AT A SEASIDE resort in a southeastern state, the beaches are combed early every morning in preparation for daily visitors. Resort hotels with Caribbean motifs boast swaying palms as vacationers lounge in the pools. Benches line the pristine boardwalk.
Scattered around this picturesque place are also many homeless people—men and women, young and old. Throw pillows are scattered on a bench alongside plastic shopping bags filled with meager possessions. On the beach, a tarp has been transformed into a makeshift shelter. It won't be there long because the police have ordered it removed.
The superficial needs of this population are obvious; their underlying needs are profound. What becomes of them when winter arrives or illness strikes? Acute care nurses know all too well how challenging it can be to attend to the healthcare needs of those without insurance and a stable living situation. This article delves deeper into the multifaceted needs of this vulnerable patient population and reveals the complex set of associated challenges facing healthcare providers, and nurses in particular, when treating homeless patients.
Who are the homeless?
Each year in late January, a one-night survey called the Point-in-Time (PIT) Count is performed by agencies nationwide to estimate the number of sheltered and unsheltered homeless people. The results of the 2017 PIT Count revealed an estimated 553,742 homeless people in the United States.1 (See Homeless population demographics.)
Since 2016, the total number of homeless people increased by less than 1%. However, the number of unsheltered homeless increased by 9%, mostly in major cities.1
The number of homeless people declined by more than 14% since 2007, yet the opposite is true for some subpopulations.1 Substantial increases have been seen in the young single mother population. Many of these women are in their 20s and are fleeing abusive situations.2 Lesbian, gay, bisexual, and transgender youth experience an estimated 240,000 to 400,000 episodes of homelessness each year, preferring the streets to an unwelcoming home.3 The risk of mental disorders, sexual exploitation, substance abuse, and physical assault is elevated in this population.4
Overall, since 2009, the number of homeless veterans has decreased 45%. Yet this past year saw a slight increase (2%), which hasn't happened since 2010.1 The count on the night of the PIT report was slightly more than 40,000, and of that, an estimated 62% of these homeless veterans were in sheltered locations. Veterans are at increased risk for homelessness compared with nonveterans. Contributing factors include mental health disorders as well as behavioral disorders, including substance abuse.5
In 2016, one in five homeless people experienced persistent substance abuse or mental illness.4 Rates for serious mental illness among runaway and homeless adolescents are more than twice that of their housed counterparts. An estimated 33% of homeless adults have a serious mental illness, such as bipolar disorder or schizophrenia.
Nearly 90% of youths who are marginally housed or unsheltered experience psychiatric disorders at a rate four times greater than that of their housed counterparts. Additionally, nearly 70% experience more than one psychiatric disorder.6 Given that certain mental illnesses typically manifest with youth onset, it's unknown whether this perpetuates chronic homelessness throughout the lifespan, or whether youth homelessness is a catalyst for serious mental illness in adulthood.7
Alcohol and/or drug abuse affects as many as 75% of homeless youths, and many self-report this as a mechanism that helps them deal with their situation.7 Substance abuse and homelessness share many risk factors, and they're closely related.8
Frameworks for care
Morbidity and mortality are higher among homeless people compared with those in the general population. Food and shelter may be scarce, and illnesses are often ignored.9 Maslow's hierarchy of needs presents the caregiver with a framework within which to prioritize care. It's universally applicable to patients with diverse healthcare needs in various healthcare settings.
Maslow's hierarchy requires meeting the most basic physiologic needs before addressing other needs. Contending with weather extremes is an example of meeting physiologic needs.10 Once these basic needs are met, higher-level needs such as safety and security can be addressed.
The moral-ethical foundation of Jean Watson's theory of human caring provides a useful framework for meeting the diverse needs of homeless people. (See Jean Watson's theory of human caring.) Nursing's vocation is to tend to the needs of patients during their most vulnerable times. Nurses must be sensitive to those needs and develop a caring, helping, trusting relationship with their patients. Nurses must support and protect each person's individuality, eschew stereotyping, and communicate respect.2 Nurses applying Watson's theory accept people as they are now, protecting each one's dignity in a healing environment.12 Each person is accepted for his or her individuality and worth. Effective caring promotes health and individual growth.
