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Obstetrics & Gynecology:
doi: 10.1097/01.AOG.0000435417.29567.90
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Committee Opinion No. 576: Health Care for Homeless Women

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Committee on Health Care for Underserved Women

This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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Abstract

ABSTRACT: Homelessness continues to be a significant problem in the United States. Women and families represent the fastest growing segment of the homeless population. Health care for these women is a challenge but an important issue that needs to be addressed. Homeless women are at higher risk of injury and illness and are less likely to obtain needed health care than women who are not homeless. It is essential to undertake efforts to prevent homelessness, to expand community-based services for the homeless, and to provide adequate health care for this underserved population. Health care providers can help address the needs of homeless individuals by identifying their own patients who may be homeless or at risk of becoming homeless, educating these patients about available resources in the community, treating their health problems, and offering preventive care.

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Background

Homelessness is an issue that can affect anyone. The odds of an individual in the United States becoming homeless in a given year are 1 in 194 (1). The number of homeless individuals was essentially unchanged between 2009 and 2011, showing no improvement (1). Being homeless has a negative effect on an individual's health. Because of decreased access to medical care, homeless individuals often use emergency departments as their primary source of health care. Because of the lack of preventive care, their disease processes are more advanced and they require longer hospitalization.

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Definition of Homelessness

Homeless is defined as the state of an individual or family who lacks a fixed, regular, and adequate nighttime residence (2). Chronic homelessness is defined by the U.S. Department of Housing and Urban Development as the state of an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more or who has had at least four episodes of homelessness in the past three years (1).

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Statistics and Demographics

Women and families are the fastest growing segment of the homeless population, with 34% of the total homeless population composed of families (3). Of these homeless families, 84% are headed by women (3). African American families are disproportionately represented among the homeless population, making up 43% of homeless families (3). Lack of education also is associated with being homeless, with 53% of homeless mothers lacking a high school diploma (3).

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Risks of Homelessness

Although extreme poverty is a characteristic of the homeless population, the shortage of affordable housing is a major precipitating factor that can render individuals homeless who are not extremely poor. Unemployment, job loss, foreclosures, mortgage defaults, personal or family crisis, an increase in rent disproportionate to income, or a reduction in public health benefits all increase the likelihood of loss of a home (4). Other risk factors include lack of job skills, inadequate social support, problems with alcohol or substance abuse, mental illness, experiences of violence, and previous incarceration (3, 5). Additionally, the prevalence of homelessness is high among military veterans (6). Approximately 13% of all homeless adults were veterans in 2012 (6).

Domestic and sexual violence is the leading cause of homelessness for women and families, and 20-50% of all homeless women and children become homeless as a direct result of fleeing domestic violence (7, 8). Homeless women are far more likely to experience violence of all sorts compared with women who are not homeless because of a lack of personal security when living outdoors or in shelters (5). Domestic violence shelter providers are prohibited from reporting client information; therefore, estimates likely undercount the number of homeless women and families seeking shelter as a result of domestic violence.

Many adolescents become homeless after leaving home because of conflicts with parents regarding sexual orientation. Lesbian, gay, bisexual, transgender, or youth questioning their sexual orientation represent 20% of homeless youth (9). Sixty-two percent of homeless gay and transgender youth will attempt suicide (10). Among lesbian, gay, bisexual, and transgender persons who experience domestic violence, 57% became homeless as a result of domestic violence (11).

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Health Issues

Lack of access to health care is a profound issue for the homeless population, with 73% of homeless individuals reporting at least one unmet health need, including medical, surgical, mental health, vision, or dental care or unmet prescription needs (12). As a result, homeless women lack preventive care such as prenatal care, mam-mograms, and Pap tests compared with women who are not homeless (13, 14). In addition, they have higher rates of poor health status, mental illness, poor birth outcomes, and mortality (13).

Chronic illnesses plague homeless women, and approximately one third of medical problems treated at locations that provide health care for the homeless population are considered chronic illnesses (15). Some of the most commonly reported chronic illnesses are asthma, anemia, chronic bronchitis, hypertension, and ulcers (16).

Substance abuse can be both a cause and result of homelessness and can occur along with mental illness (17). It has been estimated that 30% of individuals who are chronically homeless have mental health conditions and approximately 50% have substance use problems as well (18). Because few federal substance abuse treatment and prevention programs target funds specifically to the homeless population, it is important to advocate for the improvement and strengthening of such programs (17).

The rate of unintended pregnancies is higher among homeless women than other American women (19). In a study conducted by the National Health Care for the Homeless Practice-Based Network, although homeless women were found to have access to contraceptive services, they usually were only provided methods with high user-based failure rates (20). Homeless women should have increased access to long-acting reversible contraceptive options.

