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Feature: CE Connection

Caring for patients who are homeless

Mcenroe-Petitte, Denise M. PhD, MSN, RN

Author Information
doi: 10.1097/01.NURSE.0000654600.98061.61

Figure
Figure

NURSES PROVIDE CARE in various settings, including hospitals, clinics, schools, and home healthcare. People who are homeless may seek healthcare in any of these settings. This article discusses the challenges of homelessness and the role of nurses in caring for these patients.

Background

In 2018, an estimated 552,830 individuals experienced homelessness in the US (see 2018 Homeless statistics).1,2 However, the prevalence of homelessness may be underestimated.3

According to the National Alliance to End Homelessness (NAEH), approximately 17 individuals per 10,000 have experienced homelessness in the US.1 In a 2019 report, NAEH further noted an increase of 1,834 people who are homeless between 2017 and 2018.4

The rate of homelessness among older populations is also growing. As of 2008, approximately 45,000 people were homeless and over age 65 in the US; this number is expected to double by 2050.5 The reasons may vary, but lack of access to healthcare, chronic illness, poor nutrition, and unaffordable housing are all considered contributing factors.5

Meeting individual healthcare needs is crucial to population health management, and homelessness is linked to significant healthcare conditions.6 People who are homeless have a unique set of healthcare needs, many of which are unrecognized or untreated. Nurses must be available to assist them in meeting their individual needs.

Table
Table:
2018 homeless statistics1,2

Demographics

People who are homeless are defined as those who do not have a regular and appropriate place to sleep at night, and may include those who are either sheltered or unsheltered.1 Both groups are considered homeless, as they are unable to afford consistent living arrangements.

Of the 552,830 individuals who experienced homelessness in 2018, 64.8% stayed in homeless shelters, safe havens, and housing or transitional housing programs such as facilities that offer supportive services for 24 months.1 A 2016 breakdown demonstrated that unsheltered individuals such as those on the street, in vehicles, or in parks were more likely to be White, and sheltered individuals such as those in emergency shelters and safe havens were more likely to be Black.3 These findings have been significant across all age groups, especially among those under age 25 (see Special considerations for children who are homeless).1 California, New York, Florida, Texas, and Washington had the highest rates of homelessness, while the lowest rates were seen in Rhode Island, Nebraska, Delaware, Maine, and Washington, D.C.1

Veterans represent another demographic of homelessness.7 Although military benefits should be available to all veterans, they may still end up homeless.7 Many have health coverage from more than one source, including the US Department of Veterans Affairs and possibly Medicare or Medicaid.7 Although available, having multiple forms of coverage is not necessarily beneficial due to fragmented services, excessive costs, and possible duplication of diagnostic testing and subsequent treatment.7

Barriers to care

Some people who are homeless are employed but not earning enough to receive insurance benefits. These individuals typically place a higher value on going to work than on healthcare. The stigma of being homeless and difficulty obtaining medical care and securing prescription medications are also barriers to healthcare.8

Conditions commonly associated with homelessness include HIV/AIDS, pneumonia, dermatologic infections, behavioral health issues, substance abuse, dental disorders, foot conditions, malnutrition, diabetes, cardiovascular disease, cancer, and various communicable diseases such as hepatitis or tuberculosis.6,9 Most of these conditions require specific healthcare plans and treatments that are unavailable to patients who are homeless and receive care in the ED.6,9-11 Additionally, medications and supplies obtained for treatment are often stolen or are sold for money, food, or drugs.9

Aside from not having a stable home environment, additional barriers and obstacles affecting patient care for people who are homeless include sleep deprivation, low literacy rates, and cultural or language barriers. Patients may be unable to keep follow-up appointments due to compounded life stresses, legal concerns, lack of transportation, limited ability to communicate via telephone and social media, and reduced access to healthcare and healthcare professionals.9,12,13

Care for patients who are homeless must focus on knowledge of the healthcare system and opportunities to access care. Education on the prevention of acute and chronic conditions and overall health education and promotion is also needed.8

