Watts

HOMELESSNESS AND HEALTH
Bobby Watts
National Health Care for the Homeless Council
National Press Foundation Fellows
November 13, 2018
OVERVIEW
• Introduce the National Health Care for
the Homeless Council
• An overview of homelessness and health
• The Health Care for the Homeless
program
• What is working in solving homelessness?
• Conclusion: Mass homelessness can be
ended in the U.S.
THE NAT IONAL HE ALTH C ARE
F OR T HE HOME LE SS C O UNC IL
The mission of the Council is to

eliminate homelessness by ensuring
comprehensive healthcare and
secure housing for everyone.
THE NAT IONAL HE ALTH C ARE
F OR T HE HOME LE SS C O UNC IL
• 220+ Organizational Members and
4,000+ Individual Members
• Most are from Health Care for the Homeless
(HCH) programs that serve one million
homeless people each year in every state
• Headquartered in Nashville, with some staff
near D.C.
• Major Programs:
– Training & Technical Assistance
– Research
– Policy Analysis & Advocacy
OVERVIEW OF HOMELESSNESS
• Homelessness previously seen as
choice by “hobos”
• Dramatic upsurge in homelessness
beginning in early 1980s
• Largely looked at through the lens of
mental illness, with cause seen as the
closing of mental hospitals without the
corresponding community residences
being built
OVERVIEW OF HOMELESSNESS
• But also began seeing homeless
families in large numbers for the first
time since the Great Depression.
• These families’ homelessness had
nothing to do with
deinstitutionalization, but stemmed
from other policy decisions.
ANALYSIS BY WESTERN REGIONAL
ADVOCACY PROJECT
RENTAL MARKET
From U.S. Interagency Council on
Homelessness report (Nov 2017)
• For every 100 VLI (31-50% of Area
Median Income) renters, there are
only 43 affordable apartments
available
• For every 100 ELI (0-30% AMI) there are
only 38 affordable apartments
available. In the West, only 30
NUMBER OF PEOPLE EXPERIENC ING
HOMELESSNESS IN THE U.S.
• According to the 2017 Point-in-Time
Count, there were 553,000 People
Experiencing Homelessness (PEH).
• About 1/3 of them were unsheltered
• Other HUD data shows that 1.4 million
people stayed in a homeless shelter or
transitional program in 2017.
NUMBER OF PEH IN THE U.S.
• The number of people identified in the
2017 PIT reflected the first increase
since 2017. Prior to that there was a
steady decline from 647K in 2007 to
550K in 2016.
SUBPOPULATIONS OF PEH
• Chronically Homeless (17.23%)
• Single Adults
• Women
• Families with Children (33.35%)
• Children
• Runaway and Homeless Youth (7.37%)
• Veterans (7.23%)
• Racial Minorities
METHODOLOGICAL DIF F IC ULTIES IN
DETERMINING THE NUMBER OF PEH
• PIT is just that – for one point in time
→ Localities have different methodologies
→ Most advocates insist these are undercounts
• Period prevalence (as in a year)
• Lifetime prevalence
• Definitional difficulties
→ Federal government has different definitions for
HUD, HHS and Department of Education
→ Some localities have their own definition
WHAT IS WORKING
• “Ending” Veterans Homelessness
• 50 communities have reduced
veterans homelessness to “functional
zero”
• From 2011 to 2016 estimated to
reduce veteran homelessness by 47%
• Not prevention, so not “ending”
homelessness
REDUC ING VETERAN HOMELESSNESS
• New Orleans was the first major city to
declare that it had ended Veteran
Homelessness. Their advice:
• Enlist the Mayor
• Make a list of all homeless veterans BY
NAME
• Target and prioritize housing resources
• Must have passion and determination
REDUC ING VETERAN HOMELESSNESS
CHRONIC HOMELESSNESS
DECREASED
HEALTH AND HOMELESSNESS
• Poor health can lead to homelessness
• Homelessness leads to and

