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p 1 Ems Committec on Health Care for Homeless People INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washinglon, D.C. 1988

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National Academy Press ~ 2101 Constitution Avenue, NW ~ Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. The work on which this publication is based was performed pursuant to Contract No. 240-86- 0073 with the Health Resources and Services Administration of the Department of Health and Human Services. Additional support for this study was contributed by the Veterans Adminis- tration and the National Research Council (NRC) Fund. The NRC Fund is a pool of private, discretionary, nonfederal funds that is used to support a program of Academy-initiated studies of national issues in which science and technology figure significantly. The NRC Fund consists of contributions from a consortium of private foundations including the Carnegie Corporation of New York, the Charles E. Culpeper Foundation, the William and Flora Hewlett Foundation, the John D. and Catherine T. MacArthur Foundation, the Andrew W. Mellon Foundation, the Rockefeller Foundation, and the Alfred P. Sloan Foundation; the Academy Industry Program, which seeks annual contributions from companies that are concerned with the health of U.S. science and technology and with public policy issues with technology content; and the National Academy of Sciences and the National Academy of Engineering endowments. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Health Care for Homeless People. Homelessness, health. and human needs / Committee on Health Care for Homeless People. institute of Medicine. P. cm. Includes bibliographies and index. 1SBN 0-309-03835-9. 1SBN 0-309-03832-4 (pbk.) 1. HomelessnessHealth aspectsUnited States. 2. PoorMedical careUnited States. 1. Title. [DNLM: l. Delivery of Health CareUnited States. 2. Health Services AccessibilityUnited States. 3. Homeless persons. WA 300 159h] RA770.146 1988 362. 1 '08806942~c 1 9 DNLM/DLC for Library of Congress 8-25466 CIP Cover art by John Jenkins, a free-lance artist working in New York City, whose experience as a homeless man in the shelter system provided the basis for this drawing. Reprinted, with permission, from Working with Homeless People: A Guide for Staff and Volunteers (rev. ed.), Amy Haus, editor. New York City: Columbia University Community Services, 1988. Copyright ~ 1988 by the National Academy of Sciences Printed in the United States of America First Printing, September 1988 Second Printing, February 1989 Third Printing, May 1989

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Committee on Health Care for Homeless People BRUCE C. VLADECK (Chairman),* President, United Hospital Fund of New York, New York City DREW ALTMAN, Commissioner, New Jersey Department of Human Services, Trenton ELLEN L. BASSUK, Associate Professor of Psychiatry, Harvard Medical School WILLIAM R. BREAKEY, Associate Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University A. ALAN FISCHER,* Professor and Chairman, Department of Family Medicine, Indiana University School of Medicine CHARLES R. HAEPERN,* Professor of Law, City University of New York Law School at Queen's College JUDITH R. LAVE, Professor, Department of Economics, University of Pittsburgh JACK A. MEYER, President, New Directions for Policy, Washington, D.C. GLORIA SMITH, Commissioner, Michigan Department of Public Health, Lansing (currently Dean, College of Nursing, Wayne State University) LOUISA STARK, Adjunct Professor, Department of Anthropology, Arizona State University NATHAN STARK,* Kominers, Fort, Schlefer and Boyer, Washington, D.C. MARVIN TURCK, Associate Dean and Professor of Medicine, University of Washington, and Medical Director, Harborview Medical Center, Seattle PHYLLIS WOLFE, Executive Director, Robert Wood Johnson/Pew Memorial Trust Health Care for the Homeless Project, Washington, D.C. Study Staff, Division of Mental Health and Behavioral Medicine ALAN R. SUTHERLAND, Study Director DEBORAH S. SWANSBURG, Program Officer JAMES R. BRUNER, Study Secretary/Project Assistant FREDRIC SOLOMON, Director, Division of Mental Health and Behavioral Medicine ELIZABETH H. KITSINGER, Division Secretary *Member, Institute of Medicine. iii