Barriers to care may also exacerbate chronic conditions by limiting the utilization of preventive and follow-up care.9,14 For example, people who are homeless may not be able to meet healthcare appointments or testing at the scheduled place or time due to issues with mobility, such as lack of available transportation, cab or bus fare, or a facility within walking distance.15 Similarly, education and language difficulties, poor nutrition, negative feelings of self-worth due to stigma, and issues with immigration can impede ongoing healthcare.12,13,16

Lack of insurance represents another barrier. Although Medicaid and the Affordable Care Act may qualify people who are homeless for specific services, certain states may not recognize coverage or may limit its availablity.10,17

As shelters fill, tent cities have become more prevalent. These unauthorized camp settings are located around freeways, under bridges and underpasses, in parks, and in vacant lots. With the increase in these communities, government officials must consider laws and policies to address issues such as sanitation, nutrition, water, heat, exposure to extreme weather, and healthcare concerns.9,13,14

Risk factors

Homelessness contributes to illness and disease, substance abuse, unsafe sexual practices, malnutrition, infection, cardiovascular disease, and accidents.11,18 These individuals are also at an increased risk for smoking-related complications, obesity, alcohol abuse, and limited physical activity.19 Mental illness has also been found to be prevalent in homeless populations.20,21

In a systematic review of journal articles on homelessness, the authors analyzed 45 studies related to various aspects of homelessness and its effect on healthcare. Specifically, the research examined people who are homeless with chronic illnesses and the lack of effective, continued care for their required interventions. Many studies focused on ways to promote health and prevent disease for people who are homeless, noting positive outcomes associated with case management services for effective psychiatric care, increased outpatient visits, and decreased ED or inpatient stays.15 Substance abuse also decreased by incorporating case management methods.18,21

Literature review

A 2015 study from the United Kingdom utilized a qualitative design to explore the healthcare needs of people who are homeless and their experience with healthcare.12 Three themes were identified: expressed healthcare needs, actual healthcare experiences, and the encountered attitudes of healthcare staff.12

Expressed healthcare needs. The study reflected that people who are homeless seek healthcare only when extremely sick. It identified a poor understanding among healthcare professionals that these patients were not only dealing with their homelessness, but also dealing with what caused it in the first place. For example, the death of a spouse might lead to loss of housing and addiction.12

Actual healthcare experiences. Many people who are homeless do not feel accepted and learn that having no address may result in a rejection of services. They report that only certain physicians will see them, which limits access to follow-up care. Lack of transportation or inability to travel are also barriers to follow-up care. Additionally, these individuals may not be able to follow their instructions for care due to malnutrition and exposure to harsh environments, leading to complications such as frostbite and hypothermia and limiting their ability to rest and heal.12

Attitudes of healthcare staff. The study indicated that patient care is not always focused on what a person who is homeless can realistically accomplish. Participants reported feeling that they are not always being treated as a person and cannot always follow directions; for example, elevating an extremity to decrease edema or doing daily exercises to increase mobility, lose weight, or strengthen muscles using weights that may not be readily available. Inconsistencies in healthcare systems lead to more ED visits and hospitalizations, nonadherence to patient discharge instructions, and an overall lack of appropriate care.12

Similarly, a 2014 study focused on provider perceptions and home healthcare needs from shelter staff. Primary concerns included overall health concerns for homeless populations, barriers to care, and healthcare service and support needs. Acute conditions, including communicable diseases, became worse. Within shelters, close living quarters facilitated the spread of disease. Diabetes and foot-related conditions were especially prevalent, as well as mental illness. Barriers to care included lack of trust between patients who are homeless and the healthcare staff, lack of insurance, uncertainty regarding transportation, and inability to pay for healthcare services or obtain supplies, especially those for testing blood glucose.9

Hospital and ED support staff found that shelter staff and people who are homeless did not always have the necessary supplies to provide care. Although community resources may be available for some members of the homeless community, healthcare may not be easily accessible. Additionally, access to social workers, counselors, exercise materials, and improved means of nutrition could be beneficial in the prevention and control of disease in homeless populations.9,22

