Question

Why are economically disadvantaged/homeless individuals vulnerable when it comes to seeking medical care? what advantages or disadvantages do they face? what resources are out here for them to get proper medical attention for themselves and or family? What other ways can the healthcare sector provide assist to this population of vulnerable individuals? Who makes up the population of homeless individuals and why? What are the health concerns for the homeless population? How can these concerns be fixed? Provide definitions, examples, and opinions.

Thanks so much!

Answer 1

To the extent that homeless people have been able to obtain needed health care services, they have relied on emergency rooms, clinics, hospitals, and other facilities that serve the poor. Indigent people (with or without a home) experience many obstacles in obtaining health care. For homeless people there are additional barriers. Recognition of the special health care needs of homeless people has encouraged the development of special services for them. In observing and describing these health care and health care-related services, one must be mindful of the heterogeneous nature of the homeless population, as well as the structure of the communities in which such services have developed. Regardless of differences among homeless people or regional variations in services, however, homeless people are more susceptible to certain diseases, have greater difficulty getting health care, and are harder to treat than other people, all because they lack a home. Similarly, attempts to provide health and mental health care services, regardless of variations in such areas as history, funding levels, and nature of support, also have certain common elements. They arose in response to a crisis rather than developing as part of a well thought out plan. They generally brought services to homeless people rather than waiting for them to come in; increasingly, they rely on public funding because the problem has grown beyond a level that the private sector can support.

Daily Activities—Some homeless people live under circumstances that pose particular problems for developing a treatment plan. For many, it may be difficult to keep a supply of medication while living on the street. For an alcoholic trying to stay sober, a homeless existence may present too many opportunities for drinking. Some former patients complain that neuroleptic medications, prescribed for a schizophrenic illness, may make them too drowsy and interfere with their alertness against the dangers on the streets.

Multiplicity of Needs—In addition to physical and mental health problems and difficulties with such things as housing and income maintenance, homeless people often also suffer from drug or alcohol abuse. Any health care program for homeless adults should expect that 25 to 40 percent of patients will suffer from serious alcohol or drug abuse problems (Fischer and Breakey, 1986).

Disaffiliation—Although many homeless people establish individual support networks outside a family structure, some homeless people typically lack those networks that enable most people to sustain themselves in society. Such isolation often causes (and sometimes is caused by) a limited capacity to establish supportive relationships with other people. Difficulties in establishing and maintaining relationships can militate against the development of cooperation with health care providers and may be an important factor in explaining what is often inaccurately described as a "lack of motivation."

Distrust—In addition to their distrust of authority, many homeless people are disenchanted with health and mental health care providers. Some have had bad experiences with medications, hospitals, doctors, and other human service professionals and are leery of further involvement.

Except for anecdotal information and obvious indicators of utilization, it is not possible to assess the effectiveness of health care delivery systems for homeless people. There are no adequate data from which such assessments can be made. However, in its review of various programs for health and mental health care services for homeless people, the committee found that four common elements enhanced a program's ability to provide services to this population:

Communication—Those people and agencies involved in the effort to address the health care problems of homeless people interact regularly and frequently.

Coordination—Even if only in a most rudimentary form, there is some way in which clients can be linked with a wide range of existing services (i.e., health and mental health care, housing, social services, entitlements, etc.) by providers, rather than being forced to seek services without assistance.

Targeted Approach—Programs are aggressive in seeking the homeless, rather than passive in waiting for them to appear. This may be reflected by locating a program in a skid row area. Other programs provide outreach and seek out homeless individuals on the streets.

Internal and External Resources—These constitute the range of resources that a program requires to carry out its function adequately, no matter how limited that function might be. Internal resources include reasonable funding and paid employees, in addition to the utilization of volunteers and donated goods and facilities. External resources include both the network of essential services described above and the ability to access that network.

Many homeless people with physical disabilities, mental disabilities, or both who cannot live independently require supportive living settings. One program that attempts to meet this need is the Veterans Administration (VA) community placement program, which secures supervised housing for mentally or physically disabled veterans who are facing discharge from a VA medical center and who would be at extreme risk of becoming homeless. Members of the committee visited four such placement sites in Lexington, Kentucky. Three were private homes in which the individual homeowner contracted with the VA to accept patients from the medical center (the largest program accepted up to eight men) for supervised residential living. The fourth program was a personal care home licensed by the Commonwealth of Kentucky. The personal care home received clients from the state agencies serving the mentally ill and the mentally retarded, as well as from the VA medical center. This facility is larger (over 15 beds) and was specifically designed to serve a population in greater need of medical and nursing care. Although the residences were supervised and certified by government agencies, the actual funding for the individual veterans comes from their own VA benefits.

