Caring for Older Homeless Adults

Transcription

1 Partner Logo Caring for Older Homeless Adults Margot Kushel, MD Professor of Medicine UCSF/ZSFG Objectives Define homelessness Review demographics of aging homeless and at-risk population Review risk factors for homelessness Discuss approaches to improve medical care of homeless older adults 2 Which of the following older adults would you screen for homelessness? What is the Problem? A. 52 year old man with chronic alcohol use disorder B. 86 year old Spanish speaking woman with severe depression, born in Mexico, accompanied by her 62 year old daughter C. 73 year old woman, retired former skilled tradesperson; no SU or MH history D. 56 year old man, African- American, 20 year past h/o incarceration, on opioid replacement therapy 71% 29% 0% 0% 5 2 y e a r o l d m a n w i t h c h r y e a r o l d S p a n i s h s p e a y e a r o l d w o m a n, r e t i r y e a r o l d m a n, A f r i c a... Homeless population is aging Median age of single homeless population now over 50 Homeless adults have health problems similar to those years older Considered older by age 50 Hahn et al JGIM 2006 Culhane ASAP 2013 Brown et al JGIM 2012 Brown et al Gerontologist Presentation Title and/or Sub Brand Name Here 1

2 Definition of Homelessness Lacks fixed, regular night time residence (includes emergency shelter) Imminently lose their nighttime residence (within 14 days) Fleeing, or attempting to flee, interpersonal violence, stalking, sexual violence (Expanded definition for children/youth) Homeless Emergency Assistance and Rapid Transition to Housing Act 2009 (HEARTH ACT) Homelessness is state and not trait Older age at onset of homeless associated with increased risk of chronic homelessness Chronic homelessness Homeless person with a disability AND Homeless for >12 months OR Four or more times in prior 3 years, totaling >12 months Most people who become homeless do not become chronically homeless, but older adults at higher risk Chronic Homelessness Final Rule 2015 (HUD, Defining Chronic Homelessness 2007) Living situations vary Why do people become homeless in late life? In safety net settings, many individuals may live with housing instability/informal arrangements couch surfing w/o leases, guarantees Garages/trailers Overcrowded housing And go back and forth between homeless and not homeless Evictions Job loss Marital/relationship dissolution Death of spouse Death of elderly parent (with whom living) Death or job loss of roommate Health crisis 2

3 What factors heighten risk of homelessness in older adults? POVERTY African-American Native American LGBTI History of incarceration Mental health or substance use problems Adverse childhood experiences Social isolation??immigrant communities Why is homeless population aging? People born in latter half of baby-boom ( ) have had lifetime elevated risk of homelessness Among homeless people aged 50 and older, 43% never homeless prior to age 50 Nationwide 1/3 renters aged 50+ are housing cost burdened paying >30% household income in rent Increasing numbers severely cost burdened paying >50% in rent Worse in high cost areas Hawaii and California with highest housing costs nationwide Culhane ASAP 2013 Harvard Joint Center for Housing Studies 2014 Homelessness and Health Homelessness associated with poor health outcomes, likely causal Homelessness associated with underuse of non-ed ambulatory care, increased use of acute care (ED use and hospitalization) Associated with poor quality of life and increased mortality Hwang CMAJ 2001 Baggett JAMA Int Med 2013 Hwang AHRQ 2010 Fazel Lancet 2015 Older Homeless Adults Leading cause of death cardiovascular and cancer years earlier than general population High prevalence of geriatric conditions 20 years earlier than general population Increased likelihood of progression to skilled nursing facility (SNF) Concerned about mortality, but few discussed advance care planning (ACP) with healthcare providers Baggett JAMA Int Med 2013 Brown Gerontologist 2016 Song JGIM

4 What is role of healthcare providers/teams in safety net settings? Screen for risk of homelessness and homelessness Refer at-risk for prevention efforts Adapt care for those who are homeless Collect multiple contacts Consider loosening targets avoid iatrogenesis Screen (and treat/refer) for mental health and substance use problems, geriatric conditions Advance care planning/end of Life issues Know local resources and refer Permanent Supportive Housing Medical Respite Rapid Rehousing No validated screening tool for homelessness or risk of homelessness Screen for homelessness Screen for risk of homelessness Recommend against using Are you homeless? Normalize homelessness Many of our patients are finding it difficult to have a regular place to stay. Ask: Have you been without a regular place to stay in the past month? Have you stayed in a shelter/outdoors/car? If staying with friends/family ask: Can you stay there as long as you would like? Do you stay the same place every day? Do you have difficulty paying rent, mortgage or utilities? Have you fallen behind in your rent? What proportion of your total household income is going towards housing? (>50% high risk) Are you worried you will be evicted/asked to leave? Are you worried that someone else who helps you pay for your rent won t be able to pay? Is your name on the lease? 4