Homeless women also experience a higher number of adverse birth outcomes when compared with the general population. Homeless women are 2.9 times more likely to have a preterm delivery, 6.9 times more likely to give birth to an infant who weighed less than 2,000 g, and 3.3 times more likely to have a small-for-gestational-age newborn, even after adjustment for other risk factors such as maternal age, number of previous pregnancies, and smoking (21). In the United States, preterm birth rates and low birth weight rates in homeless women exceed national averages (22).

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Barriers to Health Care

Health care for the homeless is often a broken system that does not cater to the specific needs of this population. In a study in which homeless individuals were interviewed about their perspective regarding the delivery of their health care, five barriers to health care were identified: 1) social triaging; 2) being stigmatized for being homeless; 3) lack of care through the health system; 4) disrespectful treatment; and 5) feeling ignored by health care providers (23). As a result, those interviewed admitted that they often live without essential resources even though this may compromise their health, they do not use the health care system unless it is an emergency, and they develop underground resources (23). An example of an underground resource used by those interviewed is volunteering to participate in research studies to guarantee health care (23).

Fifty-seven percent of homeless individuals lack a regular source of health care compared with 24% of poor individuals and 19% of the general population (11). The factors that contribute to homeless women being unable to obtain needed health care include the lack of health insurance, the inability to purchase or acquire medications, the lack of knowledge of where and when to obtain health care, long wait times at medical facilities, and the lack of transportation to and from medical facilities. Finding resources for food, clothing, and shelter takes precedence over meeting health care needs. Mental illness, substance abuse, domestic violence, and being too sick to seek care create additional obstacles in obtaining needed services. Homeless individuals may not seek care because of denial of health problems and fear of losing their children if found to be homeless. Medical providers who do not want to care for homeless individuals in their offices and the lack of available treatment facilities result in limited access to health care. Inadequate inpatient discharge planning and follow-up care, as well as lack of referral to services available within the community for homeless individuals also act as barriers (11, 24–27). Providing housing and case management to homeless individuals with chronic medical conditions can result in fewer days in a hospital and fewer emergency department visits (28).

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Affordable Care Act and Homelessness

Although the Affordable Care Act does not directly address the homeless population, there are benefits for homeless individuals. Under the Affordable Care Act, individuals at or below 138% of the federal poverty level (which includes a portion of the homeless population) will qualify for Medicaid in states that opt to expand their Medicaid programs. There are certain Medicaid benefits that can play an important role in assisting individuals who are at risk of or experience chronic homelessness, including behavioral health services, which include mental health and substance abuse services; case management; personal care and personal assistance services; and home-based and community-based services (29). Securing Medicaid eligibility can be a complicated application process because of language, literacy, and transportation barriers (30). Agencies and organizations that assist homeless individuals can play a critical role in brokering benefits on their behalf. In addition, states can take additional steps to facilitate access to Medicaid benefits (29, 30). Increased health coverage may lead to improved access and coordination of care and less reliance on emergency department services. These adjustments could greatly improve the health care of homeless individuals. Additionally, increased coverage could result in benefits such as less uncompensated care for physicians and emergency departments, thus, lowering the health care costs of caring for homeless individuals (30).

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Preventing Homelessness

The Homelessness Prevention and Rapid Re-Housing Program has been the most effective plan for reducing homelessness. In the first year of its existence, 110,000 families were provided housing; 91% of those families were able to secure permanent housing and of those, more than 50% were able to do so within the first month of assistance (31). However, funding for this program ended in 2012. Continuation of this or a similar program is necessary to reduce the number of homeless individuals.

The National Alliance to End Homelessness has identified The Ten Essentials, a guide to help communities identify effective permanent solutions to homelessness: 1) plan, 2) data, 3) emergency prevention, 4) systems prevention, 5) outreach, 6) shorten homelessness, 7) rapid rehousing, 8) services, 9) permanent housing, and 10) income (32). Although providers may not be an integral part of implementation of these strategies outlined by the National Alliance, they can have a powerful voice for change. The American College of Obstetricians and Gynecologists encourages health care providers to advocate for improved health care for homeless individuals (Box 1) and to take steps to end homelessness (Box 2).

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Resources

The following resources are for information purposes only. Referral to these sources and web sites does not imply the endorsement of the American College of Obstetricians and Gynecologists. These resources are not meant to be comprehensive. The exclusion of a source or web site does not reflect the quality of that source or web site. Please note that web sites are subject to change without notice.

Bureau of Primary Health Care: Health Care for the Homeless (HCH) Program—funded by the Health Resources and Services Administration, makes grants to community-based health centers to assist them in planning and delivering high-quality, accessible health care to people experiencing homelessness.

