II. Definitions
- Homeless Person
- Individual without permanent housing, lacking a fixed, regular and adequate nighttime residence for sleeping
- U.S. Federal Law includes individuals and families pending imminent loss of housing without replacement
- Also includes those living in dangerous, life threatening situations (e.g. Intimate Partner Violence)
- Chronic Homelessness
- Continuous Homelessness for at least 1 year, or 4 or more homeless episodes in the prior 3 years
- Transient shelter
- No shelter in one third of homeless cases
- Living in vehicle or abandoned building
- Living in shelter or mission
- Living in constantly changing housing (e.g. moving between various family or friend's homes)
III. Epidemiology
- Prevalence: 3 million in U.S. (1% of population) per year (0.6 Million on any given night in U.S.)
- At risk for Homelessness in case of single catastrophic event (no reserve): 46 Million in U.S. (14% of population)
- Roughly three quarters of Homeless Persons in U.S. are over age 25 years, and 60% are male
- Up to 10% of teens have experienced at least one episode of Homelessness (with 20-40% identifying as LGBTQ)
- Roughly half of Homeless Persons in U.S. are white, and the remainder are black, hispanic and native american or pacific islander
- Homelessness lasts for days to weeks in most cases
- Families represent one third of cases
- Housing instability is also associated with food insecurity and social isolation
IV. Risk Factors
- Unstable job or Low wage
- Low income households use >50% of their income toward housing costs
- Low cost housing is typically well above federal minimum wage in U.S.
- Black and Hispanic patients
- Less access to low cost housing
-
Veteran status (8-13% of homeless on most nights)
- Associated with higher rates of rape and Intimate Partner Violence (esp. female Veterans)
- Higher rates of mental illness (e.g. PTSD, Eating Disorders), Traumatic Brain Injury and Substance Abuse
- Mental illness
- Physical Disability
- Inadequate access to affordable housing
- Inadequate access to affordable health care
- Inadequate to public assistance
- Alcohol Abuse
- Substance Abuse
- Domestic Violence
- Criminal behavior or prior incarceration
- Foster Care history or adverse childhood events
- Refugee (1% lifetime Prevalence)
V. History: VA Screening Tool
- In the past 2 months, have you been living in stable housing that you own, rent or stay in as part of a household?
- Are you worried that in the next 2 months you may not have stable housing that you own, rent or stay in as part of a household?
- Byrne (2015) Public Health Rep 130(6): 684-92 [PubMed]
VI. Associated Conditions: Children
- Asthma (as well as Atopic Dermatitis and severe allergies)
- Dental Caries
- Skin Infestations
- Iron Deficiency Anemia
- Lead Poisoning
- Growth Delay (and nutritional deficiencies)
- Developmental Delay
- Learning Disorder
- Childhood Depression (and increased Suicidality risk, esp. LGBTQ)
- Childhood Anxiety
- Behavioral Disorders
- Child Abuse (including emotional abuse, and exposure to household Violence, substance use)
VII. Associated Conditions: Adults
- Domestic Abuse (including sexual abuse, rape)
- Specific Concerns in Women
- Sexual Violence is associated with immediate Homelessness cause in 55%
- Young adult women (age 18 to 25 years) are pregnant or are accompanied by a child in 44% of cases
- Two thirds of pregnancies are unintended and at increased risk of Preterm Labor and low birth weight
- Older women (age >50 years) are increasing in Homelessness rates, and are at higher risk of medical complications
- Mental Illness (30-50% of patients)
- Schizophrenia
- Bipolar Disorder
- Major Depression
- Anxiety Disorder
- Post-Traumatic Stress Disorder
- Suicidality is common (especially <30 years old, LGBTQ, hispanic, longer Homelessness duration, lower educational level)
- Alcohol Abuse or Substance Abuse (20-30% of patients)
- Tobacco Abuse in 70% of Homeless Persons
- Infectious Disease
- Sexually Transmitted Disease
- Tuberculosis (up to 50 fold higher risk in Homeless Persons)
- Lice Infestation (risk of Bartonella infection such as Trench Fever, endocarditis)
- Scabies
- Foot infections, wounds and related disorders
- Cellulitis
- Pneumonia
- Uncontrolled or premature chronic disease
- Coronary Artery Disease and other cardiovascular disease is the leading cause of death among Homeless Persons
- Diabetes Mellitus
- Complicated by food insecurity, medication storage, hygiene
- Uncontrolled Hypertension
- Uncontrolled Hyperlipidemia
- Peripheral Vascular Disease
- Chronic Obstructive Pulmonary Disease (COPD)
- Cancer risk (due to lack of routine cancer screening)
- Exposure related conditions
VIII. Labs: Infectious Disease Screening
- HBsAg
- xHCV Antibody
- HIV Test
- RPR (Syphilis Test)
- Tuberculosis (use IGRA for screening)
IX. Management
- Establish rapport with patient and family
- Provide accepting environment
- Establish trust
- Trauma Informed Care
- Evaluate for significant health conditions
- See Associated Conditions above
- Develop evaluation and management plan
- Emergency contact
- Establish multidisciplinary approach to care
- Primary care
- Mental Health
- Social worker or case manager
- Future lab testing and other appointments
- Medications
- Follow-up plan
- Other topics
- Maintaining adequate hygiene esp. feet (clean socks, properly fitting shoes, medicated foot powders)
- Environmental Protection (Warm clothing, shelter from heat, clean water supply)
- Precautions: Medications
- Prescribe medications with understanding that they may lack adequate storage
- Lack of cool, dry or refrigerated storage
- Lack of privacy or security to administer and store medications
- Simplify medication administration (e.g. once daily oral medications)
- Avoid medications with risk of rebound if stopped
- Avoid medications which predispose to Heat Illness or Dehydration, or frequent toilet use
- Avoid medications that may potentiate Drug Abuse habit
- See Drugs of Abuse
- Prescribe medications with understanding that they may lack adequate storage
X. Prevention
- Preventive Health (e.g. Mammography, Pap Smears)
- Prenatal Care
- Longterm Contraception
- Screen and treat for Latent Tuberculosis
- Shelters may offer Tuberculosis Screening
- Directly observed 12 week protocol (Isoniazid and Rifapentine) with Liver Function Test monitoring
-
Immunizations
- Tetanus Vaccine (Tdap or Td) every 10 years
- Influenza Vaccine
- Covid Vaccine
- Pneumococcal Vaccine (if indicated)
- Hepatitis B Vaccine
- Hepatitis A Vaccine
- Human Papilloma Virus Vaccine (Gardasil)
- Prevent Injury (esp. in Disability, Seizure Disorder, Violence exposure)
- Traumatic Brain Injury (5 fold higher risk in Homeless Persons)
- Intimate Partner Violence
XI. Complications
- Adult Relative Risks
- Illness: 6x
- Hospitalization: 4x
- Early mortality (<52 years old): 3-4x
- Traumatic Head Injury: 5x
- Childhood Relative Risks
- Mortality under age 1 year: 9x
- Illness: 4x
- Delayed development: 4x
- Delayed Growth: 6x
- Learning Disorders: 2x
XII. Resources
- Health Care for the Homeless
- SAMHSA Homelessness Resource Center
- Association of Clinicians for the Underserved
- National Center on Family Homelessness
- National Health Care for the Homeless Council
- U.S. Dept of VA - Veteran Homeless Initiative
- Homeless and Housing Resource Center
- Homeless Shelter Directory
- Salvation Army Shelter Listing