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Preface This study was undertaken at the request of the U.S. Congress as stated in the Health Professionals Training Act of 1985 (P.L. 99-1291. The act directed the secretary of the Department of Health and Human Services to arrange with the National Academy of Sciences, through its Institute of Medicine, for a study of the delivery of inpatient and outpatient health care services to homeless people. That provision was one of various legislative initiatives concerning the growing problem of home- lessness that the Congress has considered in recent years (see Appendix A). The congressional mandate in P.L. 99-129 was implemented in October 1986, when the Department of Health and Human Services, through its Health Resources and Services Administration, entered into a contract with the Institute of Medicine. Additional funding was provided by the National Research Council and, subsequently, by the U.S. Veterans Administration. The study was directed at three tasks specified in P.L. 99-129: (1) an evaluation of whether the eligibility requirements in existing health care programs prevent homeless individuals from receiving health care ser- vices; (2) an evaluation of the efficiency of the delivery of health care services to homeless individuals; and (3) recommendations for activities by federal, state, local, and private entities that would improve the availability of health care service delivery to homeless individuals. As in all studies done under the auspices of the National Academy of Sciences, the first step in the process was to select a committee of knowledgeable people to conduct the study. A 13-member panel was drawn from the disciplines of anthropology, economics, epidemiology, family and internal medicine, law, nursing, political science, psychiatry, v

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Vi PREFACE public administration, and social work. At its initial meeting in December 1986, the Committee on Health Care for Homeless People adopted the following approach for the study. Recognizing the limitations of the research literature on homeless people, their health problems, and the health services they receive, the committee directed a search of unpublished reports as well as published studies and documents. To supplement the existing literature, the com- mittee commissioned the following 10 papers written by experts on subjects of special concern: "Legal Barriers to Access: The Unmet Health Care Needs of Homeless People," Arlene Ranter; "A Critique of the Methodologies of Counting the Homeless,', Charles Cowan, William Breakey, and Pamela Fischer; "Rural Homelessness," Lawrence Patton; "The Dynamics of Homelessness," Russell Schutt; "Homelessness: A Medical Viewpoint," William Vicic and Patricia Doherty; "Shelter and Health Care of Homeless Families, Homeless Children, Homeless Adult Individual Females, and Homeless Battered Women and Their Children," Deborah Reisman Fink; "Ancillary Health Care Services for Homeless Persons: Availability and Delivery," Marianne Gleason; "Mental Health and the Homeless Population," Andrew Ziegler; "Alcohol Problems Among the Contemporary American Homeless Population: An Analytic Review of the Literature,'' Pamela Fischer; and "Illicit Substance Abuse Among the Homeless," Virginia Mulkern. Significant findings from these papers are incorporated throughout this report; two papers, those on the methodologies of counting the homeless and on the homeless in rural areas, are included as Appendixes B and C, respectively. The committee regarded both the gaps in data and the desirability of first-hand acquaintance with homelessness as reasons to conduct site visits. Members of the committee, accompanied by Institute of Medicine staff and consultants, visited 11 cities and (with separate funding from the Department of Health and Human Services) rural areas in four states to learn the characteristics of homelessness in those communities and the nature of health services directed to homeless people. These sites were selected not as a representative sample of programs for the homeless but, rather, as potential models of service delivery. At the same time, by interviewing both homeless individuals and people attempting to help the homeless, committee members were able to assess the validity of many findings that appear in the literature.

