compliance with medication regimens for TB in order to prevent development of multi-drug resistance has resulted in programs of directly-observed therapy (DOT) for clients with active TB and directly-observed preventive therapy (DOPT) for those who have been infected. In both cases, patients are given each dose of medication directly by health care providers, sometimes even if it means finding the patient on the street (Caminero et al., 1996; Chaulk et al., 1995; McAdam et al., 1990; Pablos-Mendez et al., 1997). Incentives have also been used to enhance DOT (Mangura et al., 1997), including monetary incentives (Pilote et al., 1996).
Describing all the possible alternative treatment protocols for every illness or situation would fill up numerous volumes (e.g., see O’Connell & Groth, 1991, for a complete manual of information on common communicable diseases in shelters). Instead we will illustrate some of the problematic situations encountered in treating homeless people by reviewing some of the recommendations clinicians have made for treatment of four common chronic medical conditions and dental health
Hypertension. Fleischman and Farnham (1992) state that the difficulty of follow-up in the homeless population renders impractical the traditional recommendation of multiple blood pressure determinations before treatment for hypertension. Beginning treatment with dietary changes is also futile, since food at shelters and in soup lines is high in sodium and fat. Thresholds for starting drug therapy must be individualized, considering diminished compliance, poor follow-up, and compounding life-style variables, such as alcohol abuse. In homeless alcoholics with hypertension, referral for alcohol detoxification/treatment may be more appropriate than medications for hypertension. Many patients will refuse diuretics because of poor access to bathroom facilities (Pianteri et al., 1990). Proper storage and safe-keeping of pills is an issue, with pills often being lost or stolen. If kept in a pocket, they may be pulverized by the movement of constant walking (Filardo, 1985).
When used, the ideal medication should incorporate the following considerations: once-daily dosing, limited need for laboratory follow-up (i.e., avoid potassium-losing diuretics), and no rebound phenomenon (since poor compliance and lost medications may bring on this complication) (Fleischman & Farnham, 1992). An alternative for homeless hypertensives is the clonidine transdermal patch, which delivers a steady therapeutic level of the medication for seven days (Michael & Brammer, 1988; Pianteri et al., 1990; Popli et al., 1986). (See Vicic & Weber (1992) for additional guidelines for treatment of hypertension in homeless people.)
Diabetes. Tight control of diabetes may be a dangerous goal in homeless persons, because of their unstable eating and activity patterns (Usatine et al., 1994). Teaching a homeless person to use insulin requires frequent follow-up appointments and careful monitoring. Most shelters do not provide clean, accessible and safe storage places for insulin, medications, or blood glucose monitoring devices. In addition, possession of syringes or alcohol swabs on the street or in shelters can make homeless people into targets for theft (Scanlan & Brickner, 1990). Thus, in a homeless adult patient with noninsulin-dependent diabetes, it may be best to avoid insulin therapy by prescribing oral hypoglycemic agents at maximum dosages and tolerate less tight control of serum glucose (Usatine et al., 1994).
Peripheral Vascular Disease. “The most important intervention for peripheral vascular disease is a change in lifestyle. Elevation of legs, at least during sleep, is the key to treatment. A network of shelter referrals for beds (not pews), respite beds, or hotel vouchers may be required if the clinic is to help the homeless client find a place to elevate his or her legs. Bus tokens should be given to limit the need for walking long distances” (Fleischman & Farnham, 1992).
A similar practical approach can be used when addressing any of the orthopedic or podiatric problems of homeless people. More than 10 percent of homeless adults have impaired ability to walk and 60 percent have problems with their feet (Gelberg, Linn & Mayer-Oakes, 1990; Wrenn, 1990). These problems are related to osteoarthritis, common in the general population as well, but also are due to the life conditions that homeless individuals endure. They have to walk throughout the day to obtain their basic needs for shelter, food, and clothing, often in poorly fitting shoes, without socks. Providing well fitting shoes, changes of socks, and a bed to sleep on might seem like small interventions, but can greatly improve a homeless person’s ability to function.
Heart Disease. Treatment of heart disease in homeless adults is quite difficult. Homeless persons may need to be admitted more often to the hospital and at a lower clinical threshold than the domiciled population. For example, controlling sodium intake and enforcing bedrest, mainstays of therapy in the domiciled population, are virtually impossible. Hospitalization is often required to achieve adequate diuresis in a controlled environment where electrolytes can be monitored (Fleischman & Farnham, 1992).