In each of the programs identified above, communication and coordination were accomplished by individualized approaches developed over a period of time with systems that were more or less unique to each city. The programs were primarily targeted to the homeless; funding and other resources ranged from the purely charitable to the wholly publicly funded. However, a comprehensive, cohesive system of services is lacking. Even those programs that had strong ties with a hospital did not network with programs that serve, for example, the mentally ill or substance abusers.

Holistic Approach

Rather than treating an isolated health problem without considering the person's social or environmental situation, these programs provide treatments that recognize the interaction between the illness and the state of being homeless. The nature and level of the individual's entitlement benefits, for example, whether they are sleeping in the streets or in a shelter, where they get food, and so on, are taken into consideration in developing a treatment approach.

Outreach

Health care is brought to areas where homeless people can be found. These targeted services can then serve as a conduit by which other services (including application and advocacy for entitlement benefits) are offered.

Empathetic Staff

Staff are aware of the attitudes that increase their effectiveness in working with the homeless population. In particular, staff recognize the exigencies of survival that impinge on the day-to-day activities of the homeless and the effects of those demands on the individual's health and health care.

Multidisciplinary Approach

Teams working with the homeless encompass a range of disciplines, including physicians, nurses, physician's assistants, nurse practitioners, and social workers. Given the range and severity of illnesses present among the homeless population, when volunteers are used (especially medical or nursing students), proper supervision is provided.

Case Management and Coordination of Services

One of the most critical elements in serving the homeless involves the coordination of patient treatment and the provision of access to other health care and social services with the aim of breaking the cycle of homelessness. The most frequent approach is to include social workers as part of the multidisciplinary team. This individual keeps in touch with service providers at other treatment sites to ensure that the homeless person follows through with the treatment plan.

Continuity

Homeless individuals have few other people to rely on, often leading them to be very distrustful of people in general. The continuity of the program staff helps to build trust. Changes in personnel or disruptions in schedules increase their wariness; conversely, seeing familiar faces (especially if they can be treated by the same people both at an outreach site and then again in a clinic setting) increases their cooperation.

Each of these models has a somewhat different approach to providing health care services to homeless people. The common denominator, however, is a permanent outreach component. In some instances, a stable clinic site may be developed that has outreach workers, and in other cases the mobile teams go to places where the clients congregate for services.

Each of the different components of these models has strengths and weaknesses. For example, stationary clinics are able to provide more sophisticated technology (e.g., x-rays and electrocardiograms [ECGs]). On the other hand, such clinics might be viewed as too threatening for clients, especially if these individuals have had negative experiences with emergency rooms or clinics in the past. The informality of shelters and soup kitchens may be perceived as less threatening than an outpatient clinic; therefore, mobile teams may be in a better position to overcome such initial reluctance. Guests at these sites often ask for blood pressure checks or adhesive bandages as a means of testing the health care professionals. However, such sites do not usually provide ancillary services, such as ECGs. Many of these sites reach clients who would not otherwise have access to care; unfortunately, the sites are somewhat less stable: Soup kitchens may close down for a week or a month because of a lack of funding or to give volunteers a rest; there is sometimes difficulty finding space to set up a temporary clinic with access to running water; soup kitchens and meal programs are often open only for a brief period of time in the middle of the day or in the evening; and programs for the homeless sometimes close in April and do not reopen until November. Although there may be large numbers of guests, the patient flow and the abbreviated hours make it difficult for the efficient and effective use of staff.

Small Social Service Agencies or Large Health Care Facilities

Locating health care services in a social service agency may often mean that ancillary services or specialty clinic appointments must be negotiated on a case-by-case basis, which is a time-consuming procedure. Moreover physicians, nurse practitioners, and physician's assistants might find it professionally isolating to practice health care outside of a health care facility. Recently, a New York City mobile health team for the homeless was transferred administratively from a very small neighborhood health care center to a large teaching hospital. While the move did not affect to any substantial extent the provision of direct services to their clients (they continued to receive the same services at the same sites), it was welcomed by team members because of the additional supports that a large facility could provide.

Direct Provision of Services or Contracting Services

The model of contracting of services, while appropriate in many instances, may pose specific problems. If the contracted staff are employed by a major health care agency, they may experience a division of loyalties between their employer and the program that specifically serves the homeless. Such contract agencies often have different personnel policies in terms of holidays, vacations and pay scales, opportunities for advancement, staff development programs, and so on. These differences can negatively affect the morale of team members who work for different employers.

