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Index Access to health care bureaucratic obstacles, 95, 100, 132 documentation obstacles, 95, 100 economic barriers, 40-42, 79-81, 89, 90- 91, 100, 140, 204 entitlement problems, 94, 99, 100, 140 ethical issues, 77 indigent care system, 89-94 lack of fixed address as a barrier, 94-95 location of facilities, 99, 117, 140 through Medicaid, 82-89 by mentally ill, 58, 96-98, l l9 negative experiences with or attitudes toward service providers, 95-96, 117 private fee-for-service system, 88-89 psychiatric treatment, 58 in rural communities, 20D, 203-205, 206 scheduling of clinic appointments, 95, 100 strategies for increasing, 97, 143, 203 studies/surveys of, 77-78 for substance abuse treatment, 63 transportation barriers, 82, 89, 95, 100, 128, 140, 203 by veterans, 98-100 voluntary inpatient care, 58 Adolescents and youths, homeless alcoholism in, 213 community-based-facility needs for, 31 crisis center for, 14 eligibility for residentially based services, 31 228 health problems of, 68, 212-213 physical and mental health needs, 126 pregnancy, 67, 212-213 in rural communities, 212-213 shelters for, 14, 36, 126 size of population, 6 targeted services for, 125-127 see also Runaway and throwaway youths Adult homeless individuals characteristics of population, 6-11, 62 educational attainment, 6-7 employment status, 10 ethnic background, 6, 7, 8-10 geographic distribution, 8-l l health problems of, 43-50 marital status, 6, 7, lO mental disorders in, 50-57 public assistance benefits, 27 residence time in one place, 7, lO Adult homeless individual men acute physical disorders in, 44 age, 5-7, 10 alcoholism in, 60, 62 chronic physical disorders in, 46-47 death rates, 15 marital status, 6, 7, lO population size, 1, 5, 6 veterans, 10 see also Veterans Adult homeless individual women acute physical disorders in, 44

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INDEX 229 age, 6, 10, 192-193 chronic physical disorders in, 46 criminal victimization of, 6, 41, 44 health problems, 6, 41, 44, 66 marital status, 6, 10, 192 population size, 6 pregnancy, 66 psychiatric disorders in, 56-57, 125 studies of, 5 targeted services for, 124-125 veterans, 10 Advocates/advocacy, National Alliance to End Homelessness, 4, 137 Aid to Families with Dependent Children casework services, 151 deficiencies in benefits, 27 eligibility for, 83-86 emergency assistance program, 34, 145, 158 homeless recipients, 12 housing adequacy for recipients, 26 AIDS as a cause of homelessness, 31, 40 costs of treating, 91 dementia and, 51 education programs, 126 prevalence among homeless, 48-49, 64, 68 service needs of homeless victims, 124 targeted services for, 124 Alabama characteristics of homeless in, 17, 205 Medicaid eligibility in, 83, 84 outreach program in rural areas, 203 Alcohol problems age correlation with, 64 case management, 153 comorbidity with drug abuse and mental illness, 65-66, 138 geographic patterns, 61, 210-211 housing needs for, 123, 153, 154 mental illness/disorders and, 51, 53 physical disability and, 60 prevalence, 57, 60-61, 104, 138, 152, 207- 209, 210-211, 212, 213 relationship between homelessness and, 40, 62 secondary health effects/risks, 41, 48-50, 60, 62, 154 studies of homelessness and, 5 targeted services for, 123-124, 153-154 treatment, 62-63, 69, 114, 123, 153-154, 206 among veterans, 7 Alliance Housing Council, estimates of homeless population, 3 American Psychiatric Association, 29 Anemia and related disorders, 46, 66 Anti-Drug Abuse Act of 1986, 166 Arthritis, rates of occurrence in homeless, 46-41 Baltimore census of homeless population, 171, 172, 178-179 characteristics of homeless in, 10-11, 56, 61, 62 shelters, 56 studies of homeless, 4, 56 Black homeless geographic distribution of, 8-9, 191 psychiatric disorders among, 57 Boston Cardinal Medeiros Day Center, 16, 108, 127, 156, 218 characteristics of homeless in, 7-8, 11, 16, 30, 34, 49, 56, 61, 64 Fenway Park, 34 Greater Boston Adolescent Emergency Network, 14, 36, 68, 126 Johnson-Pew Health Care for the Homeless project, 125 Long Island Shelter, 220 Pine Street Inn, 106, 220 Project Hope, 125, 220 public assistance enrollments, 27 shelters, 14, 16, 36, 106 SRO housing costs, 27 St. Francis House, 108, 221 studies of homeless, 4, 7, 14, 68 tuberculosis prevalence in, 49 Brief Symptom Inventory, 52 California Episcopal Archdiocese, 112 estimates of homeless, 198 Medicaid program, 83, 84, 88 Oakland Independence Support Center, 220 Cancer, rates of occurrence in homeless, 46-47 Cardinal Medeiros Day Center, 16, 108, 128, 156, 218 Cataracts, 41, 46-47 Catholic Charities, 124