Dental Health. People who are homeless need access to a full array of dental services:
Ideally each individual would be engaged in a comprehensive treatment plan to address all of the dental problems that have built up over the years. Unfortunately, the homeless condition is not always conducive to follow-up with such a long-term venture. Dental staff need to have clear criteria for determining the appropriate level of care to be provided. With a person who is clearly transient and planning to move on, a short-term response such as an extraction may be more appropriate than initiating a full treatment plan. If dentures are needed, a determination needs to be made regarding the ability of the client to care for and maintain them. Setting up a complete treatment plan is most realistic for clients who are more likely to be able to follow through, or who have been stabilized in transitional housing or treatment programs.
Particular consideration also needs to be given to working with people with mental disorders and people who are known to be HIV+. Special accommodations may also be necessary to care for children (McMurray-Avila, 1997).
Treatment Services for Substance Use Disorders
A wide variety of options and treatment models can be used to develop a responsive network of substance abuse services for people who are homeless. A substance abuse services continuum should be designed to meet local needs, consistent with available resources and the special needs of homeless people (Schutt & Garrett, 1992). Barriers to accomplishing this are political, such as the NIMBY response (“Not-In-My-Back-Yard”), or due to the limited resources available from public and private funding agencies.
In general, the development of services for homeless addicts has lagged behind the development of primary health care services and services for treating mental illness. To address this lack, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) supported two rounds of community demonstration projects with funding from the Stewart B. McKinney Homeless Assistance Act to identify effective approaches for providing substance abuse treatment to homeless people (Argeriou & McCarty, 1990; Conrad, Hultman & Lyons, 1993). The following general conclusions were drawn regarding necessary and desirable program characteristics (Stahler, 1995):
Although the dynamics, demographics and legal implications of addictions to different substances may vary, the principles of treatment are the same: motivation of the person to stop using the substance, detoxification to support the person through the withdrawal process, and rehabilitation to maintain sobriety through a process of recovery. Homeless persons have particular needs at each of these stages, however it is important to recognize that these are not necessarily linear stages. Engaging a homeless person in the recovery process is a long-term undertaking, marked by numerous relapses and fluid movement in and out of stages.
Motivating the addicted person to recognize his or her need for treatment may be the most difficult. Street outreach workers, police officers, social workers, emergency medical staff and primary health care workers in individual cases have important roles in persuading a homeless individual to seek treatment. Outreach is particularly important because of the reluctance of many homeless people to seek treatment on their own behalf. Initiating contact with homeless substance abusers on the street, in shelters, drop-in centers, soup kitchens, etc., provides information about available services and begins the motivation and engagement of the person into the system of services. Effective outreach workers are often formerly homeless substance abusers who understand the situations and dilemmas of homeless people and can provide support and encouragement, drawing on their own experiences. For homeless people the likelihood of relapse, discouragement and fatalism is great for both patient and treatment provider. It is part of the outreach function to instill hope in the addict that recovery is possible. Sobering-up stations provide another form of outreach. In these small facilities, a clean sanitary, safe and supportive environment is provided to homeless substance abusers who may not yet be ready to contemplate detoxification. They are often staffed by individuals who are themselves recovering addicts. For a proportion of the users of the station it provides a first step in a recovery process.
Detoxification is technically the simplest phase of treatment, although not always the most readily available. It requires a setting where the person can go through withdrawal with the necessary support to tolerate the unpleasant and sometimes dangerous withdrawal syndromes. Medical detoxification involves prescribing medications to protect the patient from the withdrawal symptoms and complications. It is most commonly done in a residential or inpatient setting, but can be done in an ambulatory program if adequate support can be provided for the patient. Social model detoxification avoids use of medications if possible and relies on mutual support, social learning and the 12-step principles of AA/NA. Social model programs are less expensive to run than medical detoxification programs and reported to be equally safe for their clients (Whitfield et al., 1978; Lapham et al., 1996).
Once detoxification has been accomplished on a residential or ambulatory basis, a long process of rehabilitation is required. During this period the person needs protection from his or her tendency to relapse, provided through peer and professional support and appropriate supportive living situations. The individual needs opportunities for acquisition of new skills for everyday living, relationships and employment and the establishment of a drug-free lifestyle. This phase of treatment is the most time-consuming, most costly and least likely to be available and accessible for homeless people.
Elements of treatment may include individual or group counseling and education to help clients define their needs, understand their addiction(s) and develop their treatment plan. Case management is particularly valuable for homeless people in recovery to assist them in coordinating and negotiating the often fragmented systems of care that exist. Case managers can help identify resources, acquire medical or dental health care services, etc. Sometimes several elements such as counseling, education, case management, group work, etc. may be combined into an intensive day treatment program for people who have stable arrangements for where they will stay at night.