In one study, shelter workers identified the healthcare issues of the population they served. Commonly seen disorders included diabetes, hypertension, and pulmonary disease. Lower extremity ulcers were frequently seen, especially in patients with diabetes. Barriers to care included language and literacy deficiencies, as well as unaffordable, stolen, or lost medications.9
Homeless individuals are also susceptible to chronic diseases and violence.13 They experience physical illness at rates up to six times that of housed people by some estimates.14 Compared with their housed counterparts, homeless people over age 50 experience elevated rates of impairment and disability, including depression, reduced ability to perform activities of daily living, cognitive impairment, and mobility difficulties.15
Homeless seniors are identified as age 50 or older in most studies. Mortality is elevated in this population, with many homeless men dying in their early 50s due to their unique health problems. In 1990, the average age of homeless men and women was 37 years; today that average is closer to 50.16
Another recent study at a homeless shelter found that more than half the people surveyed were amenable to making lifestyle changes in areas contributing to poor health, such as obesity, lack of physical activity, and smoking. However, only 31% of those surveyed expressed the desire to curtail their alcohol intake. Traditionally, homeless shelters place more emphasis on alcohol and substance abuse cessation than on nutrition, diet, and smoking.17 Although substance abuse cessation is important, many chronic diseases are related to other poor health practices. Nurses can have a positive impact in educating and guiding patients in these areas.
Homeless people utilize the ED at a rate three times that of the housed population, which is an expensive and short-lived solution that does little to address their long-term healthcare needs.18 It's common practice to advise patients to return to the ED if their symptoms don't improve.19 This practice perpetuates the cycle of overuse.
Homeless people are also hospitalized at higher rates than their housed counterparts.9 Caring for homeless people after discharge from an acute care facility is challenging. Lack of health insurance is a major deterrent in arranging postdischarge care. Healthcare providers must be aware of available services for patients with nonemergent conditions and refer patients to continuing care in an outpatient setting.19 Interdisciplinary collaboration with social workers and case managers can facilitate referrals.
Accessing primary care is challenging for homeless people, especially those seeking treatment for mental illness and/or substance abuse.1 The Institute of Medicine report in 1988 was the impetus for improving healthcare for the homeless, ultimately resulting in the formation of a network of Health Care for the Homeless (HCH) projects in the United States, which now serve approximately 800,000 annually in over 200 facilities. Each facility must offer treatment for substance abuse. However, despite this progress, a survey of 966 homeless adults accessing care at the HCH clinics found that nearly three-quarters of the respondents reported at least one unmet health need, such as prescription medications or dental care. Unmet mental healthcare was reported by 21% of the respondents.16
It was believed that the Affordable Care Act (ACA) would make health insurance available through Medicaid coverage to approximately 1.2 million homeless people. Some suggested that many homeless people would either be unaware of their eligibility, or they'd be more concerned with the daily struggles of finding housing, work, or surviving, and wouldn't seek or obtain insurance coverage. This seems to have some validity, as one study found that 26% of homeless people seen in one ED had never heard of the ACA compared with just 10% of housed people.16
One of the provisions of the ACA was the optional state expansion of Medicaid coverage, resulting in eligibility for many homeless people previously excluded.20,21 Yet, many homeless people are unsure if they qualify for Medicaid coverage. This was the case in one ED where 91% of the homeless people who weren't sure if they qualified actually did qualify. Changes recently made to Medicaid have expanded coverage to the homeless through HCH clinics. Medicaid expansion states reported coverage increases of 50% from 2012 to 2014, compared with just 15% in states that didn't participate in the Medicaid expansion.16
Facilities in participating states can help homeless patients apply for coverage.21 Agencies must take appropriate action to notify eligible patients of coverage opportunities, especially those who are recently homeless and may be unaware of available resources.22 Nurses interacting with the homeless population in all practice settings must be familiar with possible pathways to coverage and guide patients by making appropriate referrals or providing information.
The National Academy of Medicine, formerly called the Institute of Medicine, advocates for professional nurses to act as care coordinators, primary care providers, and health coaches, and to shift from acute care settings into the community. Nurses must look forward and explore practice beyond traditional settings. Community health centers and soup kitchens may act as venues to inform homeless people of available services.23
Nurse navigators guide patients in overcoming barriers to healthcare, providing education and offering psychosocial support. Positive patient outcomes in such areas as cancer care and heart failure have been reported so far when navigator programs are utilized.24 Expanding the role of the nurse navigator to the homeless population may be an area for consideration in EDs and clinics.
Homeless people sometimes perceive healthcare providers as uncompassionate, disrespectful, and untrustworthy.14 Nursing students and nurses must be sensitive to the diverse backgrounds and cultural beliefs of the homeless population and how these elements affect both the patient's perceptions and the nurse's interventions. Dissimilarities between healthcare providers and homeless people shouldn't be an obstacle to providing care to this population.2 Clinical experiences with homeless people give nursing students firsthand exposure to the unique needs and challenges this population presents. Comprehension is enhanced when experiential learning opportunities are presented.25
The Institute of Medicine report on the future of nursing recognized nursing as a fundamental factor in transforming healthcare in the United States.6 It's simply not enough for nursing students to read or study about the homeless population. They must be able to assimilate this knowledge and apply it comprehensively and compassionately into their care. Increased exposure to vulnerable populations helps students better realize the multifaceted challenges they'll face as healthcare professionals.