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230 INDEX Cellulitis, 45 Center for Epidemiological Studies Depression Scale, 52 Chicago census of homeless in, 175-176 characteristics of homeless in, 7-8, 10, 15-16, 24, 52 Cook County Jail, 219 Cooper's Place, 219 Firehouse Annex, 125, 219 Near North Health Center Outpost Clinic, 220 public assistance in, 27 SRO housing, 25, 26, 27 studies of homeless, 4 Children, homeless characteristics and needs of, 13, 67, 156- 157 education/learning problems, 11 emotional and intellectual impairment, 57, 66, 68, 157, 205 health problems, 66-67, 157, 213 immunization delays, 67 placement with welfare authorities, 34 psychiatric disorders in, 57, 68 in rural areas, 213 school attendance, 14, 67 services recommendations for, 157 size of population, 13-14, 138 Child Welfare League, 14 Christ House, 109, 130, 218 Chronic obstructive pulmonary disease, 46- 47 Clinics common problems, 82, 89, 95, 107 dental, 108 free-standing, 92, 108-109 funding for, 92, 106-107, 109 hours of operation, 82, 89, 95 importance, 92-93 location, 112, 114-115, 117, 128 mobile, 112, 116-117, 125 nonsectarian, 106-107 physical amenities, 82 public-private, 107 quality of care, 92 religious-sponsored, 106 respite center adjacent to, 109 shelter-based, 106-107, 112 staffing, 115, 117 stationary, 116-117 Veterans Administration, 98 waiting times, 82, 141 Zacchaeus Clinic, 108-109 Community health centers in rural areas, 205 Community Mental Health Centers Act of 1962, 145 Community support services for Reinstitutionalized mentally ill, 29-30 inadequacies of, 29-30 needs, 142-143 residential placement for disabled, 110 Community Support Systems Program demonstration grants, 97 rehabilitation services, 120 Connecticut health care financing in, 91 Medicaid program, 84, 88 Convalescent facilities for alcoholics, 63 Christ House, 109, 130, 218 COSMOS Corporation definition of case management, 131-132 Day centers for homeless Cardinal Medeiros (Boston), 16, 108, 128, 156, 218 day care for children, 157 self-help centers for mentally ill, 121 services offered by, 33, 107-108 So Others Might Eat, 108 St. Francis House, 108 Degenerative diseases of joints, 41 Deinstitutionalization, 28-32 Dental/periodontal disease, prevalence in homeless, 41, 46-47, 50, 185, 206, 207- 209, 212 Denver Developmental Screening Test, 67 Detroit characteristics of homeless in, 8, 11, 52 Johnson-Pew Health Care for the Homeless projects, 111, 114, 115-116 Development disabilities, prevalence among homeless, 52 Diabetes, 42, 50, 59, 65 Disabled persons cash assistance program, 28, 59 residential placement programs, 110 Domiciled poor access to health care, 79, 82, 143 characteristics of, 27, 78-79 clinics for, 109 health insurance status, 80

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INDEX 231 medical services utilization, 78-79 in rural areas, 82 sources of housing for, 25; see also Housing, low-income Drug abuse/addiction age factors in, 64, 123 as a cause of homelessness, 40 comorbidity with alcohol abuse and mental illness, 65-66, 138, 155 environmental exposure problems, 50 ethnicity and, 64 housing needs for, 123 illnesses/medical conditions related to, 41, 47, 48, 63-65, 155; see also AIDS mental illness and, 51, 53 prevalence among homeless, 63, 104, 138, 152, 155, 207-209 studies of homelessness and, 5, 63 targeted services for, 123-124, 155 Edema, dependent, 45 Education Head Start program, 157 health insurance coverage and, 80 medical, subsidization, 93 school attendance by homeless children, 14 status of rural homeless, 193 Elderly homeless people cash assistance programs, 28 causes of homelessness, 40-41 characteristics of homeless, 15-17 degenerative diseases in, 40-41 facilities for, 16 fear of shelters, 16 geographic distribution of homeless, 15-16 health risks of, 48 outreach program, 108 public assistance entitlements, 41 size of homeless population, 15, 138 studies of homeless, 5, 15-16 Eligibility for entitlements age and, 6, 15, 31 Aid to Families with Dependent Children, 83 categorically related people, 83 decoupling from receipt of cash assistance, 88, 89, 147 disability-based, 28 documentation requirements, 27, 28, 95 fixed-address requirement, 27-28, 89, 94, 146, 166 food stamp program, 202 legislation improving, 166 Medicaid, 6, 83-88, 88, 94, 100 mentally ill homeless, 96 recommendations, 146 state discretion in conferring, 83 Supplemental Security Income program, 28, 83, 89, 96, 131 thresholds by state, 84-86 unemployment compensation, 27 Veterans Administration, 98, 99 Emergency Jobs Appropriations Act of 1983, 165 Employment health insurance coverage and, 80-81 impediments to finding, 33, 203 jobs available to homeless, 10 loss of, by AIDS patients, 31 in rural areas, 185-186, 196-197 status of adult individual homeless, 10 trends, 27 Endocrinological disorders, rates of occurrence in homeless, 46-47 Eye disorders, 41, 46-47 Families, homeless age of children in, 11 benefits for, 27; see also Aid to Families with Dependent Children causes of homelessness, 13, 23 characteristics of, 11-14 day care for children, 125 doubling up of, 13, 23-24 emotional problems, 11 ethnic status, 12 female-headed, 5, 11, 12, 23, 27, 56, 138, 204; see also Mothers, homeless health care services delivery, 116 health status, 11, 66 multiple problems of, 13 nutritional status, 11 placement of children with welfare authorities, 34 population size, l, 4, 5, 6, 138 regional variations in, 12 rural, 189-190 shelter problems of, 33-34, 36, 190 social services contacts, 13 studies of, 5, 11-12 support networks, 12-13 targeted programs for, 125 two-parent, 5, 12, 13, 204

