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BASICS

Description

  • Lacking fixed, regular, and adequate nighttime residence.
  • Chronic homelessness: ≥1 year or ≥4 episodes of homelessness in 3 years totaling ≥1 year.
  • Complex medical comorbidities common (mental illness, substance use, physical disabilities).

Epidemiology

  • Increasing incidence since 2017 (6% increase).
  • 2022: 0.18% of U.S. population (~582,462 individuals) homeless nightly.
  • 61% sheltered, 39% unsheltered.
  • 6% veterans, 28% families with children, 5% unaccompanied youth (<25 years), 22% chronically homeless.
  • 50% of homeless population is white.

RISK FACTORS

  • Poverty (2023 federal poverty level ~$30,000/year for family of 4).
  • Unemployment (3.6% in June 2023).
  • Lack of affordable healthcare (8.6% uninsured in 2022).
  • Housing costs >30% or >50% of income for millions of U.S. households.
  • Intimate partner violence (IPV), affecting 12% homeless overall, 20% of homeless families.
  • Veterans (declining numbers but still at risk).
  • Transgender and gender nonconforming individuals.
  • Substance use disorders (~46% report use contributing to homelessness).
  • Psychiatric illness (~25% adults homeless).
  • Post-incarceration (50,000 annually enter shelters).

GENERAL PREVENTION

  • Policy/funding for emergency, rapid rehousing, permanent supportive housing.
  • Medicaid expansion and community-based services.
  • HUD increasing permanent housing and targeted services.
  • Social justice measures: affordable housing, homelessness prevention, decriminalization.

COMMONLY ASSOCIATED CONDITIONS

  • Hunger, malnutrition
  • Exposure-related injuries (frostbite, heatstroke)
  • Substance use disorders & complications (abscesses, overdose)
  • Dental issues
  • Psychiatric illness
  • Trauma, assault, hate crimes
  • Infectious diseases (TB, HIV/AIDS, STIs)
  • Chronic disease exacerbation (poor medication access/storage, sleep deprivation, low health literacy)

DIAGNOSIS

History

  • Living conditions: location, food access, safety, medication storage.
  • Prior homelessness causes and duration.
  • Family and dependent children status.
  • Medication and substance use history.
  • Mental health status: mood, cognition, hallucinations, trauma.
  • Legal issues/incarceration.
  • Work, education, social support, strengths.

Physical Exam

  • Comprehensive exam with focus on dermatologic, oral, cardiopulmonary, neurologic, mental status.
  • Dental assessment.

Diagnostic Tests

  • Mental health screening (PHQ-9, GAD-7, MMSE, MOCA).
  • Developmental and cognitive assessment if indicated.
  • Interpersonal violence and forensic evaluation.
  • Labs as clinically indicated.
  • TB and STI screening (HIV, hepatitis B/C, syphilis, chlamydia, gonorrhea, trichomoniasis).
  • Substance abuse screening.

TREATMENT

Community Resources

  • Mental health, substance abuse programs.
  • Free clinics, case management.
  • Vaccinations: Hepatitis A/B, pneumococcal, Tdap, influenza, SARS-CoV-2.
  • Chronic disease and cancer screening.
  • Basic needs: food, clothing, housing.
  • Individualized care plans prioritizing patient goals.
  • Extended clinic hours and emergency plans.

Medication

  • Simple regimens (low pill burden, once daily).
  • On-site dispensing, small quantities.
  • Medication storage considerations (avoid refrigeration dependence).
  • Patient assistance programs.
  • Harm reduction, outreach, directly observed therapy.
  • Address medication side effects impacting adherence.
  • Nutritional supplements.

Additional Therapies

  • Integrated care for concurrent mental illness and substance use.
  • Support for abuse victims and their families.
  • Coordination of care among multiple providers.

Hospital Admission

  • When living conditions impede treatment.
  • Address wound care, DME needs, medication access.
  • Facilitate outpatient follow-up and transportation.

ONGOING CARE

Follow-up Recommendations

  • Additional support for patients with nonadherence history.
  • Alternative contact methods documented.
  • Coordination with specialized health and social service agencies.
  • Frequent, flexible clinic visits and incentives.
  • Monitor school attendance and developmental issues for homeless children.

PATIENT EDUCATION

  • National Health Care for the Homeless Council: https://www.nhchc.org/
  • National Alliance to End Homelessness: http://www.endhomelessness.org/

PROGNOSIS

  • Mortality 3–4 times higher than general population.

REFERENCES

  1. National Alliance to End Homelessness. State of homelessness: 2023 edition. https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness/. Accessed July 9, 2023.

  2. U.S. Department of Health and Human Services. HHS poverty guidelines for 2023. https://aspe.hhs.gov/topics/poverty-economic-mobility/povertyguidelines. Accessed July 9, 2023.

  3. de Sousa T, Andrichik A, Cuellar M, et al; for Abt Associates. The 2022 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: Point-in-Time Estimates of Homelessness: December 2022. Washington, DC: U.S. Department of Housing and Urban Development, Office of Community Planning and Development; 2022.

Clinical Pearls

  • Permanent supportive housing using a Housing First model is key to ending homelessness.
  • Assisting with benefits access and basic needs reduces stress and improves healthcare engagement.