Although many communities have moved toward outpatient treatment to save costs, people without homes are less likely to benefit from such a program. Treatment and rehabilitation are unlikely to be effective as long as the person lives on the streets or in the general shelter system where the daily pressure to use drugs or drink remains high. A range of appropriate opportunities for supportive housing must therefore be available (NIAAA, 1991a; NIAAA, 1991b; Wittman & Madden, 1988). Residential recovery programs can be designed for the different stages of recovery, including detoxification, primary treatment or as a half-way house or quarterway house. Recovery houses can be based on a social model design where residents are responsible for running the house or on a therapeutic model with greater staff involvement. For some homeless people in recovery, a group home or adult foster care arrangement may be appropriate. Sober housing—housing that is alcohol/drug-free—is an essential follow-up to the treatment process. Months of hard work in treatment and recovery can be lost if the client must then return to the streets. Sober housing may include supportive services or simply be a transitional stage to independent housing in the community.
Throughout the entire process of recovery, peer group support is of great importance, usually provided by groups such as Alcoholics Anonymous or Narcotics Anonymous, that provide both a theoretical model for the process of recovery and the emotional support of other addicts. Groups exist in every city and meetings occur every day of the week.
Total abstinence has traditionally been the goal of substance abuse services, but in many cases, addicts are unwilling or unable to contemplate abstinence. Strategies for harm reduction serve to reduce the risk of complications or other adverse effects until such time as the person is willing and able to enter the recovery process (Marlatt, Somers & Tapert, 1993; Marlatt et al., 1997). Thus methadone maintenance programs provide a substitute for heroin on a daily basis, with the aim of enabling the person to avoid drug dealing and other crimes, and also to avoid some of the other health hazards of street drug use. Needle exchange programs for IV drug users are effective in reducing the incidence of blood-borne infections such as Hepatitis B or C and HIV, but are not legal in all states. Many programs also make bleach kits available to IV drug users so that they can perform a rudimentary sterilization of their syringes and needles.
As a low-demand approach to keeping people safe and alive until they are ready for treatment, wet housing allows residents to drink in their room, while damp housing does not allow drinking on-site, but does allow for relapses. Wet shelters, similarly, provide shelter for alcoholics who can not contemplate abstinence, and thus enable them to avoid some of the dangers of street life while permitting them to continue drinking. Homeless health care providers can make use of all these harm reduction techniques to support and assist those clients who are not yet willing or able to enter a treatment process of detoxification and rehabilitation.
Treatment Services for Serious and Persistent Mental Illnesses
Within the broad scope of mental health, many disorders can be diagnosed by the primary care practitioner (Slavney, 1998) and in many cases treated effectively, with or without the assistance of a therapist or counselor or support group. This is particularly so in relation to the depression and anxiety that are the natural and understandable accompaniments of life on the streets. Health care projects can also expand their clients’ access to therapy by linking with other agencies that offer specialized counseling, including rape crisis services, domestic violence programs, and programs for veterans.
The treatment of major mental illnesses in adults requires expertise that in general can only be provided by a team of professionals including a psychiatrist. Illnesses in this category include major affective disorders, including recurrent major depression and bipolar disorder, schizophrenia and related paranoid disorders, severe personality disorders and dementia. Nevertheless in some situations primary care practitioners may find themselves where psychiatric consultation is not available, or a patient is unwilling to accept a referral. There may be no local community mental health centers or they may not be responsive to the needs of homeless people. In this situation the clinician should be able to provide at least basic pharmacological treatment for a mental illness and possibly enlist the assistance of a social worker or other colleagues or agencies to attempt to address some of the person’s other needs.
Psychiatric specialists may also be called upon to assist in diagnosing disorders associated with physical illness, although the primary treatment responsibility remains with the general physician (e.g., delirium associated with liver failure) (Slavney, 1998). It is important, therefore, that primary care practitioners have the needed knowledge and skill to make this diagnostic distinction and have access to psychiatric consultation when needed.
Services for homeless people with serious mental illnesses are distinct from psychiatric services for other low-income people in that they have two principal goals: remission of the illness and resolution of the person’s homelessness. Services for homeless people are also distinctive in that they must take into account the patients’ transience, the hardship of their living circumstances, their distrust of formal service systems, their lack of effective social supports, and their extreme poverty (Fischer, Colson & Susser, 1996).