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232 INDEX see also Children, homeless Federal Emergency Management Agency funding for convalescent care, 155 funding for food and shelters, 158, 165, 166-167 Federal funding for casework services, 151-152 for categorical programs, 93 Florida health care financing in, 91 Medicaid program in, 84 Food outreach programs with, 108 preparation and storage in welfare motels, 34 So Others Might Eat, 108, 220 soup kitchens, 33, 112, 117, 152, 166, 199, 200, 210 supplemental food program for Women, Infants and Children, 207 Temporary Emergency Food Assistance Program, 165, 166, 167 see also Nutrition Food Security Act of 1985, 166 Food stamps, 152, 166, 202, 203 Fountain House, 59 Frostbite, 50 Gastrointestinal disorders, prevalence in homeless, 46-47 General Health Questionnaire, 52 Genitourinary disorders, prevalence in homeless, 46-47, 65 Hawaii Medicaid eligibility thresholds, 84 Medicaid enrollments, 87 Health care services for alcoholics and drug abusers, 123-124 area to be served by, 118 case management, 112, 113, 116, 123, 131- 132, 143, 149, 151-152, 153 categorical programs, 93-94 characteristics of homeless that affect planning for, 104 communication and coordination in, 105, 109-110, 113, 120, 127-128, 151 contracting versus direct provision, 117- 118 convalescent care, 109-110, 114, 155 day programs, 107-108 discharge planning, 29-30, 110, 130, 143, 147-148, 200 effective models of delivery, 106- 109, 112 funding of, 103, 106-107, 112, 128-129 holistic approach, 113 internal and external resources, 105 for mentally disabled, see Mental health care multidisciplinary approach, 113 nonsectarian, 106-107 obstacles to, see Access to health care prenatal, 66, 114 public-private programs, 107, 126-127 range needed, 129-130 recommendations, 148-158 religious-sponsored, 106 residential placement, 110, 119, 128, 151 respite care, 109-110 rural area resources, 203-207 separation of systems for domiciled and homeless, 111 size of facilities, 117 stationary clinics versus mobile teams, 116-117 subsidization by paying patients, 91 successful elements, 105, 113-116 targeted approaches, 105-134, 141 utilization rates, 60, 62, 78, 205-207, 208- 211 see also Clinics; Johnson-Pew Health Care for the Homeless projects; Medical treatment; Outreach programs Health care/social service providers, 35 availability in rural areas, 204 characteristics of personnel, 133-134, 141 communication deficiencies/needs among, 35 hours of operation, 82, 89, 95 liability insurance coverage, 107, 132-133 perceptions/attitudes about homeless, 58, 82, 89, 95-96, 113 physical amenities, 82 training for, 141, 149 waiting times for, 82 Health insurance coverage by age and race, 79-81 effects of lack of, 40, 42, 79, 82 through Medicaid or Medicare, 80, 81 Health problems/illnesses acute physical disorders, 44-45, 62, 206, 207 of adult homeless, 43-50

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INDEX 233 age factors in, 45, 47, 49 blood disorders, 46, 66, 209 cancer, 46-47 causing homelessness, 39-41, 68, 139-140 chronic physical disorders, 46-47, 49-50, 62, 65, 66, 69, 185, 207 data base on, 69 degenerative diseases, 40-41, 46-47 dental/periodontal disorders, 41, 46-47, 50, 185, 206, 207-209, 212 diabetes, 42, 46-47, 69 ear disorders, 46-47 endocrinological disorders, 4~47 from environmental exposure, 50, 140, 154, 205, 207, 212 ethnic differentials in, 44, 46, 48, 49 eye disorders, 41, 46-47, 209 foot problems, 50 gastrointestinal disorders, 46-47, 2065 209 gender differentials in, 44, 46, 48 genitourinary problems, 4~47, 65, 209 geographic differences in, 44 hepatic cirrhosis, 41 hypertension, 42, 49, 62, 69 infectious/communicable disorders, 41, 48, 64-65, 66 infestational ailments, 44-45 liver disease, 41, 46-47, 65 musculoskeletal disorders, 40-41, 46-47, 209 neurological disorders, 46-47 nutritional deficiencies, 41, 44-45, 66, 185, 206, 207-209, 212, 213 obesity, 44-45 occurrence rates, 44 49 parasitic infections, 41, 209 pregnancy, 46-47, 207, 209 respiratory disorders/infections, 44-49, 62, 65, 66, 154, 206, 209, 212 resulting from homelessness, 41, 140 of rural populations, 206-207 seizure disorders, 46-47 skin ailments/disorders, 41, 44, 45-47, 62, 64, 69, 140, 206, 209 traumatic disorders, 41, 43-45, 62, 69, 140, 209 vascular disorders, 41, 42, 45-47, 62, 64- 65, 140, 209 venereal diseases, 41 see also Alcohol problems; Drug abuse/ addiction; Mental illness/disorders; and specific illnesses and conditions Health Professions Training Act, 136, 166 Hepatic cirrhosis, 41 Hepatitis, infectious, 41, 64 Hispanic homeless geographic distribution of, 8-9 psychiatric disorders among, 57 Homeless Chronically Mentally Ill outreach program, 7, 10, 65 Homeless Eligibility Clarification Act, 166 Homeless Housing Act of 1986, 167 Homelessness case studies of causes, 40, 41 chronic, 24, 33 definition, 2, 137, 170 deinstitutionalization and, 25, 28-32, 139 dynamics of, 22-36, 39-43 economic factors in, 11, 22, 23, 25-28, 40, 139 employment trends and, 27, 196-197 episodic, 23-24 family violence/abusive relationships and, 13, 14-15, 23 health care complications of, 42-43; see also Access to health care health problems resulting from, 41, 141- 142 health-related causes, 39-41, 50-51 housing availability and, 11, 22, 25-26, 139 income losses and, 11, 25 intervention strategies, 25, 82, 144-148; see also Recommendations length of, 194 patterns of, 23-25, 143, 170, 176 risk factors, 4, 12-13, 22, 25, 30, 41, 130, 138 running away and, 13 substance abuse and, 7 support and service system failures and, 22 temporary, 23 Homeless people with AIDS, 31 barriers to health care; see Access to health care changes in, l, 3-4 characteristics affecting health care, 104 common problem, 18 composition, 1, 17-18, 60, 103 counting methodologies, 2-4, 169-181, 198-199; see also Studies of homeless criminal victimization of, 6, 41, 44, 140

