The U.S. Department of Housing and Urban Development (HUD) defines someone as chronically homeless if he or she is homeless now, has one or more disabling conditions and has been homeless continuously for a year or more or has had four or more homeless episodes in the previous three years.2 This definition applied only to single adults through 2009, when the Homeless Emergency Assistance and Rapid Transition to Housing Act extended it to include families with a parent who meets the same criteria.3
Many people experiencing chronic homelessness have been on the streets or in shelters for years. They often have complex physical, mental, and substance use conditions that can only be ameliorated if they have a safe, stable, and secure living environment. Their homelessness may exacerbate health difficulties, making it increasingly unlikely that they can get back into housing on their own. Many people who experience chronic homelessness are not effectively engaged in treatment or ongoing care for their chronic health conditions, mental health or substance use disorders. They may be distrustful of treatment systems or mainstream health care providers, and they may find it difficult to access care or participate in treatment programs because they are focused on meeting other priorities such as finding food or shelter.
Further, many people who experience chronic homelessness make frequent and avoidable use of emergency rooms and inpatient hospital treatment.4 This use of expensive crisis public services has been a major motivator for developing PSH, which has been shown to help tenants reduce inappropriate use of services. The supportive services offered in PSH can help tenants access more appropriate primary care and treatment, learn or restore coping and independent living skills that have been impaired by disability, and avoid actions or resolve problems that could cause them to lose their housing again and return to homelessness and previous expensive patterns of crisis health service use.
From a Medicaid point of view, a key distinction within the chronically homeless population and those now living in PSH is whether or not a person has serious mental illnesses (SMI).5 Many Medicaid state plans make a wide array of mental health services available to people who qualify to receive these services by reason of SMI, while offering a less-intensive set of behavioral health services to those who do not. Most people with SMI who are or have been chronically homeless also have co-occurring substance use disorders and/or chronic medical conditions.6
Among chronically homeless people who do not have a SMI, disabling health conditions often include chronic conditions such as hypertension or heart disease, substance use disorders, mobility impairments, cognitive impairments including traumatic brain injury, developmental disabilities, and mental health disorders such as depression, anxiety, or trauma that do not meet the criteria for SMI.
Individuals experiencing chronic homelessness are getting older. Researchers have identified a cohort of people now in their late 50s who face the highest risk of continuing homelessness.7 In 2012, approximately 29 percent of individuals who stayed in homeless shelters or transitional housing programs were over age 50.8 In Los Angeles, more than one in three people experiencing chronic homelessness in 2011 (34 percent) was age 55 or older.9 As a result, the rates of age-related chronic health conditions and risks of mortality are increasing for this group. People experiencing homelessness who are age 65 or older are usually eligible for both Medicare and Medicaid.