The risk of being uninsured in this country is highest among those on the lowest rungs of the economic ladder, and it's a sad truth that the majority of homeless Americans lack any type of coverage. Being homeless puts a person at high risk for a variety of health problems, but homelessness and health care are intertwined. Poor health can be both a cause and a result of living on the streets or in shelters, and the National Health Care for the Homeless Council (NHCHC) notes that 70% of its clients don't have health insurance. The overall health of homeless people in the United States is worse than that of the general population; issues commonly encountered include mental health problems, substance abuse, bronchitis, pneumonia, and wound and skin infections.
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INSIGHT FROM A COMMUNITY PROJECT
The Patient Protection and Affordable Care Act (ACA), which was signed into law in 2010 and recently upheld by the U.S. Supreme Court, includes a number of provisions that are designed to give Americans greater access to care, improving its availability and quality at a reduced cost. But will health care reform have any real impact on health care for the homeless, and if so, what does that mean for nurses, especially those working in primary care?
The law has yet to go fully into effect, but there's “an enormous opportunity to provide better care while also managing high health care costs by offering solid home- and community-based services and comprehensive behavioral health supports,” wrote Jennifer Ho, deputy director of the United States Interagency Council on Homelessness (USICH), in a USICH blog post. “These are the kinds of benefits that will allow communities to help sick and vulnerable people get off the streets and out of shelters into homes.” (Read the post at http://1.usa.gov/MLMxoj.)
Ryan Greysen, MD, MHS, MA, of the University of California, San Francisco, points out that the effects are already being seen. Greysen and his colleagues created a partnership between Yale-New Haven Hospital and Columbus House, the largest homeless shelter in New Haven, Connecticut, as part of a study to better understand patients' experiences of transitions from a hospital to a homeless shelter (the report was published online June 16 in the Journal of General Internal Medicine).
“One of the outcomes of our project was greater engagement of the shelter with other local stakeholders,” he told AJN, to improve transitions in care for the homeless and increase the stakeholders' ability to pursue funding for that cause through such partnerships.
One of these funding opportunities is a Medicare innovations grant that was established by the ACA, which calls on hospitals to partner with community-based organizations—like the shelter in New Haven—to help the most needy and vulnerable Medicare patients, he explained. “It certainly applies to [the] homeless, even if it wasn't specifically designed for them,” said Greysen.
One of the key elements of health care reform is the planned expansion of Medicaid coverage in 2014, which will affect an estimated 16 million more people. In essence, this makes Medicaid “a primary platform for comprehensive health care reform,” according to the National Alliance to End Homelessness.
With the new law, people younger than 65 years with an income below 133% of the federal poverty level will be eligible for Medicaid. There will be greater support from the federal government, which will provide 100% funding for newly eligible people for three years (and 90% thereafter). Additionally, the legislation is designed to streamline Medicaid and the Children's Health Insurance Program (CHIP) and modernize the system for determining eligibility and facilitating enrollment and renewal.
Beginning in 2016, according to current estimates from the Congressional Budget Office (1.usa.gov/PcMG3W), between 20 million and 23 million people will be covered through the new insurance exchanges, and 16 million to 17 million additional people will be enrolled in Medicaid and CHIP. Conversely, 3 million to 5 million fewer people will be covered through their employer.
However, it will take more than just the passage of a law to bring health care on a large scale to the homeless population. With the passage of the ACA, “one might assume that everyone will have access to health care, but that isn't necessarily correct,” said Angela Hudson, PhD, FNP-C, an assistant professor of nursing at the University of California, Los Angeles. “Some homeless people are also very mobile and itinerant. If they have substance abuse issues, severe mental illness, or comorbidities,” she said, they may have difficulty articulating a health history.
Hudson pointed out that homeless patients will need good case management and someone to help them navigate the system. If the ACA can provide them with that type of support, she said, it's hoped that their health outcomes will improve, too.
Barbara DiPietro, PhD, director of policy at the NHCHC and at Health Care for the Homeless of Maryland, agrees. She notes that there may be 15 million adults who are eligible for Medicaid and that of this group, about 7 million will initially enroll. “For the homeless population, much will depend on how aggressive we are in reaching them,” she said. “It's not just getting them a card; they need to be engaged.”
Nurses can play a tremendous role on a number of fronts, contends DiPietro. Outreach is needed, to both identify homeless patients and provide education regarding Medicaid eligibility and what it means for them. “Eligibility isn't going to do anything for them if they're unaware of the benefit or if they don't understand how it will help them,” she told AJN.
Many homeless patients will have chronic conditions, including mental health and substance abuse problems, that aren't seen in traditional primary care. “Complex medical care plans need to be put in place,” DiPietro said. “In addition, addicted and complex patients often have a hard time being accommodated in a traditional setting. They can be aggressive and disruptive.” She emphasized that this doesn't apply to everyone who is homeless. “But we're going to be seeing behavioral health problems and substance abuse in the primary care setting. Nurses need to be aware of this.”
Another issue is discharge planning. When the homeless are discharged from acute care or skilled nursing facilities, they may not have a place to go where they can recuperate, DiPietro said. Homeless patients often have longer hospital stays because they don't have a safe option for discharge. They also often come to the ED for basic health care and are admitted more frequently than the general population. “But we haven't created a system of care that accommodates homeless patients being released from acute care,” said DiPietro. And there is always pressure to cut costs.
Advocacy is also an area where nurses can make a huge difference. Most health care policymakers aren't thinking about the homeless—they're thinking about the general population. “Nurses are the best providers to sit down at the table with health care policymakers,” said DiPietro, “and discuss what's needed for this population.”
Nurses also need to speak with state and local representatives, as well as those in the federal government, she said. “Whoever is making the decisions, nurses need to make sure they're at the table representing the community.”—Roxanne Nelson, BSN, RN
© 2012 Lippincott Williams & Wilkins, Inc.