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234 INDEX demographic characteristics, 5-17, 63, 138, 192-194 distrust of authority, 58, 103, 104 enrollments for public assistance, 27 ethnicity, 6, 138, 192 health risks, 39, 103; see also Health problems/illnesses hidden, 24 illness prevalence among, 39 life satisfaction, 212-213 medical treatment of, 42-43, 49-50, 57-60, 140 personal safety, 32 reintegration into community, 23, 25 sheltering, 32-36; see also Housing, low- income; Shelters size of population, 1, 3, 17, 137-138, 171 stereotypes, 50, 60, 138 studies, see Studies of homeless transience, 195-196 transportation needs, 14 see also Adult homeless individuals; Children, homeless; Elderly homeless people; Families, homeless; Runaway and throwaway youths; Rural homeless/ homelessness; Veterans Hospitals clinic affiliation, 109-110 closures, 91, 204 community, 90 deficit operation, 91 emergency room utilization, 208-209 public, 90 role in caring for poor people, 90 rural, 204 teaching, 90, 133 uncompensated care by, 90-91, 204 Veterans Administration, 98 voluntary, 90 Housing for alcoholics and drug abusers, 123 for Reinstitutionalized populations, 30-31 Fountain House, 119 funding for, 119 income percentage paid for, 26 loss of, by AIDS patients, 31 for mentally disabled, 30-31, 60, 119, 121, 145 overcrowding in, 26, 190 quality, 26 substandard, 17, 188, 202, 213 transitional, 200 Veterans Administration domiciliary facilities, 98 Housing costs and homelessness, 4, 11, 138, 139, 142 SRO units, 26 Housing, low-income apartments, 30 causes of losses of, 25, 30 federal support for, 25 impediments to augmenting, 145 recommendations, 144-145 in rural areas, 188, 202 sources, 25 SRO units, 25-26, 30, 62 supply, 22, 25, 139, 142, 202 transition into, 34 Hypertension in alcoholics, 62 causes, 49 dementia and, 51 rates of occurrence in homeless, 46-47 treatment difficulties and needs, 42, 49-50, 69, 140 Hyperthermia, 50 Hypothermia, 50 Illinois Medicaid program, 84, 87, 88 public assistance benefits in, 27 services for alcoholics and drug abusers, 123 income and eligibility for entitlements, 83 and homelessness, 11, 27, 142 minimum wage, 27, 142, 146 recommendations, 146-147 Indigent care system categorical programs, 93-94 clinics, 92-93 hospitals, 90-92 National Health Service Corps, 93 Infectious/communicable diseases in drug abusers, 64-65 hepatitis, 41, 64 malaria, 65 rates of occurrence in homeless, 48-49 see also AIDS; Respiratory diseases/ disorders; Venereal diseases Interagency Council on the Homeless, 156, 167 International Union of Gospel Missions, 106 Iowa, Youth and Shelter Services, 213-214

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INDEX Job Training Partnership Act, 166 Johnson-Pew Health Care for the Homeless projects benefit status of clients of, 87, 94 case management and coordination of services, 113, 116 characteristics of homeless, 15, 43 common elements, 112-116 effectiveness, 105 holistic approach, 113, 141 issues raised by, 116-118 outreach component, 113-115, 116-117 program guidelines, 111 prevalence/incidence of health problems among homeless in, 43-49, 57, 63-64, 67, 68 range of services, 114-116 structure, 111-112 Joint Commission on Mental Illness and Health, 96 Kansas City City Union Mission, 218-219 coordinated health care services in, 127- 128 Emergency Lodge, 219 Pilgrim House, 125, 220 Restart, Inc., 220 shelter-based clinics, 106 Kit Clarke Senior House, 16, 108 Labor market shifts, 27 Legislation to aid homeless Anti-Drug Abuse Act of 1986, 166 bedding for shelters, 166 block grant program for chronically mentally ill homeless, 97 Community Mental Health Centers Act of 1962, 145 Demonstration projects, 167, 168 Domestic Volunteer Service Act Amendments of 1983, 166 educational programs, 168 on eligibility for entitlements, 27-28, 94 Emergency Jobs Appropriations Act of 1983, 165 food assistance, 165, 166-167 Food Security Act of 1985, 166 Health Professions Training Act, 136, 166 Homeless Eligibility Clarification Act, 166 Homeless Housing Act of 1986, 167 235 housing, 167 Job Training Partnership Act, 166 Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963, 97 Military Construction Authorization Act of 1986, 166 Older Americans Act, 156 Omnibus Budget Reconciliation Act of 1981, 92, 98-99 for outreach program for homeless veterans, 98-99 Protection and Advocacy for Mentally Ill Individuals Act, 151-152 provision of