Essential Elements of a Responsive Service System. The Federal Task Force on Homelessness and Severe Mental Illness, in a 1992 report, Outcasts on Main Street (Federal Task Force on Homelessness, 1992), recommended the following essential elements of a system that would be responsive to homeless people with severe mental illness:
In each area, clinicians and other professionals working with homeless people must team together through alliances, cooperative agreements and coalitions to provide the array of services in the form best suited for their local situation, culture and available resources.
Treatment Process. There are four principal stages in providing psychiatric services for homeless people (Breakey and Thompson, 1997):
Engagement. Homeless mentally ill people often do not want the treatment that they badly need. Primary care practitioners, shelter workers and others may have vital roles in gently persuading patients to accept help. Outreach teams are vital. They may either work to motivate the person to come in to a treatment center, or may bring the treatment resources to the homeless person “on the street.”. Outreach workers go to shelters and soup kitchens, to the streets and alleys, parks and railroad stations (Susser, Valencia & Goldfinger, 1992). In some cases outreach may be life saving, where individuals risk death or injury through exposure. The process of engagement, however, is often slow and outreach workers must be prepared to devote many hours over many weeks or months on occasion, using much creativity, to establish trust and rapport. Outreach is an ideal staff role for formerly homeless people, whose knowledge of the territory and ability to establish rapport with homeless people is frequently superior to that of most professionals (Van Tosh, 1993).
Basic Service Provision. Shelter, food, income support, clothing, and general health care will be needed in most cases, in addition to whatever psychiatric treatment may be indicated. It is unrealistic to expect homeless people to participate in treatment programs until their basic survival needs have been met. Coordinating the various social and health agencies is frequently a major problem; case management has come to be the major strategy employed. (Billig & Levinson, 1987; Goering & Wasylenki, 1996; Swayze, 1992).
Clinical mental health services needed for homeless people cover the full range of services generally provided by a community mental health center: diagnosis and evaluation, pharmacological and psychotherapeutic treatments, and linkage to inpatient services when needed. Treatment teams need to have the skills necessary to understand and treat some of the most difficult cases they are likely to encounter in clinical practice. Empathic approaches are needed to gain the cooperation of people who may have had bad experiences with treatment or its side-effects in the past, as is respect for the individuality and integrity of each person.
Sophistication in psychopharmacology is essential. Homeless people may be more intolerant of side-effects of medications than many other patients. Drowsiness, neuromuscular abnormalities or diminished alertness may expose a person to increased risk of victimization. A psychiatrist must be careful to avoid such problems for patients while getting maximum therapeutic benefit. Effective medications with potential for hazardous side effects may have to be avoided if patients are not able to have blood tests at regular intervals. Oral medications may be lost, so that long-acting injectable preparations are preferable where feasible. Some medications with street resale value will have to be avoided. In some cases arrangements can be made for shelter staff or others to act as custodians of a person’s medications.
Transition and Integration. Community mental health programs understand that their patients with severe and persistent mental illnesses in all probability will require treatment for life. On the other hand, programs for homeless people can not, by definition, provide indefinite care for people. Once a person has been engaged, and basic service needs met, he or she must be moved into the mainstream mental health service system. Homeless health care programs should work at developing collaborative professional relationships and establishing linkages to community mental health programs in their areas. There are many instances where the homeless health care program, with its special expertise, can be of assistance to staff of the mental health center, just as there are instances where the homeless program staff will look to the mental health center for long term support and treatment of their clients. To facilitate transition the therapist in the homeless program may continue to work with the person after they become settled in a home. A special model for this approach has been described “Critical Time Intervention” (Susser et al., 1997).
Transitioning care into the mainstream system may prove extremely difficult or impossible in some cases or situations, creating a dilemma for the homeless program. Either the mainstream system may not be receptive, or the patient may not want to make the transition from a clinical situation he or she feels comfortable with, to one that is unknown. In the latter case, the clinical team must work though this difficulty with the patient explicitly, perhaps emphasizing the fact that other people may need to have access to the benefits he or she has enjoyed. Where the mainstream system is unreceptive, the only solutions are personal bridge-building and political advocacy at whatever level is necessary to compel the system to respond to the needs of all citizens.