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PREFACE Vii The committee benefited greatly from the assistance of the national Health Care for the Homeless program of the Robert Wood Johnson Foundation and the Pew Memorial Trust. The directors and staff members of the 19 projects supported by these foundations provided much valuable information for this report. In addition, the Social and Demographic Research Institute of the University of Massachusetts at Amherst, which is under contract with the Robert Wood Johnson and Pew foundations to provide program monitoring and evaluation, generously shared its data and undertook special analyses on the committee's behalf. This report begins by trying to answer the question, "Who are the homeless?" To dispel myths about homelessness and to provide infor- mation about its causes, Chapter 2 discusses the dynamics of homeless- ness. Chapter 3 describes the health problems of homeless people. Chapter 4 describes the major barriers homeless people encounter in their effort to obtain health care. Chapter 5 examines health care and health-related service programs designed to meet the special needs of homeless people. Chapter 6 summarizes the committee's findings and sets forth its recommendations. Two aspects of the work of the committee warrant further explanation. First, although the committee's charge was fairly narrow, its examination perforce was fairly broad. Early in the study, the committee determined that the specific aspects of health and health care contained in the congressional charge could not be separated from many aspects of homelessness itself. The second has to do with the relative amounts of attention, both in the study and in the report, invested in specific health problems and particular subpopulations of the homeless. Reports of studies of some health problems common among homeless people, such as alcoholism or mental illness, are numerous and readily available; these could be summarized rather succinctly. Information on other types of health- related problems, however, often was more anecdotal or based on very recent data, some of which were provided especially for use in this study. Therefore, parts of this report may appear to place greater or lesser emphasis on certain problems than might seem to be warranted by their actual proportion among the hardships of the homeless. The report, in response to P.L. 99-129, is directed to the United States Congress and to policymakers on the national, state, and local levels, but the committee hopes it will also be of value to those who work directly with the homeless and to the average citizen who has concern for them. * * * * *

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viii PR E FA C E As chairman of the committee responsible for this report, I want to take this opportunity to thank my colleagues on the committee for their dedication, patience, and extremely hard work on this study. I also wish to acknowledge the many people outside the Institute of Medicine who gave so generously of their time to help enrich our study (see Appendix E). In addition to the authors of commissioned papers listed in the Preface, we take particular note of the contributions of Pamela Fischer of John Hopkins University; Deborah Franklin, a doctoral student in history of science at the University of Pennsylvania; Max Michael of the University of Alabama at Birmingham Medical Center; and James Wright of the University of Massachusetts. I owe a particularly large debt of personal gratitude to Susan Neibacher, director of the New York City Health Care for the Homeless Program at the United Hospital Fund, who generously served, with her customary great patience and tolerance, as my personal guide through the thicket of issues the committee encountered on homelessness. None of these efforts, of course, would have produced a report without the intensive labors of a dedicated professional staff at the Institute of Medicine, especially the study director, Alan Sutherland, and his deputy, Deborah Swansburg. An especially large thank you is owed to their supervisor, Fredric Solomon, director of the Division of Mental Health and Behavioral Medicine, and to the Institute's Associate Executive Officer for Programs, Marian Osterweis. BRUCE C. VLADECK, Chairman Committee on Health Care for Homeless People

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Contents 1 WHO ARE THE HOMELESS? INTRODUCTION, 1 DEFINITION OF HOMELESS, 2 COUNTING THE HOMELESS, 2 STUDIES OF HOMELESSNESS, 4 CHARACTERISTICS OF HOMELESS PEOPLE, 5 Homeless Individual Adults, 6; Homeless Families, l l; Homeless Runaway and Throwaway Youths, 14; Homeless Elderly People, 15; The Rural Homeless, 17 SUMMARY, 17 REFERENCES, 18 2 DYNAMICS OF HOMELESSNESS INTRODUCTION, 22 PATTERNS OF HOMELESSNESS, 23 HOUSING, 25 INCOME AND EMPLOYMENT, 26 DEINSTITUTIONALIZATION, 28 Mental Health System, 28; Other Systems, 31 SHELTERING THE HOMELESS, 32 Shelters, 32; Welfare Hotels and Motels, 34; Extent of the Shelter System, 35 SUMMARY, 36 REFERENCES, 36 IX 1 22

