Health Care of the Homeless


Health Care of the Homeless, Homeless Person, Homelessness, Homeless Health Concerns

  • Definitions
  1. Homeless Person
    1. Individual without permanent housing, lacking a fixed, regular and adequate nighttime residence for sleeping
    2. U.S. Federal Law includes individuals and families pending imminent loss of housing without replacement
    3. Also includes those living in dangerous, life threatening situations (e.g. Intimate Partner Violence)
  2. Chronic Homelessness
    1. Continuous Homelessness for at least 1 year, or 4 or more homeless episodes in the prior 3 years
  3. Transient shelter
    1. No shelter in one third of homeless cases
    2. Living in vehicle or abandoned building
    3. Living in shelter or mission
    4. Living in constantly changing housing (e.g. moving between various family or friend's homes)
  • Epidemiology
  1. Prevalence: 3 million in U.S. (1% of population) per year (0.6 Million on any given night in U.S.)
  2. At risk for Homelessness in case of single catastrophic event (no reserve): 46 Million in U.S. (14% of population)
  3. Roughly three quarters of Homeless Persons in U.S. are over age 25 years, and 60% are male
  4. Up to 10% of teens have experienced at least one episode of Homelessness (with 20-40% identifying as LGBTQ)
  5. Roughly half of Homeless Persons in U.S. are white, and the remainder are black, hispanic and native american or pacific islander
  6. Homelessness lasts for days to weeks in most cases
  7. Families represent one third of cases
  8. Housing instability is also associated with food insecurity and social isolation
  • Risk Factors
  1. Unstable job or Low wage
    1. Low income households use >50% of their income toward housing costs
    2. Low cost housing is typically well above federal minimum wage in U.S.
  2. Black and Hispanic patients
    1. Less access to low cost housing
  3. Veteran status (8-13% of homeless on most nights)
    1. Associated with higher rates of rape and Intimate Partner Violence (esp. female Veterans)
    2. Higher rates of mental illness (e.g. PTSD, Eating Disorders), Traumatic Brain Injury and Substance Abuse
  4. Mental illness
  5. Physical Disability
  6. Inadequate access to affordable housing
  7. Inadequate access to affordable health care
  8. Inadequate to public assistance
  9. Alcohol Abuse
  10. Substance Abuse
  11. Domestic Violence
  12. Criminal behavior or prior incarceration
  13. Foster Care history or adverse childhood events
  14. Refugee (1% lifetime Prevalence)
  • History
  • VA Screening Tool
  1. In the past 2 months, have you been living in stable housing that you own, rent or stay in as part of a household?
  2. 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?
  3. Byrne (2015) Public Health Rep 130(6): 684-92 [PubMed]
  • Associated Conditions
  • Children
  1. Asthma (as well as Atopic Dermatitis and severe allergies)
  2. Dental Caries
  3. Skin Infestations
  4. Iron Deficiency Anemia
  5. Lead Poisoning
  6. Growth Delay (and nutritional deficiencies)
  7. Developmental Delay
  8. Learning Disorder
  9. Childhood Depression (and increased Suicidality risk, esp. LGBTQ)
  10. Childhood Anxiety
  11. Behavioral Disorders
  12. Child Abuse (including emotional abuse, and exposure to household Violence, substance use)
  • Associated Conditions
  • Adults
  1. Domestic Abuse (including sexual abuse, rape)
  2. Specific Concerns in Women
    1. Sexual Violence is associated with immediate Homelessness cause in 55%
    2. Young adult women (age 18 to 25 years) are pregnant or are accompanied by a child in 44% of cases
    3. Two thirds of pregnancies are unintended and at increased risk of Preterm Labor and low birth weight
    4. Older women (age >50 years) are increasing in Homelessness rates, and are at higher risk of medical complications
  3. Mental Illness (30-50% of patients)
    1. Schizophrenia
    2. Bipolar Disorder
    3. Major Depression
    4. Anxiety Disorder
    5. Post-Traumatic Stress Disorder
    6. Suicidality is common (especially <30 years old, LGBTQ, hispanic, longer Homelessness duration, lower educational level)