Housing Stabilization. Treatment of severe mental illness is difficult or impossible until the person has some measure of stability in his or her housing. Initially, some type of emergency shelter must be found until resources are obtained to provide a transitional housing arrangement and, in due course, more permanent housing. Many individuals with severe psychiatric disabilities need much support in coping with even the simple tasks of everyday living, so supervision and case management support will be needed. Some emergency shelters are able to provide this level of support. Supervised group homes may be of value for some clients, but many are solitary individuals who prefer to be on their own. Single room occupancy (SRO) hotels may be ideal for such people, provided that they meet acceptable standards and provide needed support services. Safe Havens provide safe environments and basic needs with low demand on adherence to rules or participation in treatment (Federal Task Force, 1992). The Department of Housing and Urban Development’s Section 8 housing subsidies have been demonstrated to increase the likelihood that mentally ill formerly homeless people will remain housed (Hough et al., 1997). Another HUD program, Shelter Plus Care, provides housing subsidies linked to treatment and case management.
Service Integration. The treatment process described above requires that patients have access to a full range of treatment, rehabilitative and support services, including needs assessment, diagnosis and treatment planning, medication management, counseling and supportive therapy, hospitalization and inpatient care, 24-hour crisis-response services, rehabilitation and social skills training, income support, housing and case management. Categorical federal and other governmental funding, as well as the structure of human service organizations at the local level, have long been the source of service fragmentation which interferes with the smooth and coordinated provision of this complex array of services. A series of recent initiatives have therefore focused on the provision of comprehensive services. Beginning in the early 1990s, the Center for Mental Health Services (Substance Abuse and Mental Health Services Administration) funded the Projects for Assistance in Transition from Homelessness (PATH) Program, which has been successful in providing outreach and case management to homeless mentally ill individuals. To test a variety of services integration strategies, the Center for Mental Health Services subsequently awarded ACCESS (Access to Community Care and Effective Services and Supports) grants to nine states. These strategies range from an innovative voucher system to co-location of services, cross-training of staff, and the use of interagency, multidisciplinary treatment (Calloway & Morrisey, 1998; Randolph et al., 1997; Rosenheck et al., 1998).
At the clinical level, the use of interdisciplinary teams to provide coordinated care is best exemplified by the Assertive Community Treatment (ACT) model, which has been extensively evaluated and found effective for domiciled individuals with serious and persistent mental illnesses (Burns and Santos, 1995; Olfson, 1990; Primm, 1996). This approach has also been found effective for work with homeless people. Mobile teams consisting of clinicians, case managers and advocates, accessible to patients 24 hours per day and 7 days per week provide long term care and are prepared to work with the person in whatever is the most appropriate setting (Dixon et al.,1997; Lehman et al., 1997)
The National Institute for Mental Health and the Center for Mental Health Services sponsored a series of research demonstration projects in five cities in the 1990s. This series of experiments tested a variety of strategies for case management, transition out of shelters, rehabilitation and housing integration, and demonstrated that with appropriate methods, such as those listed above, 80 percent of seriously mentally ill homeless people can be assisted to remain satisfactorily housed in the community (Shern et al., 1997; Thompson and Breakey, 1997).
People who suffer both from a major mental illness and a substance use disorder pose major challenges to developing services that will successfully address both types of disorder. Their treatment is particularly problematic because of the historic separation between addiction and mental health services, which extends as far as the federal agencies concerned. Bringing together resources and treatment philosophies in the service of a particular patient has proved difficult, but the current professional opinion is that integrated treatment and rehabilitation approaches are most effective and model treatment programs provide substance abuse and mental illness treatment simultaneously (Minkoff & Drake, 1991).
In homeless persons, the prevalence of substance use disorders in mentally ill persons is at least as high as in those without mental illnesses. Estimates are fairly consistent that between 10 percent and 25 percent of homeless people have dual diagnoses (Breakey et al., 1989, Koegel & Burnam,1988; Tessler & Dennis, 1989).
The Center for Mental Health Services and the Center for Substance Abuse Treatment sponsored a Collaborative Demonstration Program at 16 sites for services for dually diagnosed homeless people. The report of this program defines five critical client characteristics that influence program design:
Major interventions employed by the 19 programs were similar to those that have been employed for other homeless subgroups: outreach, case management, detoxification, day treatment, residential treatment and system-wide coordination.
The initiative clearly established the importance of collaboration between professionals in the substance abuse and mental illness fields to provide integrated services for this particularly vulnerable group who constitute a significant segment of the homeless population (Winarski & Dubus, 1996). Ideally treatment for substance abuse and mental illness should be provided simultaneously in the same facility. Where this is not possible, close referral agreements should be established so that the maximum level of coordination can be attained.