Web: http://bphc.hrsa.gov/

National Coalition for the Homeless (NCH)—a national network of people who are currently experiencing or who have experienced homelessness, activists and advocates, community-based and faith-based service providers, and others committed to a single mission to prevent and end homelessness while ensuring the immediate needs of those experiencing homelessness are met and their civil rights protected.

Web: http://www.nationalhomeless.org

National Health Care for the Homeless Council (NHCHC)—advocates for federal policy with regard to issues of health care for the homeless.

Web: http://www.nhchc.org

Directories: http://www.nhchc.org/resources/publications/directories

National Law Center on Homelessness and Poverty—mission to prevent and end homelessness by serving as the legal arm of the nationwide movement to end homelessness.

Web: http://www.nlchp.org/

National Low-Income Housing Coalition—only national organization dedicated solely to ending America’s affordable housing crisis.

Web: http://nlihc.org

The United States Interagency Council on Homelessness—coordinates the federal response to homelessness.

Web: http://www.usich.gov

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Box 1 Recommendations for Health Care Providers Cited Here...

* Identify patients within the practice who may be homeless or at risk of becoming homeless (ie, ask about living conditions, nutrition, mental health issues, substance abuse, domestic violence).*

* Provide health care for these homeless women without bias, including preventive care, and do not withhold treatment based on concerns about lack of adherence.

* Become familiar with and inform patients who are (or at risk of becoming) homeless about appropriate community resources, including local substance abuse programs, domestic violence services, and social service agencies.

* Simplify medical regimens and address barriers, including transportation needs, for follow-up health care visits.

* Advocate for initiatives to address homelessness such as increased funding for housing, case management services, substance abuse treatment, mental health services, domestic violence programs, and primary and preventive care for homeless individuals.

* Volunteer to provide health care services at homeless shelters and other facilities that serve homeless individuals.

* Increase access to long-acting reversible contraceptives.

*Allen J, Bharel M, Brammer S, Centrone W, Morrison S, Phillips C, et al. Adapting your pracice: treatment and recommendations on reproductive health care for homeless patients. Nashville (TN): Health Care for the Homeless Clinicians’, Inc.; 2008. Available at: http://www.nhchc.org/wp-content/uploads/2001/09/ReproductiveHealth.pdf. Retrieved May 29, 2013.

Community involvement and volunteerism. ACOG Committee Opinion No. 437. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:203–4.

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Box 2 Efforts for Health Care Improvement for Homeless Women Cited Here...

The American College of Obstetricians and Gynecologists supports the following efforts for improved health care for homeless women:

* Improved coordination between community programs and specific health care services such as prenatal care, cervical cancer screening, immunizations, mental health, substance abuse, and treatment for sexually transmitted infections and tuberculosis

* Donations of medications from pharmaceutical companies for use in homeless clinics and shelters, being mindful of influences on prescribing behavior

* Modified residency and medical student curricula to increase awareness of health care issues of homeless individual and promote involvement in direct care

* Indexing the minimum wage locally to the cost of housing

* Adequate disability benefits for those who are unable to work

* Increased funding for comprehensive programs, such as the Health Care for the Homeless programs, and research directed to the prevention of homelessness

* Professional liability protection for physicians who volunteer their services to homeless individuals

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References

1. National Alliance to End Homelessness, Homelessness Research Institute. The state of homelessness in America 2012. Washington, DC: NAEH; 2012. Available at: http://b.3cdn.net/naeh/9892745b6de8a5ef59_q2m6yc53b.pdf. Retrieved May 29, 2013.

2. General definition of homeless individual, 42 U.S.C. § 11302 (2011).

3. The National Center on Family Homelessness. The characteristics and needs of families experiencing homelessness. Newton Centre (MA): NCFH; 2008. Available at: http://www.familyhomelessness.org/media/147.pdf. Retrieved May 29, 2013.

4. National Coalition for the Homeless. Why are people homeless? Washington, DC: The Coalition; 2009. Available at: http://www.nationalhomeless.org/factsheets/Why.pdf. Retrieved May 29, 2013.

5. Zlotnick C, Zerger S. Survey findings on characteristics and health status of clients treated by the federally funded (US) Health Care for the Homeless Programs. Health Soc Care Community 2009;17:18–26.

6. Department of Housing and Urban Development. The 2012 point-in-time estimates of homelessness. Volume I of the 2012 Annual Homeless Assessment Report. Washington, DC: HUD; 2012. Available at: https://www.onecpd.info/resources/documents/2012AHAR_PITestimates.pdf. RetrievedMay 29, 2013.

7. Jasinski JL, Wesely JK, Mustaine E, Wright JD. The experience of violence in the lives of homeless women: a research report. Orlando (FL): University of Central Florida; 2005. Available at: http://www.ncjrs.gov/pdffiles1/nij/grants/211976.pdf. Retrieved May 29, 2013.