Nutrition was also addressed in the literature related to patients who are homeless. Studies of homelessness have indicated a limited availability of vegetables, fruits, dairy products, and meats for these individuals.16,21 Food insecurity is prevalent and related to increased obesity rates, as people who are homeless typically consume cheap, fatty, high-calorie, and low-nutrient foods.16,19,22,23 Approximately 68.4% of participants in a Rhode Island study were either overweight or obese.16 Even in those with subsidized housing, nutrition was lacking due to other, higher priority expenses.23 Improving health equity for people who are homeless would help to reduce premature aging and high mortality in this patient population.23

Nursing considerations

Many nurses feel they lack the power to make a difference for patients who are homeless.13 Building trust and accepting an individual's situation is important. Nurses must understand what life is really like for these patients and consider why they are homeless without judgment. Discussing the specifics and logistics of a patient's needs can be daunting, so effective communication is vital. Nurses can better assess and provide individualized care for people who are homeless by using open-ended, easy-to-understand questions, an interpreter to address language barriers, and a multidisciplinary approach.13

Many patients who are homeless return to the ED with the same problems multiple times.6,13,22,24 Patient education at discharge is essential and may be inadequate for these patients as they try to obtain the necessary supplies for care.6,15,24 Nurses, case managers, and social workers must be aware of the challenges facing patients who are homeless and devise strategies to meet the required follow-up care despite these limitations.7,11,22,24

Prevention is a primary goal in healthcare and nurses can provide interventions and services to guide these patients.25 Additionally, nurses may assist patients who are homeless by providing healthcare handouts with information on food pantries, healthcare resources, and support. Access to employment opportunities, health insurance, and adequate housing can be facilitated through referrals within the community, online and print newspaper ads, and government websites and facilities.13,19,23

Soaring medical costs may leave patients who are homeless unable to access the necessary care. Nurses can assist by referring these patients, especially older individuals, to social workers and case managers. Despite the available resources, uncertain utilization remains a concern for this patient population. Not only will patients who are homeless need initial health assessments, but they will also require continued follow-up care.13,19,20 Nurses will inevitably encounter homelessness and provide interventions for these patients across the continuum of care.

Patient discharge

Depending on their condition and plan of care, patients who are homeless require healthcare education and discharge planning. This may focus on issues such as where the patient will be able to recuperate, including shelters, hospice, or a family member or friend's home; who will be providing follow-up care; what resources are available; and who will support the patient in getting to appointments, obtaining medications, and seeking care. Teaching patients to recognize early signs and symptoms of worsening conditions or complications is also crucial. Community-based services, social workers, and onsite multidisciplinary and interprofessional healthcare services in shelters are key to continuity of care.7,26

Looking forward

As the focus of research into homelessness has often dealt with homelessness as a whole rather than the healthcare needs of these individuals, many key issues have not been addressed. These include access to immunizations, health screenings, and support groups for people who are homeless from all age groups, as well as families, veterans, convicts, minority communities, and culturally diverse individuals.25 Topics for future nursing research related to homelessness may include skin care, foot care, personal hygiene, and signs and symptoms of conditions such as infections, cardiovascular disease, respiratory disease, arthritis, hypothermia, stress, and anxiety.15,25

As part of the Healthy People 2020 campaign, the CDC has developed several goals related to homelessness. These include achieving and promoting health equity, eliminating health disparities, improving health literacy, and creating healthy social and physical environments.27,28 Although there have been both improvements and shortcomings in healthcare for patients who are homeless, quantifying the details has represented a challenge.29 Identifying a systematic plan to measure change, determining the disparity gaps, and providing the appropriate interventions in patient care are areas of major importance.24

For patients who are homeless, both direct and indirect actions to promote wellness, prevent disease, and identify potential health problems early are vital. Methods to disseminate information and resources quickly and easily will help this patient population, as will multidisciplinary care and collaboration.

Although significant progress has not yet been demonstrated in addressing the needs of people who are homeless, the CDC is building upon current Healthy People objectives and improving data collection and evaluation for the future.29,30 Hopefully, continued research will reveal more strategies and interventions to benefit this underserved population.