health care professionals, 93 Public Health Service Act, 92 recommendations, 151-152 Runaway and Homeless Youth Act, 156 shelter assistance, 34, 165, 166 Stewart B. McKinney Homeless Assistance Act of 1987, 2, 93, 97, 105, 153, 155, 156, 167-168 transfer of mental health care to community-based centers, 96-97 Lexington, Kentucky coordinated health care services in, 127- 128 Horizon Center for the Homeless, 219 residential placement program, 110, 221 Liability and medical malpractice insurance difficulty of service providers in obtaining, 107, 132-133, 159 recommendations on, 159 Liver diseases, 41, 46-47, 65 Los Angeles characteristics of homeless in, 7, 9-11, 15-16, 24, 30, 52, 53, 61 housing for alcoholics and drug abusers, 123 Johnson-Pew Health Care for the Homeless projects, 128 shelter-based clinics, 106 studies of homeless, 4, 7, 53, 56 Union Rescue Mission, 221 Valley Shelter, Inc., 221 Venice Family Clinic, 125, 221 Maine health care financing in, 91 Medicaid program, 85 services for alcoholics and drug abusers, 123

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236 INDEX Maryland community-based-facility beds, 31 deinstitutionalization plan, 31 estimates of homeless, 172, 179, 198 health care financing in, 91 Medicaid program, 85, 87 Massachusetts characteristics of homeless in, 12, 57 health care financing in, 91 housing for alcoholics and drug abusers, 123 Lemuel Shattuck Hospital, 220 Medicaid eligibility in, 85 public assistance benefits in, 27 shelters, 33, 34, 57, 123 see also Boston Medicaid application process, 87 availability to homeless, 89, 204 benefits, 88-89 coverage, 82, 204 eligibility for, 6, 83-88, 94-95, 146, 147, 204 enrollments, 82, 87-88, 89, 94 health insurance through, 80-82 impediments to receiving, 41, 82 largest groups of recipients, 87 limitations, 88 payment restrictions, 88, 147, 204 recommendations, 147 state-only program, 87 state variation in, 83-87, 88, 94, 146 Medical treatment characteristics of homeless that affect, 104 continuity of care, 114 detoxification, 62-63 for diabetes, 42 difficulties in compliance with, 42-43, 49- 50, 69, 103, 140 for hypertension, 42, 49-50, 140 overspecialization of, 66 recommendations, 149 Mental health care ambulatory treatment, 58 case management, 132, 153 clinical problems of providing, 57-60 community-based facilities, 30-31, 57, 96- 97 demonstration projects, 97, 153 discharge planning, 29-30, 130 hospitalization, 30, 58 housing and, 30-31, 57, 119, 153 involuntary commitment, 30, 58-59, 97-98 model programs, 119 negative experiences of homeless with, 58, 98 obstacles to, 58, 96-98, l l9 outpatient commitment, 97-98 outreach programs, 7, 59-60, 98-99, 121- 123, 153 recommendations, 153-154 rehabilitation services, 119-120 residential placement programs, 110, 122- 123, 128 resource allocation needs, 58 Robert Wood Johnson Foundation project, 120 self-help centers, 120-121 successful elements, 119 targeted services for, 118-123, 153-154 Veterans Administration program, 121-123 see also Psychiatric treatment facilities Mental illness/disorders affective disorders, 51, 53-57, 68, 212 anxiety, 51, 68, 212 as a cause of homelessness, 23, 25, 39, 50-51, 53, 68 in children, 57, 68 chronic, in young adults, 29 combat-related posttraumatic stress disorder, 10 comorbidity with alcohol abuse and drug abuse, 65-66, 138, 153 as a consequence of homelessness, 50, 51, 53 dementia, 51, 53-55 depressive disorders, 51 disability entitlements, 28 personality disorders, 51, 53-57 phobic disorders, 51 prevalence, 50, 51-52, 53-56, 66, 118, 152, 207-208, 21~211, 212 schizophrenia, 39, 51, 53-57, 59, 68, 104, 138 screening instruments for, 52-53, 56 studies of, 5, 53-56, 138 substance abuse and, 53-56 among veterans, 7, 10 in women, 56-57, 125 Mentally ill causes of homelessness, 23, 25, 39 community-based facility needs for, 30- 31, 57 deinstitutionalization, 25, 28-32, 97, 119, 139, 210

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INDEX 237 discharge planning for, 30 eligibility for benefits, 96 gender differences in, 56 housing needs, 30-31, 57, 119 involuntary commitment, 30, 58-59, 97-98 patterns of homelessness, 24 public assistance programs for, 28 reality problems, 58, S9 risk of homelessness, 30 rural homeless, 190, 207-208 treatment histories, 52 veterans, 7, 10 women, 6 Mentally retarded community-based facility needs for, 31 studies of homelessness among, S. 52 Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963, 97 Michigan Medicaid eligibility thresholds, 85 Medicaid enrollments, 87 Military Construction Authorization Act of 1986, 166 Milwaukee characteristics of homeless in, 9, 10, 16, 24, 56 Emergency Lodge, 219 Family Crisis Center, 219 Guest house, 123, 219 Johnson-Pew Health Care for the Homeless projects, 114 low-income housing availability in, 26, 123 St. Benedict's Meal Site, 221 studies of homeless, 4 Minneapolis, characteristics of homeless in, 61 Minnesota access to health care in, 204 characteristics of homeless in, 17 Dorothy Day House, 200 Medicaid eligibility thresholds in, 85 transitional housing plan, 200 Minorities acute physical disorders in, 44 geographic distribution of