Size of Areas To Be Served

Another area of concern in developing models for delivering health care is the size of the geographic area to be served. In some JohnsonPew cities, services have been focused in one downtown area where there may be the heaviest concentration of homeless people, effectively excluding large numbers of homeless people outside that catchment area. Other cities have tried to cover as broad an area as possible, which may result in the loss of valuable service delivery time because of the amount of time spent in transit. If the area covered is substantial, a sizable number of backup agreements may be necessary to ensure the provision of ancillary and diagnostic laboratory services for each treatment site. To a great extent, the combination or range of services and the geographic size of the area to be served are dependent on the amount of resources available.

Studies of the mental health of homeless people indicate that the prevalence of serious mental disorders is considerably higher among the homeless than it is among the general population. The provision of mental health services to homeless people is made difficult primarily by the lack of appropriate facilities and resources and by their extreme poverty, their lack of insight into their psychiatric problems, their distaste for psychiatric treatment, and the complexities of their service needs. Those needs, therefore, are often poorly met (Lamb, 1984).

Rehabilitation

Structured psychosocial rehabilitation programs are often necessary to enable mentally ill people to function at their maximum capacity in the community. For the homeless, in most cases, the very structure of such programs may be a deterrent. Therefore, the principles of psychosocial rehabilitation must be brought to the shelters or residences. Over time, this should enable the individual to move from the on-site setting to a community setting. Assistance is also needed for homeless people to regain lost skills in the activities of daily living (ADL) that most of us take for granted (e.g., personal hygiene, cleaning, and basic meal preparation). The Community Support Systems program at the Volunteers of America shelter in New York is an example of such an effort. It provides a model apartment as part of an ADL skills training program. A similar program exists in Phoenix, where six apartments are used to help chronically mentally ill homeless people learn the skills required for independent living before moving into such situations.

A comprehensive array of services is needed by chronically mentally ill homeless people, but in most communities a full range of services does not exist. Until comprehensive service systems for mentally ill homeless people are developed, the care that clinicians can give to these patients is limited.

Alcohol and Drug Abuse

As with the mentally ill, a homeless person who is an alcohol abuser is unlikely to benefit from an approach that does not include a range of services. Nonalcohol substance abuse is a more recent phenomenon and appears to be limited somewhat to younger homeless people (under age 40) and to certain cities, primarily on the East Coast. Again, this population needs a full range of services, including specialized housing. The committee was able to identify several programs targeted toward homeless people with alcohol or drug problems. The Guest House in Milwaukee serves a homeless population that is evenly divided between the chronically mentally ill and chronic substance abusers. Harbor House in St. Louis is an alcohol rehabilitation program for homeless men; health care services are provided to Harbor House by a local voluntary hospital.

The following are some examples of programs that have been described in the professional literature.

• Case management teams, such as those funded by the Illinois Department of Alcoholism and Substance Abuse.

• Shelters specifically for homeless people who are alcoholics or drug abusers; the Illinois Department of Alcoholism and Substance Abuse funds three such programs, as does the Massachusetts Division of Alcoholism and Drug Rehabilitation. The Maine Office of Alcoholism and Drug Abuse Prevention funds four shelters, one of which is also the site of a bakery that is used to provide training and employment for the homeless clients.

• Programs for permanent or long-term housing, such as those funded by the Massachusetts Division of Alcoholism and Drug Rehabilitation; alcohol-free housing programs developed in Los Angeles, Seattle, and Portland, Oregon. In addition,

• Intensive residential programs that combine treatment on-site; one example of this is a program in New Jersey, funded by the state Division of Alcoholism. Under this program, a small (10-person) group home for homeless alcoholics is also the setting for day activities (e.g., counseling, vocational training, education, and leisure time activities), as well as referrals for health and mental health care services.

These examples indicate that programs can be developed to address the needs of homeless people who have problems with alcohol or drugs.

Aids

It has been only 8 years since AIDS was first publicly identified. Since then the disease has reached epidemic proportions, and services for people that have been affected have not kept pace with demand. This is especially true for homeless people with AIDS. During a site visit to San Francisco, members of the committee met with the AIDS Advisory Committee of the San Francisco City/County Department of Public Health, as well as the AIDS discrimination specialist of the San Francisco Human Rights Commission. That meeting basically confirmed that those issues described in the Institute of Public Services Performance, Inc., report in New York (see Chapter 2) are not limited to any one community. The advisory committee reported that such matters as loss of housing due to loss of employment, discrimination, or while awaiting entitlement eligibility determinations are very real problems.