    7. Alcohol Abuse or Substance Abuse (20-30% of patients)
      1. Tobacco Abuse in 70% of Homeless Persons
  4. Infectious Disease
    1. Sexually Transmitted Disease
      1. HIV Infection
      2. Syphilis
    2. Tuberculosis (up to 50 fold higher risk in Homeless Persons)
    3. Lice Infestation (risk of Bartonella infection such as Trench Fever, endocarditis)
    4. Scabies
    5. Foot infections, wounds and related disorders
    6. Cellulitis
    7. Pneumonia
  5. Uncontrolled or premature chronic disease
    1. Coronary Artery Disease and other cardiovascular disease is the leading cause of death among Homeless Persons
    2. Diabetes Mellitus
      1. Complicated by food insecurity, medication storage, hygiene
    3. Uncontrolled Hypertension
    4. Uncontrolled Hyperlipidemia
    5. Peripheral Vascular Disease
    6. Chronic Obstructive Pulmonary Disease (COPD)
    7. Cancer risk (due to lack of routine cancer screening)
  6. Exposure related conditions
    1. Heat Illness
    2. Frostbite
    3. Hypothermia
    4. Immersion Foot
  • Labs
  • Infectious Disease Screening
  1. HBsAg
  2. xHCV Antibody
  3. HIV Test
  4. RPR (Syphilis Test)
  5. Tuberculosis (use IGRA for screening)
  • Management
  1. Establish rapport with patient and family
    1. Provide accepting environment
    2. Establish trust
    3. Trauma Informed Care
      1. See Post-Traumatic Stress Disorder
  2. Evaluate for significant health conditions
    1. See Associated Conditions above
  3. Develop evaluation and management plan
    1. Emergency contact
    2. Establish multidisciplinary approach to care
      1. Primary care
      2. Mental Health
      3. Social worker or case manager
    3. Future lab testing and other appointments
    4. Medications
    5. Follow-up plan
    6. Other topics
      1. Maintaining adequate hygiene esp. feet (clean socks, properly fitting shoes, medicated foot powders)
      2. Environmental Protection (Warm clothing, shelter from heat, clean water supply)
  4. Precautions: Medications
    1. Prescribe medications with understanding that they may lack adequate storage
      1. Lack of cool, dry or refrigerated storage
      2. Lack of privacy or security to administer and store medications
    2. Simplify medication administration (e.g. once daily oral medications)
    3. Avoid medications with risk of rebound if stopped
      1. Beta Blockers
      2. Clonidine
    4. Avoid medications which predispose to Heat Illness or Dehydration, or frequent toilet use
      1. Diuretics
      2. Anticholinergics
    5. Avoid medications that may potentiate Drug Abuse habit
      1. See Drugs of Abuse
  • Prevention
  1. Preventive Health (e.g. Mammography, Pap Smears)
  2. Prenatal Care
  3. Longterm Contraception
  4. Screen and treat for Latent Tuberculosis
    1. Shelters may offer Tuberculosis Screening
    2. Directly observed 12 week protocol (Isoniazid and Rifapentine) with Liver Function Test monitoring
  5. Immunizations
    1. Tetanus Vaccine (Tdap or Td) every 10 years
    2. Influenza Vaccine
    3. Covid Vaccine
    4. Pneumococcal Vaccine (if indicated)
    5. Hepatitis B Vaccine
    6. Hepatitis A Vaccine
    7. Human Papilloma Virus Vaccine (Gardasil)
  6. Prevent Injury (esp. in Disability, Seizure Disorder, Violence exposure)
    1. Traumatic Brain Injury (5 fold higher risk in Homeless Persons)
    2. Intimate Partner Violence
  • Complications
  1. Adult Relative Risks
    1. Illness: 6x
    2. Hospitalization: 4x
    3. Early mortality (<52 years old): 3-4x
    4. Traumatic Head Injury: 5x
  2. Childhood Relative Risks
    1. Mortality under age 1 year: 9x
    2. Illness: 4x
    3. Delayed development: 4x
    4. Delayed Growth: 6x
    5. Learning Disorders: 2x
  • Resources
  1. Health Care for the Homeless
  2. SAMHSA Homelessness Resource Center
  3. Association of Clinicians for the Underserved
  4. National Center on Family Homelessness
  5. National Health Care for the Homeless Council
  6. U.S. Dept of VA - Veteran Homeless Initiative
  7. Homeless and Housing Resource Center
  8. Homeless Shelter Directory
  9. Salvation Army Shelter Listing