homeless, 8-9,12 poverty among, 186 psychiatric disorders among, 57 size of homeless population, 6 unemployment among, 27 ~ , . . . . MlSSlSSlppl characteristics of homeless in, 17 Medicaid eligibility thresholds in, 85 Mothers, homeless age, 12 educational status, 12 heads of households, 5, 11, 12, 23, 27, 56, 57, 204 health problems, 66 marital status, 12 Medicaid eligibility, 204 psychiatric disorders, 57, 66 substance abuse by, 57 Musculoskeletal disorders, rates of occurrence in homeless, 46-47 Nashville census of homeless in, 176 Downtown Clinic, 114- 115, 219 Johnson-Pew Health Care for the [Iomeless projects, 111, 114-115, 121 Meharry Community Mental Health Center, 220 shelter-based clinics, 106 Union Rescue Mission, 221 National Alliance to End Homelessness, estimate of homeless population, 4, 137 National Ambulatory Medical Care Survey, 43 National Association of Public Hospitals, 91 National Center for Health Statistics, 77-78 National Commission to Prevent Infant Mortality, 91-92 National (Iovernors' Association Task force on Welfare Prevention, 131-132 National Health Interview Survey, 77-78, 80 National Health Service Corps, 93, 115 National Institute of Mental Health Community Support Program, 97 demonstration grants, 97 diagnostic interview schedule, 53 Epidemiological Catchment Area program, 56, 60 National Rural Health Association, 199 Native American homeless geographic distribution of, 8-9 Neurological disorders, rates of occurrence in homeless, 46-47 Nevada health care financing in, 91 Medicaid program in, 85 New Jersey health care financing in, 91 Medicaid program in, 85

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238 INDEX residential treatment programs for alcoholics, 124 New York City AIDS patients and resources in, 31, 124 Bailey House, 124, 126-127 Bowery, 50 Central Park, 121 characteristics of homeless in, 5, 6, 8, 10- 11, 14, 16, 24, 30, 31, 48-49, 50, 52, 56, 57, 61, 62, 66, 67 Charles H. Gay Shelter Care Center for Men, 109 Fountain House, 119 Housing Authority, 26 Human Resources Administration, 107, 109, 124 low-income housing, 25, 26, 62, 66, 67 mental health care services, 119, 120, 121 Project Reachout, 121 shelters, 33, 34, 56, 66, 67, 109-110 studies of homeless, 4, 14 St. Vincent's Hospital and Medical Center SRO and Shelter Program, 107 tuberculosis prevalence in, 48-49 United Hospital Fund, 112 New York State census of homeless in, 173, 176 characteristics of homeless in, 61 health care financing in, 91 Medicaid program, 85, 87, 88 Nursing homes, Veterans Administration, 98 Nutrition assistance programs, see Food stamps deficiencies resulting from homelessness, 41,66,67, 152 recommendations, 152 screening programs, 152 Ohio characteristics of homeless in, 9, 10, 15- 17, 24, 52, 61, 192-197 Medicaid eligibility thresholds, 85 Medicaid enrollments, 87 studies of homeless, 4, 5, 53, 191-197, 207-214 Older Americans Act, 156 Omnibus Budget Reconciliation Act of 1981 funding for clinics, 92 funding for outreach program for homeless veterans, 98-99 Outreach programs for elderly, 108 for families, 125 for mentally ill homeless, 59-60, 98-99, 119-120, 121-123, 150-151 mobile clinics, 112, 125 needs, 143 recommendations, 146, 148, 149-151 street teams, 121 training of workers, 123 see also Johnson-Pew Health Care for the Homeless projects Parasitic infestations, 41 Pew Memorial Trust, see Johnson-Pew Health Care for the Homeless projects Philadelphia characteristics of homeless in, 53 Health Management Corporation, 112 studies of homeless, 4, 30, 53 Phoenix characteristics of homeless in, 9, 16, 24, 52, 56, 61 mental health care programs, 120 studies of homeless, 4, 61 Physically disabled homeless, studies of, 5 Physicians availability in rural areas, 204 recruitment by National Health Service Corps, 93 Portland, Oregon characteristics of homeless in, 6, 9, 10, 16, 24, 52, 61 housing for alcoholics and drug abusers, 123 studies of homeless, 4, 61 Poverty growth of, 26-27, 186 rural, 186 see also Domiciled poor Pregnancy rates of occurrence in homeless, 46-47 President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 77, 143 Programs for homeless fears of public officials about, 7 see also Outreach programs; Public assistance Protection and Advocacy for Mentally Ill Individuals Act, 151-152 Psychiatric disorders, see Mental illness/ disorders

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Psychiatric treatment facilities bed needs, 31 community-based, 31 discharge planning, 30 rehabilitative value of short stays, 29 restrictive admission policies, 29 St. Elizabeth's Psychiatric Hospital (Washington, D.C.), 31 Public assistance availability of benefits, 27, 94 barriers to receipt of cash assistance, 28 benefit levels, 94, 140 budgetary concerns, 28 discouragements of applications, 27, 146 eligibility for, see Eligibility for entitlements enrollments, 27, 28 food stamps, 152 fraud and abuse in, 28 negotiation of public welfare system, 41 recommendations, 145-147 rural homeless use of, 17 unemployment compensation, 27, 40 value of, 27 see also Indigent care system Public Health Service Act, Section 330, 92 Rape/assault of homeless women, 6, 