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X CONTENTS 3 HEALTH PROBLEMS OF HOMELESS PEOPLE TYPES OF INTERACTIONS BETWEEN HEALTH AND HOMELESSNESS, 39 Health Problems That Cause Homelessness, 39; Health Problems That Result from Being Homeless, 41; Homelessness as a Complicating Factor in Health Care, 42 GENERAL HEALTH PROBLEMS OF HOMELESS ADULTS, 43 Traumatic Disorders, 43; Disorders of Skin and Blood Vessels, 45; Respiratory Illnesses, 47; Chronic Diseases, 49; Miscellaneous Health Problems, 50 MENTAL ILLNESS, ALCOHOLISM, DRUG ABUSE, AND COMORBIDITY OF HOMELESS ADULTS, 50 Mental Disorders, 50; Clinical Problems in Providing Mental Health Care for the Homeless, 57; Alcoholism and Alcohol Abuse, 60; Illness Associated with Abuse of Drugs Other Than Alcohol, 63; Comorbidity, 65 HEALTH PROBLEMS OF HOMELESS FAMILIES, CHILDREN, AND YOUTHS, 66 SUMMARY, 68 REFERENCES, 71 ACCESS TO HEALTH CARE SERVICES FOR HOMELESS PEOPLE.................................. INTRODUCTION, 76 HEALTH CARE OF THE INDIGENT, 77 MEDICAID, 82 Eligibility, 83; Benefits, 88; Medicaid and the Homeless, 89 THE INDIGENT CARE SYSTEM, 89 Hospitals, 90; Clinics, 92; The National Health Service Corps, 93; Categorical Programs, 93 ADDITIONAL BARRIERS TO ACCESS FOR HOMELESS PEOPLE, 94 MENTAL HEALTH CARE, 96 VETERANS, 98 SUMMARY, 100 REFERENCES, 100 ...... 39 76

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CONTENTS Xi 5 HEALTH CARE SERVICES FOR HOMELESS PEOPLE . e ~ e ~ e e e e e e e e e e e e e e e e e e e e e e e e e ~ e e e e e e e e e e e e e e e INTRODUCTION, 103 PRE-JOHNSON-PEW MODELS, 106 Shelter-Based Clinics, 106; Health Care Services in Day Programs, 107; Free-Standing Clinics, 108 SPECIALIZED HEALTH CARE APPROACHES, 109 Respite and Convalescent Care, 109; Residential Placement, 110 THE JOHNSON-PEW HEALTH CARE FOR THE HOMELESS PROJECTS, 110 Structure of the Johnson-Pew Projects, 111; Common Elements of Health Care Programs for the Homeless, 112; Issues Raised by the Johnson-Pew Project Models, 116 TARGETED SERVICES FOR POPULATIONS WITH SPECIAL NEEDS, 118 The Chronically Mentally Ill, 118; Alcohol and Drug Abuse, 123; AIDS, 124; Homeless Individual Women, Families, and Youths, 124 OTHER ISSUES IN HEALTH SERVICES FOR THE HOMELESS, 127 Coordinated Efforts in Non-Johnson-Pew Cities, 127; Range of Health Care Services, 129; Discharge Planning, 130; Case Management, 131; Liability Insurance Coverage for Providers, 132; Personnel, 133 SUMMARY, 134 REFERENCES, 135 6 SUMMARY AND RECOMMENDATIONS ORIGIN OF THIS STUDY, 136 STUDY PROCESS, 137 WHAT WAS LEARNED, 138 Who Are the Homeless?, 138; Why Do People Become Homeless?, 139; What Are the Health Problems of the Homeless?, 139; What Other Problems Do Homeless People Have with Health Care?, 140; What Is Being Done About the Health Problems of Homeless People?, 141 CONCLUSIONS AND RECOMMENDATIONS, 141 Five Critical Observations, 141; Preventing and Reducing Homelessness and Its Related Health Problems, 144; Health Care and Related Services, 148; Special Needs of Homeless Children and Their Parents, 156; Shelters, 157; Volunteer Efforts, 158; Research, 159 REFERENCES, 161 103 .136

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All CONTENTS APPENDIXES A. Legislative Efforts to Aid the Homeless, 165 B. The Methodology of Counting the Homeless, 169 Charles D. Cowan, William R. Breakey, and Pamela J. Fischer The Rural Homeless, 183 Larry T. Patton D. Site Visits and Meetings with Local Providers of Services to the Homeless, 218 E. Acknowledgments, 223 F. Biographical Notes on Committee Members, 225 INDEX

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Homelessness Health' argot Human Needs

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