Equipped for success
Homelessness is a pervasive problem in our cities, suburbs, rural areas, and resorts. Although strides have been made to reduce the number of homeless people, much work remains. Their healthcare needs are vast. Each person's circumstances present unique obstacles to overcome. Exposing nursing students to the needs of homeless people will equip students with the knowledge, skills, and attitudes necessary to provide culturally competent and compassionate care.
Homeless population demographics1
The following statistics are provided by the 2017 PIT Count.
- Nearly 61% of homeless people were men.
- Approximately 39% were women.
- Less than 1% were transgender or didn't identify.
Sheltered vs. unsheltered homeless people
- Approximately 65% were sheltered in emergency shelters or transitional housing programs.
- Approximately 35% were in unsheltered locations.
Homelessness in families with children
- Approximately 33% of the homeless population were people in families with children.
- This number has declined 5% from 2016 to 2017.
Unaccompanied homeless youth
- Approximately 88% of unaccompanied homeless youth were between ages 18 and 24. The PIT Count defines unaccompanied youth as people under age 25 experiencing homelessness on their own.
- Approximately 55% of unaccompanied youth were unsheltered.
Jean Watson's theory of human caring11
The nurse creates a caring relationship that will heal the body, mind, and soul. Watson's 10 carative factors provide the foundation for the nurse to provide a deeper, more genuine relationship with the homeless patient. The nurse respects and honors the dignity of others, is available, and supports one's sense of hope in a nonjudgmental atmosphere. The nurse anticipates the needs of others and creates an environment that enables spiritual, emotional, and physical healing.
2. Gerber L. Bringing home effective nursing care for the homeless. Nursing
3. Ream GL, Forge NR. Homeless lesbian, gay, bisexual, and transgender (LGBT) youth in New York City: insights from the field. Child Welfare
5. Metraux S, Clegg LX, Daigh JD, Culhane DP, Kane V. Risk factors for becoming homeless among a cohort of veterans who served in the era of the Iraq and Afghanistan conflicts. Am J Public Health
. 2013;103(suppl 2):S255–S261.
6. Poghosyan L, Nannini A, Clarke S. Organizational climate in primary care settings: implications for nurse practitioner practice. J Am Assoc Nurse Pract
7. Childress S, Reitzel LR, Maria DS, Kendzor DE, Moisiuc A, Businelle MS. Mental illness and substance use problems in relation to homelessness onset. Am J Health Behav
8. Lowe J, Gibson S. Reflections of a homeless population's lived experience with substance abuse. J Community Health Nurs
9. Hauff AJ, Secor-Turner M. Homeless health needs: shelter and health service provider perspective. J Community Health Nurs
12. Lukose A. Developing a practice model for Watson's theory of caring. Nurs Sci Q
13. de Chesney M, Anderson BA. Caring for the Vulnerable. Perspectives in Nursing Theory, Practice and Research
. 2nd ed. Sudbury, MA: Jones & Bartlett Publishers, LLC; 2008.
14. Loewenson KM, Hunt RJ. Transforming attitudes of nursing students: evaluating a service-learning experience. J Nurs Educ
15. Culhane DP, Metraux S, Byrne T, Stino M, Bainbridge J. The age structure of contemporary homelessness: evidence and implications for public policy. Anal Soc Issues Public Policy
16. Donley AM, Wright JD. The health of the homeless. Sociol Compass
17. Taylor EM, Kendzor DE, Reitzel LR, Businelle MS. Health risk factors and desire to change among homeless adults. Am J Health Behav
18. Wise C, Phillips K. Hearing the silent voices: narratives of health care and homelessness. Issues Ment Health Nurs
19. Parker RD, Dykema S. The reality of homeless mobility and implications for improving care. J Commun Health
20. Kozloff N, Cheung AH, Ross LE, et al Factors influencing service use among homeless youths with co-occurring disorders. Psychiatr Serv
21. Tsai J, Rosenheck RA, Culhane DP, Artiga S. Medicaid expansion: chronically homeless adults will need targeted enrollment and access to a broad range of services. Health Aff (Millwood)
22. Weber M, Thompson L, Schmiege SJ, Peifer K, Farrell E. Perception of access to health care by homeless individuals seeking services at a day shelter. Arch Psychiatr Nurs
23. Su Z, Khoshnood K, Forster SH. Assessing impact of community health nurses on improving primary care use by homeless/marginally housed persons. J Community Health Nurs
24. Pruitt Z, Sportsman S. The presence and roles of nurse navigators in acute care hospitals. J Nurs Adm
25. Garner L. Reducing barriers to healthcare for rural homeless individuals and families: experiences of community health nursing students. Online J Rural Nurs Health Care