41, 44 Recommendations alcoholism programs/services, 152-154 case management, 151-152 child support and treatment services, 156- 157 convalescent services, 155 discharge planning, 147-148 drug treatment programs/services, 152- 154, 155 health care and related services, 148-156 housing, 144-145 income and benefits, 145-147 mental health programs, 152-154 nutrition, 152 outreach programs, 149-151 research, 159-160 shelters, 157-158 volunteer efforts, 158-159 Rehabilitation programs for alcoholics, 63 for mentally ill, 59 Residential facilities for alcoholics, 63 for families, 67 INDEX 239 for mentally ill, 60 Respiratory diseases/disorders in alcoholics, 62 asthma, 67 chronic obstructive pulmonary disease, 46-47 infections, 44-45 predisposing conditions, 47-48 rates of occurrence, 44-47 in rural homeless, 206, 209, 212 tuberculosis, 48, 62, 65, 154 Robert Wood Johnson Foundation chronically mentally ill project, 120 study on access to health care, 77, 78 see also Johnson-Pew Health Care for the Homeless projects Runaway and throwaway youths causes/process of homelessness, 14-15, 23, 68, 126 shelters for, 14 studies of, 5, 14, 23, 68 Rural homeless/homelessness access to health care, 82, 184-185, 203, 212-213 alcohol abuse by, 210-211, 213 attitudes of community toward, 201-202 campground usage by, 190 causes, 128, 183, 184, 194-195 characteristics of, 12, 17, 184, 189-191 counting, 2, 198-199 definition, 187-188 economic issues, 183, 185-186, 189-191, 202 emergency room utilization, 208-210 employment, 196-197 environmental factors affecting community response to, 199-203 environmental hazards, 185 extended family network, 17, 187-188, 190, 196 farmers/farm-related workers, 190-191, 200, 202, 212 health care resources for, 203-207 health problems of, 17, 185, 206-213 health status of, 207-208, 212-214 hermits, 191, 198 housing needs, 202 in large communities, 199-201 length of time, 194 magnitude, 183 migration to cities, 17, 186 mental illness among, 190, 210-211, 212

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240 INDEX needs of, 191, 212 in Ohio, 4, 5, 53, 191-197 peer counseling program, 200-201 private assistance efforts, 184 problems of, 17 public perceptions of, 198-199 shelter availability and utilization, 189, 190, 195, 199-200 in small communities, 201-202 social services network, 17, 184, 199-202 spouse and child abuse, 213 studies of, 5, 17, 188 substandard housing utilization, 17, 213 suicidal tendencies, 212, 213 temporary housing arrangements, 187-188, 195 transience/transients, 195-197, 201 transportation needs, 203 Salvation Army, 125 San Diego Balboa Park, 35 characteristics of homeless in, 5, 61 coordinated health care services in, 127- 128 Life Ministries, 220 shelter-based clinics, 106 women's programs, 125, 126, 221 San Francisco characteristics of homeless in, 7, 44 Folsom Street Hotel program, 124, 127, 219 Johnson-Pew Health Care for the Homeless projects, 128 Larkin Street Youth Center, 68, 126, 127, 156, 220 residential program for AIDS victims, 124 self-help centers for mentally ill, 120-121 St. Anthony's Clinic, 125, 220 Seattle, housing for alcoholics and drug abusers, 123 Seizure disorders, 46-47, 51 Shelters adequacy, 32 for adolescents, 14, 36, 200, 213-214 for alcoholics and drug abusers, 123 burdens on, 139 cars, tents, and boxes, 34 Charles H. Gay Shelter Care Center for Men, 109 clinical examinations in, 53 clinics based in, 106-107 dangers in, 16 day centers, 16, 33 demand for, 32, 35, 200 design for emergencies, 33, 35, 36, 139, 158 extent of system, 35-36 for families, 13, 33-34, 36, 57, 158, 20O, 219 funding, 109 limit on consecutive nights' stay, 33 location relative to homeless populations' needs, 14 missions, 32, 34, 56, 106, 196, 218-219 night operation, 33 organization, 33-34 projections of needs, 169 public facilities, 32-33 public opposition to, 35 in public parks, 34-35 recommendations, 157-158 rejection of alcoholics, 62 in rural areas, 189, 190, 195, 200 siting dilemmas, 35 staffing, 35-36 subsidization of, 33 substitution for other systems, 36 standards for health and safety, 33, 158 utilization rates, 144, 190, 195, 210 variability in size and operation, 32 welfare hotels/motels, 13, 34-35, 36 for women, 125, 210 Skid rows, 1, 15, 53 Skin disorders, 45~7, 62, 64 Social and support services, inadequacies of, 22 Social Security Administration, outreach efforts, 149-150, 166 So Others Might Eat, 108 South Carolina health care financing in, 91 Medicaid program in, 85 South Dakota characteristics of homeless in, 17 Medicaid eligibility thresholds, 85 Medicaid enrollments, 87 Special Supplemental Food Program for Women, Infants, and Children, 152 St. Anthony's Foundation, 125 St. Elizabeth's Psychiatric Hospital (Washington, D.C.), 31 Stewart B. McKinney Homeless Assistance Act