8. Zorza J. Woman battering: a major cause of homelessness. Clgh Rev 1991;25:421–7.

9. National Alliance to End Homelessness. LGBTQ youth. Available at: http://www.endhomelessness.org/pages/lgbtqyouth. Retrieved May 29, 2013.

10. United States Interagency Council on Homelessness. LGBTQ youth. Available at: http://www.usich.gov/issue/lgbt_youth. Retrieved May 29, 2013.

11. GLBT Domestic Violence Coalition, Jane Doe Inc. Shelter/ housing needs for gay, lesbian, bisexual and transgender (GLBT) victims of domestic violence: analysis of public hearing testimony October 27, 2005 Massachusetts State House. Boston (MA): GLBT Domestic Violence Coalition; Jane Doe Inc.; 2006. Available at: http://www.ncdsv.org/images/shelterhousingneedsforglbtvictimsdv.pdf.Retrieved May 29, 2013.

12. Baggett TP, O’Connell JJ, Singer DE, Rigotti NA. The unmet health care needs of homeless adults: a national study. Am J Public Health 2010;100:1326–33.

13. Teruya C, Longshore D, Andersen RM, Arangua L, Nyamathi A, Leake B, et al.. Health and health care disparities among homeless women. Women Health 2010;50: 719–36.

14. Chau S, Chin M, Chang J, Luecha A, Cheng E, Schlesinger J, et al.. Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev 2002;11:431–8.

15. Silver G, Panares R. The health of homeless women: information for state maternal and child health programs. Baltimore (MD): Johns Hopkins University School of Public Health; 2000. Available at: http://www.jhsph.edu/sebin/g/m/homeless.PDF. Retrieved May 29, 2013.

16. Weinreb L, Goldberg R, Perloff J. Health characteristics and medical service use patterns of sheltered homeless and low-income housed mothers. J Gen Intern Med 1998;13:389–97.

17. National Coalition for the Homeless. Substance abuse and homelessness. Washington, DC: NCH; 2009. Available at: http://www.nationalhomeless.org/factsheets/addiction.pdf. Retrieved June 6, 2013.

18. Substance Abuse and Mental Health Services Administration. Current statistics on the prevalence and characteristics of people experiencing homelessness in the United States. Rockville (MD): SAMHSA; 2011. Available at: http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf. Retrieved June 6, 2013.

19. Crawford DM, Trotter EC, Hartshorn KJ, Whitbeck LB. Pregnancy and mental health of young homeless women. Am J Orthopsychiatry 2011;81:173–83.

20. Saver BG, Weinreb L, Gelberg L, Zerger S. Provision of contraceptive services to homeless women: results of a survey of health care for the homeless providers. Women Health 2012;52:151–61.

21. Little M, Shah R, Vermeulen MJ, Gorman A, Dzendoletas D, Ray JG. Adverse perinatal outcomes associated with homelessness and substance use in pregnancy. CMAJ 2005;173:615–8.

22. Stein JA, Lu MC, Gelberg L. Severity of homelessness and adverse birth outcomes. Health Psychol 2000;19:524–34.

23. Martins DC. Experiences of homeless people in the health care delivery system: a descriptive phenomenological study. Public Health Nurs 2008;25:420–30.

24. Lewis JH, Andersen RM, Gelberg L. Health care for homeless women. J Gen Intern Med 2003;18:921–8.

25. Nickasch B, Marnocha SK. Healthcare experiences of the homeless. J Am Acad Nurse Pract 2009;21:39–46.

26. Gelberg L, Browner CH, Lejano E, Arangua L. Access to women’s health care: a qualitative study of barriers perceived by homeless women. Women Health 2004;40:87–100.

27. Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons. JAMA 2001;285:200–6.

28. Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA 2009;301:1771–8.

29. Department of Health and Human Services. Condensed version of a primer on how to use Medicaid to assist persons who are homeless to access medical, behavioral health, and support services. Available at: http://www.hhs.gov/homeless/research/condensedprimer.html. Retrieved May 24, 2013.

30. Henry J. Kaiser Family Foundation. Medicaid coverage and care for the homeless population: key lessons to consider for the 2014 Medicaid expansion. Washington, DC: KFF; 2012. Available at: http://kff.org/health-reform/report/medicaid-coverage-and-care-for-the-homeless/. Retrieved May 29, 2013.

31. National Alliance to End Homelessness. Rapid re-housing: successfully ending family homelessness. Washington, DC: NAEH; 2012. Available at: http://b.3cdn.net/naeh/35f1338115aabf3410_0bm6iioyi.pdf. Retrieved May 29, 2013.

32. National Alliance to End Homelessness. Ten essentials. Available at: http://www.endhomelessness.org/pages/tenessentials. Retrieved May 29, 2013.

© 2013 by The American College of Obstetricians and Gynecologists.

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