Special considerations for children who are homeless6,13,20,25,31,32

Although this article focuses on the needs of adults who are homeless, discussion of the needs of children in the same situation should be encouraged and taken into consideration. These children may require more specialized care to address developmental issues, immunizations, mental health needs, vision and dental needs, substane abuse counseling and treatment, sexual abuse counseling and therapy, educational needs, nutritional needs, social isolation, and the identification of at-risk children. Child support agencies and educational systems provide a significant resource.

Mental illness is prominent in homeless populations, especially for young individuals experiencing social isolation and rejection. Mental illness may present as violence, aggression, depression, developmental delays, and language and reading difficulties. The lack of a stable home environment accelerates these conditions.

Those attending school may be provided with provisional assistance for their studies, as well as nutritional support and other services. Children who are homeless and not attending school, such as those on summer or winter break, may be missing important benefits from the educational environment, such as school lunches or assistance from school nurses.

Children who are homeless with their families tend to work as a team, while those who do not have the support of a family structure find other means of support. This may result in negative interactions with others, leading to crime, sexual encounters, and personal harm. The prominence of human trafficking is another concern for children who are homeless, and they may be lured into these activities with the promise of adequate shelter without understanding the consequences.

Resources

Homeless Advocacy Project

https://haplegal.org

National Alliance to End Homelessness: How to get help if you are experiencing homelessness

https://endhomelessness.org/how-to-get-help-experiencing-homelssness

Substance Abuse and Mental Health Services Administration: Homelessness programs and resources

www.samhsa.gov/homelessness-programs-resources

US Department of Health and Human Services: Resources

www.hhs.gov/programs/social-services/homelessness/resources/index.html

US Department of Housing and Urban Development: Homelessness resources

www.hud.gov/sites/documents/hudhomerefctsht.pdf

REFERENCES

1. National Alliance to End Homelessness. State of Homelessness. 2019. https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-report.
2. Henry M, Mahathey A, Morrill T, et al. The 2018 Annual Homeless Assessment Report (AHAR) to Congress. US Department of Housing and Urban Development. 2018. https://files.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf.
3. Henry M, Watt R, Rosenthal L, Shivji AAbt Associates. The 2016 Annual Homeless Assessment Report (AHAR) to Congress: November 2016. US Department of Housing and Urban Development. 2016. https://files.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf.
4. Gardiner D. Homelessness statistics in America 2019. Many Facets of Life. 2019. https://manyfacetsoflife.com/homelessness-statistics-in-america-2019.
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26. Whittaker E, Dobbins T, Swift W, Flatau P, Burns L. First examination of varying health outcomes of the chronically homeless according to Housing First configuration. Aust N Z J Public Health. 2017;41(3):306–308.
27. Centers for Disease Control and Prevention. Healthy People 2020. 2010. www.cdc.gov/nchs/healthy_people/hp2020.htm.
28. Office of Disease Prevention and Health Promotion. Healthy People 2030 Framework. HealthyPeople.gov. 2019. www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework.
29. Centers for Disease Control and Prevention. Chapter III: Overview of Midcourse Progress and Health Disparities. Healthy People 2020. 2017. www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-B03-Overview.pdf.
30. Besser R. Comments from Richard Besser, MD, on Healthy People 2030 Proposed Framework. Robert Wood Johnston Foundation. 2017. www.rwjf.org/en/library/articles-and-news/2017/09/comments-from-richard-besser-on-healthy-people-2030-proposed-framework.html.
31. Khan Z, Koehne S, Haine P, Dorney-Smith S. Improving outcomes for homeless inpatients in mental health. Housing Care Support. 2019;22(1):77–90.
32. National Network for Youth. Human trafficking and the runaway and homeless youth population. 2015. www.1800runaway.org/wp-content/uploads/2015/05/Homeless-Youth-and-Human-Trafficking.pdf.
Keywords:

community; environment; healthcare; homelessness; nurses

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