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INDEX 241 block grant program for chronically mentally ill homeless, 97, 168 definition of homeless, 2, 137 demonstration projects for drug and alcohol treatment, 153, 168 food and shelter funding provided by, 97, 141, 167-168 highlights of, 167-168 impetus for, 105 literacy programs for adults, 168 provision of health care professionals, 93 recommended amendments of, 155, 156 St. Francis House, 108 St. Francis Residence, 60 St. Louis alcohol rehabilitation program, 123 characteristics of homeless in, 8, 16, 24, 30,52 Christ Church shelter, 218 coordinated health care services in, 127- 128 Emergency Lodge, 125 Harbor House, 123,219 Hospitality House, 219 Shamrock Club, 220 studies of homeless, 4 Veterans Administration Outreach Program, 221 St. Vincent's Hospital and Medical Center SRO and Shelter Program, 107,109-110 Studies of homeless biases in, 170,180, 181, 198 capture-recapture methods, 176-180 clinical examinations in shelters, 53 comparative general-population data, 43, 56, 60 comparison/generalization of, 2,43, 44, 51, 176, 181, 191 counting the homeless, 2-4, 169-181, 198- 199 data collection, 2, 53, 170, 171,174-175 data sources, 12,43, 112, 159, 198,208 demographic and social issues as a focus of, 5 dual-system estimation in, 178 focus of, 4, 160 and health-related issues, 5 indirect estimation of homeless, 170-173, 179 through Johnson-Pew Health Care for the Homeless projects, 43 maximum likelihood techniques in, 178 methodological problems, 2, 15-16,51,53, 56, 137, 159-160, 170, 171, 176, 180, 188, 198 multiple count, 175-176 national, 3 recommendations on, 160, 180 sample size, 2, 4 - 52-53, 67, 173 15-16 screening instruments, self-selected samples? similarities in data, 4 single-contact census, 173-176 sites for data collection, 4, 53,56, 174- 175, 179 snowball sampling, 171 subpopulations, 4-5, 7, 10 survive provider data, 172-173 Substance abuse by adolescents and youths, 68 comorbidity with psychiatric disorders, 53-57 counseling services, 108 by homeless mothers, 57 patterns of homelessness and, 24 prevalence, 56, 68,206, 212 Veterans Administration program, 98 see also Alcohol problems; Drug abuse/ addiction Supplemental Security Income adequacy of benefits, 96 cost-containment measures, 96 early predischarge application and review, 131 eligibility requirements, 28, 84-86, 96, 130, 147,149-150 Medicaid eligibility for recipients, 87 potential of mentally ill for eligibility, 96, 150 recommendations, 147, 150 Swords to Plowshares, 100 Tennessee, Medicaid eligibility in, 83, 85 Texas Medicaid eligibility thresholds, 85 Medicaid enrollments, 87 Toronto, study of adolescent homeless in, 14 Transportation needs of children, 14 education-related, 14 health care-related, 82, 141 in rural areas, 203, 205 Traveler's Aid Program, 14

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242 INDEX Traumatic disorders among alcoholics, 62 occurrence rates, 43-44 Tuberculosis in alcoholics, 62, 154 in drug abusers, 65 predisposing factors, 48 rate of occurrence among homeless, 48-49 United Way, 112, 159 Urban Family Center (New York City), 67 U.S. Conference of Mayors housing program for mentally ill, 120 surveys of homeless population, 3-4, 5, 6, 32, 144 see also Johnson-Pew Health Care for the Homeless projects U.S. Department of Housing and Urban Development estimate of homeless population, 3, 171- 172 housing program for mentally ill, 120 Vascular disorders in alcoholics, 62 arterial vascular disease, 45 bacterial endocarditis, 65 in drug abusers, 64-65 peripheral vascular disease, 45, 46-47, 65 rates of occurrence in homeless, 45-47 thrombophlebitis, 64-65 treatment difficulties, 50 varicose veins, 41 venous stasis, 45 venous valve incompetence, 45 Venereal diseases, prevalence among homeless, 41, 48-49, 68, 212 Vermont Medicaid eligibility thresholds in, 86 studies of homeless, 4, 5, 17, 192-193, 214 Veterans access to health care, 98-100 alcohol and drug abuse among, 7, 65 characteristics of, 7, 10-11 counseling programs, 100 educational programs, 100 eligibility for benefits, 98, 99-100 geographic distribution, 11, 193, 194 Korean era, 10 mental illness/psychiatric problems, 7, 10, 65 outreach program for mentally ill, 7, 10, 65 rural, 214 size of homeless population, 138 Vietnam era, 10-11, 98, 138, 191, 193 wariness of Veterans Administration medical centers, 122 World War II era, 10 Veterans Administration benefits enrollments, 87 Community Residence Program, 221 expansion of services for homeless, 98-99 health care system, 98 outreach program for mentally ill, 7, 10, 65, 98-99, 121-123, 150-151, 221 recommendations for, 150-151 Vietnam Veterans of America, 100 Volunteers drawbacks to reliance on, 35-36 former mentally ill homeless as, 120-121 health care personnel, 106 legislation authorizing use of, 166 recommendations on, 158-159 Volunteers in Service to America, 166 Volunteers of America, 109, 120, 121, 127 Wages gender differentials in, 27 minimum, 27, 146 Washington, D.C. census of homeless in, 174 characteristics of homeless in, 61 Christ House, 109, 130, 218 Columbia Road Physician Group, 108, 109 community-based-facility needs for mentally disabled, 31 House of Ruth, 125, 220 Medicaid eligibility thresholds in, 84 So Others Might Eat, 108, 220 Zacchaeus Clinic, 108-109 Welfare hotels/motels costs, 34 family residence in, 13, 34, 36, 66, 67 food storage and preparation deficiencies, 34, 67 Wisconsin, Medicaid program, 83, 86, 88 Workers' compensation, 27, 40