Members of the committee toured the Folsom Street Hotel program in San Francisco, a residential program for homeless people with AIDS operated by Catholic Charities, with partial funding by the City and County of San Francisco. Although it did not tour the facility, the committee is also aware of Bailey House, a similar program in New York City that is operated by the AIDS Resource Center with funding from the New York City Human Resources Administration and a grant from the U.S. Department of Health and Human Services. Both of these programs were developed to provide housing and supportive services to this population. However, because many patients with AIDS are increasingly disabled as the disease progresses, additional forms of housing with varying levels of physical care, up to and including skilled nursing facilities and hospices, are needed. The alternative seems to be hospitalization, which is extremely expensive.

Homeless Youths

The three studies of homeless youths cited in Chapter 1 (Boston, New York, and Toronto) each reported on shelter populations. Despite the differences among the study populations, the similarities in the findings regarding the physical and mental health needs of this population are even more significant. All three studies reported that supportive services, rather than the provision of housing alone, are needed. Each also reported that both the number of attempts to run away and the length of time that the teenager has been away or in shelter(s) are important. The greater the number of attempts to run away and the longer the adolescent is in an institutional setting, the more difficult it becomes to place that youth in a noninstitutional setting or, having made such a placement, for that youth to remain there. While the three studies disagreed on the form that noninstitutional services should take, they agreed that, given the problems of this population, specialized services for this group are necessary.

Other Issues in Health Services for the Homeless.

Communication

Coordination

Funding

1.Outreach to people where they are, including the streets.

2.General medical assessment and treatment for chronic and acute illnesses.

3.Specific screening, treatment, and follow-up for such health problems as high blood pressure.

4.Pediatric services (including well-baby clinics, immunizations, and screening for lead poisoning) and diagnostic and psychosocial intervention programs for both preschool and school-age children to address emotional disability and developmental delays.

5.Ancillary services (dentistry, podiatry, optometry, and specialized diets).

6.Access to mental health care and substance abuse services, including access to specialized housing.

7.Referral and access to convalescent care, as well as long-term medical and nursing care for catastrophic illness.

8.Gynecological services.

9.Prenatal care.

10.Educational services, primarily with regard to family planning and the prevention of sexually transmitted diseases (including the free distribution of condoms as part of AIDS education efforts).

• identification and outreach—determining who is in need of services and bringing them into the service delivery system;

• assessment—determining the client's individual strengths and determining the needs that must be met;

• service planning—developing a plan to meet those needs;

• coordination and facilitation—working with the client and service providers to arrange for the actual delivery of services necessary to meet those needs;

• monitoring—working with the client and service providers to determine whether each service provider (or all service providers, if there is more than one) is meeting its obligations;

• evaluating—determining when and if changes in the service delivery plan are necessary and then negotiating and monitoring the implementation of those changes; and

• advocacy—acting for or with the client in obtaining those services (including housing) that are needed, with one of the ultimate goals being that the client eventually becomes his or her own advocate.

• communication skills, both with the client and with service providers;

• knowledge of such things as rules, regulations, programs, and resources;

• empathy with the client and the ability to assist in seeing the client's strengths and to capitalize on those strengths;

• ability to identify the critical issues facing the client and to identify the appropriate resolutions for those issues; and

• ability to hold others—both the client and the service providers—accountable for their performance.

Liability Insurance Coverage for Providers

The committee received several reports of programs that have encountered difficulties in obtaining malpractice insurance. Part of the problem may be that the programs are based in social service agencies rather than in health care facilities, but the committee is unaware of instances in which legal judgments have been rendered in favor of a homeless plaintiff in a malpractice action. Therefore, the basis for setting extraordinarily high premiums for or denying malpractice insurance is unclear. The committee also received reports that several not-for-profit organizations lost their liability insurance coverage or were charged very high premiums, causing them to either suspend or curtail operations for extended periods of time. At present, these reports appear to be scattered and do not seem to represent any specific pattern of denial of coverage. The potential negative impact of the loss of insurance coverage on the ability of the private sector to continue to provide services to homeless people cannot be ignored.

The potential lack of insurance coverage is of special concern with respect to the growing involvement of universities (especially medical, dental, and nursing schools) in the provision of health care services to the homeless. The committee observed the involvement of the schools of nursing of the University of Kentucky in the programs for the homeless in Lexington and of the University of California, Los Angeles, in the Johnson-Pew project in Los Angeles. In addition, the committee is aware of similar programs with the Johns Hopkins Medical Institutions in Baltimore and the Georgetown University Dental School in Washington, D.C. Problems with insurance—both malpractice and general liability—could effectively forestall such efforts.