Despite the tremendous amount of knowledge and experience that has been gained over the past decade in adapting clinical practice to the needs of homeless people, there is still much to be learned, as well as numerous threats that challenge the successful continuation of this work. Recommendations to address research and policy that will strengthen our knowledge and diminish the threats follow:
Continue to Support Increased Funding for Integrated Health Programs
Advances have been made in primary care, mental health and substance abuse services for homeless people, only to be set back by the inability to maintain effective models. Demonstration projects need the option of ongoing funding, if the program proves to be successful. Funding is also needed to expand into areas now recognized as vital for improving and maintaining health, such as dental services, respite care during convalescence, and integration of housing into mental health and substance abuse programs. This is especially relevant in an environment of increasing need and decreased capacity to meet that need (O’Connell, Lozier and Gingles, 1997).
Work For Universal Health Care Coverage to Eliminate the Negative Impact of Market Influences on Delivery of Health Care
The rush by many health care organizations to stay afloat by increasing Medicaid revenue has resulted in loss of access to services for uninsured homeless people. Even for those who do have insurance, conversion of Medicaid to a managed care system has made access more problematic. It is interesting to note in the discussion of clinical treatment above that the recommendations frequently include a lower threshold for initiating treatment or hospitalization, necessity of frequent follow-up visits (sometimes daily), use of alternative medications which may be more expensive (e.g., once-daily dosing), divergence from strict protocols, flexibility in service location and easy access to a wide range of integrated services, including specialty care. In other words, the kinds of adaptations to clinical care needed by homeless people are in many cases the very practices that managed care discourages. Wunsch (1998) summarizes the challenges of involving homeless people in managed care:
Develop a Federally-Funded Substance Abuse Program Targeted to Homeless People
As a society, we continue to deny the vast extent of the pathology and social dislocation attributable to alcohol and drugs (Wilhite, 1992). The impact of substance abuse in causing and perpetuating homelessness cannot be adequately addressed without significant additional resources. Existing community resources are not sufficient—and often not appropriate—to meet the needs of homeless people with substance abuse disorders, especially those with co-occurring mental illness.
Develop Effective Methodologies to Collect and Analyze Cost and Outcome Data.
Data on health care utilization, cost and outcomes have not been collected and analyzed for homeless people as a group, undermining the ability of states to effectively serve them through managed care arrangements (Wunsch, 1998). There is a consensus in the field that more information is needed on costs of caring for homeless people, as well as which practices result in the best outcomes for which types of people who are homeless. The BPHC initiative on outcomes mentioned earlier is one potential source for developing approaches to measuring outcomes (U.S. Department of Human Services, 1996). Although little has been done in the difficult arena of accurately determining costs of care, there is evidence of the cost of not providing the care that results in expensive hospitalization (Salit et al., 1998).
Improve Dissemination to the Field of Results of Research and Practice
Additional research will not be useful without better strategies for incorporating research findings into actual practice in the field. Health care is a rapidly changing and evolving field, with new technologies, medications and treatment approaches being developed constantly. Not only do new practices need to be tested for relevance with people who are homeless, mechanisms need to be developed to assure that homeless health practitioners receive that information in a format that is useful and practical, including a method to provide feedback and engage in ongoing dialogue with researchers.
Increase Training for Recruitment and Retention of Skilled Practitioners
Committed practitioners who are skilled in working with homeless people and willing to accept the difficulties of the work are scarce. There is a need to continue training for providers already in the field—both to continually improve quality and stay abreast of current practices, as well as to enhance retention by preventing burnout. New practitioners also need to be trained. The reform in medical education toward a more humanistic primary care model will hopefully result in the creation of a cadre of medical providers who are trained to care for vulnerable populations such as people without homes.
More mental health professionals are also needed in health care programs treating homeless persons. Their training should include placement in community-based health programs so that they can learn to work hand-in-hand with generalist physicians in treating the intertwined physical and mental health problems of homeless people. Since a great deal of care is also provided to homeless people in emergency rooms, all medical and surgical trainees in medical school, residency, and fellowship programs must be trained to develop an appreciation for their patients' housing and poverty status, and victimization history.
Unless they are resolved, all of the above factors—inadequate funding to fully implement the integrated approach to homeless health care, impact of market-driven managed care, lack of funding for accessible and appropriate substance abuse treatment, limited cost and outcome data, the disconnect between research and practice, and the scarcity of skilled practitioners willing to serve this population—threaten the survival of the unique integrated approach to care that has evolved to treat the health of homeless people. Until such time as there is universal health care coverage and adequate housing for all, people experiencing homelessness will need access to a health care system designed specifically to respond to their unique needs.
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