exacerbates poor health
• Homelessness makes it harder to treat

every medical condition
POOR HEALTH  HOMELESSNESS
• Medical bills are the leading cause of
personal bankruptcy
• Poor health reduces the ability to earn
income to maintain housing
• Mental illness and substance use
disorders can make it harder to
maintain housing
HOMELESSNESS  POOR HEALTH
• Exposure to the elements lead to
hypothermia and heat stroke
• Poor nutrition and trauma weakens the
immune system
• Living in crowded shelters can promote
the transmission of disease (e.g., TB)
• Living on the streets or in
encampments  transmission (Hep A)
HOMELESSNESS MAKES IT HARDER TO
TREAT MEDICAL CONDITIONS
• There is no condition that is easier to treat
for a PEH than a domiciled person
• No place to store or refrigerate medication
• No place to safely store or carry syringes.
• Can’t “Stay off your feet, stay in bed and
rest for a few days until you’re better.”
• Diabetes rate is the same, but uncontrolled
diabetes is higher in PEH
HOMELESSNESS  HIGHER DEATH
RATES
• The average life span in the U.S. is about
80 years
• The average age of death of those dying
while living on the street is about 50 years
old – a loss of three decades of life!
• The age-adjusted mortality rate for PEH is
about 3-4 times that of the general
population
HEALTH CARE F OR THE HOMELESS
(HCH) PROGRAM
• Began in 1985 as a demonstration
project of the RWJF and Pew
Memorial Trust
• There were 19 projects in cities across
the U.S.
• Very successful and the federal
government adopted the model in
1987
HEALTH CARE F OR THE HOMELESS
• There are now 300 HCH programs
funded by the federal government,
with at least one in every state
• HCH programs served over 1 million PEH
in 2017
• HCH programs are stand-alone
agencies, part of larger community
health centers, public health
departments and hospitals.
HCH: OUTREAC H
• Philosophy of “meeting patients
where they are” figuratively and
literally.
• Outreach through various means:
locating a clinic on skid row, street
medicine, co-locating clinics in soup
kitchens or shelters, mobile health
vans.
HCH: WHOLE-PERSON CARE
• From the very beginning HCH
programs focused on more than the
physical health of patients – they had
to in order to improve health.
• Now the larger health system
recognizes the importance of
addressing the Social Determinants of
Health (SDH)Social Work
HCH: WHOLE-PERSON C ARE
• To address the many factors affecting
their patients, teams were
interdisciplinary with the TEAM
delivering care.
• Teams usually consist of a medical
practitioner, social worker, health
educator, with other professions
added as needed – and increasingly
peer workers.
HCH: BEHAVIORAL HEALTH
• Address mental health issues
• Address Substance Use Disorders
• Integrated care
• Leaders in treating SUD through
Medication Assisted Treatment (MAT).
HCH programs serve 4% of all health
center patients, but 38% of those
treated with MAT
SUC CESSES IN ADDRESSING HEALTH
AMONG PEH
• Housing First
• Permanent Supportive Housing
• Street Medicine
• Targeting Frequent Users of ERs
• Medical Respite
MEDICAL RESPITE/
REC UPERATIVE CARE: DEF INITION
• Acute & post-acute medical care for Diversity of
people who are homeless who are too ill Programs
or frail to recover from sickness or injury
on the street, but not sick enough to  Size
warrant hospital level care
 Facility
• Short-term residential care that allows
people who are homeless to rest in a  Length of stay
safe environment while accessing
medical care and support services  Staffing &
services
• NOT: skilled nursing facility, nursing home,
assisted living, or supportive housing  Admission criteria
MEDICAL RESPITE/
REC UPERATIVE CARE: RATIONALE
• Reduced hospitals stays
• Homelessness adds 4 days to length of stay
• AT LEAST $4,000 more per admission
• Reduced hospital readmissions
• 30-day ED readmission rate nearly 6x higher
• Hospital inpatient readmission rate nearly 2x
higher
• Safe, legal and ethical discharge option
• Improves patient health outcomes
HOUSING IS HEALTH C ARE EXAMPLES:
• Cincinnati Hospital System
• Portland Consortium
• Colorado Coalition for the Homeless
• Dignity Health System
• Kaiser Permanente Thriving
Communities Fund
• United Health Care
COMMON PITF ALLS
• Reinforcing stereotypes that all PEH
are the same
• Focusing on the individuals
experiencing homelessness without
the context of systemic failures
• Reinforcing that there are “deserving”
and “undeserving poor” – they are all
humans with human need
RESOURCES:
National Health Care for the Homeless Council (www.nhchc.org)

HUD Annual Homeless Assessment Reports: https://www.hudexchange.info/homelessness-
assistance/ahar/#2017-reports
United States Interagency Council on Homelessness (USICH) www.usich.gov
Corporation for Supportive Housing (www.csh.org)
National Coalition for the Homeless (www.nationalhomeless.org)
National Law Center on Homelessness and Poverty (www.nlchp.org)
National Low Income Housing Coalition (www.nlihc.org)
Western Regional Advocacy Project (www.wraphome.org)
Good books on housing policy:
Evicted: Poverty and Profit in the American City, Matthew Desmond, New York: Penguin
Random House, LLC, 2016)
The Color of Law: A Forgotten History of How Our Government Segregated America,
Richard Rothstein, New York: Liveright, 2017
CONTAC T INFORMATION
National Health Care
for the Homeless Council
www.nhchc.org
(615) 226-2292
Bobby Watts, CEO

[email protected]

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HOMELESSNESS AND HEALTH

The mission of the Council is to

• Homelessness leads to and

• Homelessness makes it harder to treat

National Health Care for the Homeless Council (www.nhchc.org)

Good books on housing policy:

Bobby Watts, CEO

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