Partner Logo Issues in the Care of Homeless Adults Margot Kushel, MD Professor of Medicine UCSF/ZSFG @mkushel Objectives Strategies to screen for homelessness Understand risk factors for homelessness Know management principles and best practices Understand resources for homelessness 2 Which of the following older adults would you screen for homelessness? A. 23 year old full time student at local community college 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. 35 year old man with new diabetes, night cleaning staff at local hospital 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) 3 4 1
Homelessness is common Special Populations Estimated 2.5-3.5 million people experience homelessness in US annually Chronic homelessness decreasing with interventions Over 1/3 of those who experience homelessness are individuals in families Young mothers with children at high risk Median age of single adults rising Those born between 1954-1964 at elevated risk 13% community college students homeless Homeless population is aging Median age of single homeless population now over 50 Homeless adults have health problems similar to those 15-20 years older Considered older by age 50 Hahn et al JGIM 2006 Culhane ASAP 2013 Brown et al JGIM 2012 Brown et al Gerontologist 2016 5 6 Why is homeless population aging? People born in latter half of baby-boom (1954-1964) have had lifetime elevated risk of homelessness Among homeless people aged 50 and older, 44% 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 7 8 2
Older Homeless Adults Leading cause of death cardiovascular and cancer 15-20 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) Homelessness is state and not trait For most people, homelessness lasts less than a year 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 Baggett JAMA Int Med 2013 Brown Gerontologist 2016 Song JGIM 2008 9 10 (HUD, Defining Chronic Homelessness 2007) Living situations vary Management of patients experiencing homelessness 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 Many at risk for eviction despite being up to date on rent due to overheated housing market Screen for risk of homelessness and homelessness Refer at-risk for prevention efforts Adapt care for those who are homeless Know local resources and refer 11 12 3
What factors heighten risk of homelessness? POVERTY African-American Native American LGBTI History of incarceration Mental health or substance Prior history of homelessness use problems Spending 50% household Adverse childhood experiences income on rent Social isolation Immigrant communities Being a new mother Interpersonal violence Low wage work Chronic health problems No validated screening tool for homelessness or risk of homelessness 13 14 Screen for homelessness at every visit Screen for risk of homelessness at every visit 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? 15 16 4
Screen for risk of homelessness at every visit Key referrals for those at-risk of losing housing Be aware of high risk periods Interpersonal violence Birth of new child (younger mothers at high risk) Death of household member Job loss (patient or household member) Illness/injury (patient or household member) Incarceration Homelessness/eviction prevention Short and medium term rental subsidies, utility deposits and payments, legal services Case management Housing search and placement Credit repair Legal resources Seniors and people with disabilities may have extra protections beyond general tenancy protections 17 18 Gather contact information Environment: Use stigma-free language How do you prefer to be contacted? Do you have a phone? If mobile phone: most are month to month, number may change Where do you stay? (Get specifics) Is there anyone who may be in touch with you? Is there any place you attend regularly where we could leave messages? (church, senior center, food program) Where do you stay? What is your transportation? Is there place to stay during day? Do you have a bed? Do you have storage? Place to store medications? Refrigeration? How do you obtain/store/prepare food? Bathing facilities? Fall risks? Do you feel safe? Is facility smoke free? 19 20 5
The more you understand your patient s lived experience, the better your care plan will be Engage patients in developing treatment plans People who experience homelessness are experts in their own lives Management Principles Ask about and understand competing risks Recommend behavioral risk reduction where appropriate Keep medication regimens simple Avoid need for refrigeration; consider food access; side effects (toileting) Consider loosening targets Avoid iatrogenesis Before sending tests, have plan on conveying results, reaching for follow-up Consider sending STAT tests while patient waits or having patient scheduled to check in within a few days 21 22 Offer health promotion and disease prevention Annual PPD testing (consider quantiferon so no return visit) When doing testing (i.e. pap, mammo), be sure you have contact info for follow up Address contraception needs; offer long-acting removable contraception Only start colon cancer screening if you have plan to do colonoscopy Vaccinations! HIV rapid testing; STI testing Violence screening Tobacco TOBACCO: Assess and treat at EVERY visit 5As (Ask, Advice, Assess, Assist, Arrange) Screen, assess readiness to quit, brief counseling, NRT Ask about smoke free policies at shelters or other places participants stay in 23 24 6
Pain and Symptoms Mental Health and Substance Use Problems High prevalence of chronic non-cancer pain Multifactorial causes Be thoughtful about use of opioid analgesics; avoid where possible For older homeless adults, consider screening for symptoms Fatigue/insomnia Pain Guilt, regret Loneliness 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 25 26 Screen for geriatric conditions, starting at 50 Cognitive Impairment Mini Cog, MOCA ADL and IADL impairments Katz ADL, BIFS (adapted IADL) 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! Hearing and vision Life threatening conditions and mortality Homeless adults are worried about dying High prevalence of personal experience of death Close family member, witnessing death 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 27 28 7
Advance Care Planning Code it! 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 Make effort to do and to be thoughtful about how decisions relayed to treating facilities Housing Circumstance Affecting Care Z59.9 Homelessness Z59.0 29 30 Know Key Interventions Housing First Permanent Supportive Housing Housing First Permanent Supportive Housing Medical Respite Rapid Rehousing 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 https://www.hudexchange.info/resources/documents/housing-first- Permanent-Supportive-Housing-Brief.pdf http://portal.hud.gov/hudportal/hud?src=/program_offices/public_i ndian_housing/programs/hcv/vash 31 32 8
Medical Respite Rapid Rehousing 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 https://www.nhchc.org/resources/clinical/medicalrespite/ For people who meet Federal criteria for homelessness Temporary financial assistance and services to return people experiencing homelessness to permanent housing http://www.endhomelessness.org/pages/rapid-rehousing 33 34 Summary Summary Homelessness common in safety net settings Young mothers with children are at high risk Median age single adults about 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 Mental health, substance use problems and geriatric conditions prevalent and start early Screen for them and treat as possible Engage in advance care planning Know key interventions 35 36 9