5 Screen for risk of homelessness Be aware of high risk periods Death of household member Job loss (patient or household member) Illness/injury (patient or household member) Why ask? Even if you can t do anything, it will help you understand your patient and build trust Be aware of stigma and stigmatizing language Refer to appropriate programs Recognize that not all will want to go to shelter settings even if available Most shelters require residents to leave during day Gather contact information Where do you stay Is there anyone who may be in touch with you? Is there any place you attend regularly where I could leave messages? (church, senior center, food program) Key referrals for those at-risk of losing housing Code it! Homelessness/eviction prevention Short and medium term rental subsidies, utility deposits and payments, legal services Case management Housing search and placement Credit repair Housing Circumstance Affecting Care Z59.9 Homelessness Z59.0 Legal resources Seniors and people with disabilities may have extra protections beyond general tenancy protections 5

6 Avoid Iatrogenesis High fall risk and lack of regular access to food Consider loosening control of blood pressure, diabetes Lack of toileting, bathing and cooking facilities Diuretics, medications that cause diarrhea Feet and skin care Avoid medications that require refrigeration If use opioids: Small quantities with frequent refills and NALOXONE Prior to sending screening tests, ask Do you have follow-up for abnormal results? Will patient be able to do follow-up test (i.e. FIT colonoscopy) Mental Health and Substance Use Problems High prevalence of mental health and substance use problems Screen for Depression, post traumatic stress disorder PHQ 9 or Geriatric Depression Screening Tool Primary Care PTSD Screener Alcohol and Substance Use Disorder AUDIT and ASSIST Tobacco use 5As (Ask, Advice, Assess, Assist, Arrange) 22 Geriatric Conditions Geriatric Conditions Cognitive Impairment ADL and IADL impairments Mobility impairments, Falls Urinary incontinence Depression Vision and hearing impairments Common Severe Onset much earlier than general population 6

7 Screen, starting at 50 Life threatening conditions and mortality Cognitive Impairment Mini Cog, MOCA Homeless adults are worried about dying ADL and IADL impairments High prevalence of personal experience of death Katz ADL, BIFS (adapted IADL) Close family member, witnessing death Mobility impairments/falls Do you have difficulty walking across a room Have you fallen in the prior six months? Timed Get Up and Go Test Urinary Incontinence Screen, recognize role of environment! Worries include: No one will find them Wishes won t be followed Won t be remembered or memorialized Concerns about what will happen to their bodies after death Song JGIM 2007 Hearing and vision Advance Care Planning and End of Life Care Know Key Interventions Don t assume estrangement from family, but if patient expresses reluctance or resistance, respect that Homeless individuals can be engaged in ACP Issues include documentation and communication of wishes Housing First Permanent Supportive Housing Medical Respite Rapid Rehousing Make effort to do and to be thoughtful about how decisions relayed to treating facilities Recognize that home hospice is not option if someone is living on streets Consider: Respite Care, PSH, hospice within SNF

8 Housing First Permanent Supportive Housing Medical Respite Subsidized housing with on-site or closely linked supportive services Low barrier to entry: no requirements of sobriety or adherence to mental health plans prior to housing Tenant has tenancy rights For veterans, called HUD-VASH Permanent-Supportive-Housing-Brief.pdf ndian_housing/programs/hcv/vash Acute and post-acute care for homeless individuals too ill to be on street, but not meeting requirement for hospitalization Variety of settings Shelters, freestanding facilities, SNF, transitional housing National Health Care for the Homeless Council Rapid Rehousing For people who meet Federal criteria for homelessness Temporary financial assistance and services to return people experiencing homelessness to permanent housing Summary Median age of homeless population is increasing Median age >50 Almost half of older homeless newly homeless in older age Screen and refer to services for both homelessness and risk of homelessness Think about homelessness risk and refer for prevention efforts! Homelessness associated with poor health outcomes Adapt care as appropriate Collect contacts Loosen targets Consider medication side effect profile Think before sending screening tests! 32 8

9 Summary Mental health, substance use problems and geriatric conditions prevalent and start early Screen for them and treat as possible Address concerns about dying, end of life care Discuss fears openly Engage in advance care planning Recognize challenging in EOL care Know key interventions Housing First Permanent Supportive Housing Medical Respite Rapid Rehousing 33 9