“Doris Foy’s varicose veins occasionally result in swollen ankles. When homeless, she sleeps upright, and her legs swell so severely that tissue breakdown develops into open lacerations. She covers these with cloth and stockings—enough to absorb the drainage but also to cause her to be repugnant to others because of the smell and unsightly brown stains. She is eventually brought to a clinic by an outreach worker. When the cloth and stockings are removed from the legs, there are maggots in the wounds. She is taken to the emergency room of a hospital, where her wounds are cleaned.”
The abrasive hardships of homelessness can turn manageable health problems into intolerable conditions such as that of Doris Foy. The significant and raw adversities created by poverty, unstable housing, and homelessness exacerbate physical and mental health conditions, making management of these conditions even more difficult and their presentation more prevalent among the homeless population.
Homelessness and Physical Health Conditions
Persons experiencing homelessness are three to six times more likely to suffer from serious illness and injury. A substantial proportion of the homeless population suffers from chronic health conditions such as cardiovascular disease, cancer, diabetes, asthma, and overweight/obesity. Many also suffer from infectious illnesses such as pneumonia, tuberculosis, hepatitis C, and HIV/AIDS.
In regards to children, those experiencing homelessness are twice as likely to be in poor health condition than other children. For example, they experience more ear infections, speech problems, stomach problems, and higher rates of asthma than children who are stably housed.
Homelessness and Mental Health/Substance Abuse Conditions
Nearly 112,000 persons nationwide experiencing homelessness are severely mentally ill, comprising 17.7 percent of the entire homeless population. This ratio is in stark contrast to that of the general population, where only 5 percent of population is severely mentally ill.
One study found that homeless females and low-income housed females experience more depressive disorders than the overall female population, and that one-third of homeless females have attempted suicide at least once. These high levels of mental illness and suicide risk can be attributed in part to heightened levels of domestic violence. More than 90 percent of homeless mothers are victims of domestic violence, and have three times the rate of post-traumatic stress disorder.
Substance abuse, which is also common among the homeless population, has been shown to increase risk of heart disease and other cardiovascular-related illnesses, and increase the risk of contracting sexually transmitted diseases. It also hampers efforts to seek proper care and treatment. Injections drugs increase the risk of contracting HIV. One study indicated that homeless women experience substance abuse twice as much as females in the general population, this includes 41.1 percent of homeless mothers.
Substance abuse and mental health often accompany one another, presenting as co-occurring conditions. For example, according to the most recent data available from the US Department of Housing & Urban Development (HUD), 34.7% of homeless persons in shelters experience chronic substance abuse.
And, according to HUD, 54.5 percent of homeless persons in permanent Supportive Housing programs suffered from mental illness and/or chronic substance abuse problems. However, only 24 percent of this population suffered from mental illness alone, and less than 12 percent suffered from substance abuse only, thus highlighting the prevalence of comorbid substance abuse and mental illness.
These high levels of (often co-occurring) chronic health problems, infectious diseases, mental illness, and substance abuse have ramifications that reach beyond the interpersonal and social realms. They place a constant economic strain at both local and national levels, consequently affecting the nation as a whole.
This economic strain is reflected in overtaxed emergency departments. Obstacles including, but not limited to, lack of health insurance and limited transportation force many persons experiencing homeless to turn to emergency departments for basic care. In Los Angeles for example, one-third of homeless families reported using the emergency department for their preventative and sick care. Nationwide, 63 percent of the $40.7 billion in uncompensated care left to be funded by the government is accrued in hospitals.
Yet emergency department and other hospital services provide insufficient care in treating the chronic health conditions that are so characteristic of the homeless population—they treat symptoms as opposed to the causes of the illnesses.
Causes of poor health among those children, families, and individuals experiencing homelessness has multiple causes including lack of health insurance, high copays and deductibles, and poor nutrition.
However, patterns exist in the relationship between health and homelessness. The Committee on Health Care for Homeless People observed three different types of interactions between health and homelessness:
- Health conditions can precede and causally contribute to homelessness (e.g. major mental illness such as schizophrenia).
- Some health conditions (such as that of Doris Foy) are consequences of homelessness. (e.g. malnutrition, hepatic cirrhosis, hepatitis C).
- The treatment of some health conditions is complicated by the experience of homelessness (e.g. lack of shelter beds for bed rest; inconsistent insulin treatment; barriers to therapeutic diets).
How CoCs Can Address Health Issues Among Homeless Populations
The above patterns delineate opportunities for CoCs to effectively address health issues among those experiencing homelessness in their communities. A primary method of action to address these health needs is through coordinated intake and assessment as outlined by the CoC Interim Rule.
The CoC Interim Rule provides a strategic opportunity for CoCs to develop common and streamlined processes for treating and preventing health conditions among those persons they serve. By enabling CoCs to provide consistent homeless prevention, diversion, and supportive services, coordinated intake and assessment can streamline the process of achieving continuous and comprehensive medical care for persons experiencing homelessness.
In order to achieve the level of coordinated intake and assessment necessary to address such health issues as those mentioned above, CoCs need to adopt high performing Homeless Management Information System (HMIS) solutions.
A customizable HMIS solution that is equipped with powerful reporting capabilities and is characterized by ease of use is vital to any community that is determined to address health problems among their homeless population. Such a solution can help CoCs achieve better health care, documentation, reporting, and contribute to the evidence-based decision-making that is integral in addressing the health concerns of those experiencing homelessness.
NOTE: For summary of statistics on health and homelessness see Poor Health in Homeless Families Has Far-reaching Consequences.