Tuesday, October 13, 2009

Homeless Health care

Clearly, the United States values populations that hold power. The homeless community is powerless, and because of that their basic needs, even if they are a United States citizen, are flat out not being met. I found this article, about homeless and health care in England. Although community spoken of in the article is not of the U.S., the general issues among the homeless are exactly the same, regardless of location. For example, the cycle of mental illness that is a trend among most homeless families. The resource for this article was also The Health Reference Center Academic Infotrac, the link follows the article.

Health without a home: through user involvement, the QNI Homeless Health Initiative has identified key ways in which health care for homeless people needs to be improved.

Many community practitioners have homeless and insecurely housed patients on their caseload. Yet it is often difficult for them to meet the needs of this highly vulnerable group, due to a lack of support and of specialist knowledge and skills.

The Queen's Nursing Institute (QNI) Homeless Health Initiative (HHI) is funded by the Big Lottery Fund, and offers a way forward for practitioners through peer networking, information sharing and support, and professional training opportunities and resources. In order to ensure the input of homeless people in informing its work, the HHI commissioned the user involvement organisation Groundswell to research homeless people's experiences with health care. (1)

Multiple risk factors

There are an estimated 380 000 single homeless people (adults with no children) in England. (2) Homeless families (adults with children) in England include an estimated 116 000 homeless children. (3) Rough-sleeping is the most visible, extreme aspect of homelessness, but the vast majority of homeless people live in hostels, squats or bed and breakfasts, or in insecure conditions with friends or family.

Homelessness creates multiple risk factors to health, which almost inevitably deteriorates as a result of the prioritisation of immediate needs such as shelter, food and warmth. Health problems can severely affect homeless people's quality of life and limit their ability to access routes out of homelessness. Homeless people suffer significant inequalities in terms of both health and ability to access services.

People who are homeless experience significantly higher rates of health problems such as respiratory disorders, skin and dental problems, musculoskeletal problems and sexually transmitted diseases. Those sleeping rough have a rate of physical health problems two or three times greater than the general population's. (4) Homeless children are 'more likely to have a history of low birthweight, anaemia, dental decay and delayed immunizations ... to suffer accidents, injuries and burns', and the development of a substantial proportion of them is delayed (p463-4). (5)

Homeless children are up to four times more likely to experience mental health problems (6) and their parents are also more likely to experience them: 'Homeless mothers had a 49% prevalence rate of psychopathology and an 11% rate of contact with mental health services in the previous year' (p465). (5)

Indeed, mental health problems are a leading cause of homelessness--in a third of cases, losing a home is associated with mental health problems. (7) Homelessness can create mental health problems for the first time and exacerbate those that already exist. Mental health problems have been found to be eight times as high among hostel and bed and breakfast residents, and 11 times as high among people sleeping rough compared to the general population. (8) Many have multiple needs requiring appropriate health care.

Barriers to services

Homeless people frequently experience great difficulties in accessing the health care services that they need. They are 40 times more likely to not be registered with a GP and four times more likely to use accident and emergency (A&E) than the general population. (9)

Many mainstream providers lack knowledge on homeless people's health needs, impacting adversely on the care provided. There are examples of good practice, such as allowing homeless people to register with a GP using the surgery's address as their own and homelessness training for professionals, and there are a number of specialist services that offer a range of flexible, accessible services (including outreach). However, provision may be patchy, with a lack of specialist services in many areas and a lack of knowledge in generalist services.

Report findings

The Groundswell report (1) was commissioned with these issues in mind, along with the QNI's commitment to service user involvement. Focus groups with 25 homeless people were held in Grimsby, London and Gloucester, with professional facilitators who had personal experiences of homelessness. Recommendations to improve health care for homeless people were based on the findings (see Box 1).

The most important factor in a health service for the participants was the people, since what mattered was 'respect, good people, tolerance, care, compassion, friendly, no general rudeness.' Specific health issues varied according to circumstances--for example, rough sleepers identified cleanliness, safety and foot care.

Barriers to accessing services included waiting times, insufficient time with professionals, opening times and a lack of information. Service users expressed diverse experiences of staff attitudes, but frequently perceived these to be more negative due to their being homeless:

I was homeless and [the GP] didn't want me around ... he's a lot better now I've got a stable address and all that, he treats me with respect.

Different problems with A&E were noted, including a perception that triage and security staff often had a negative "gate-keeping" role.

Around 38% stated that their first port of call for health care would be a 'one-stop shop'--centres offering homelessness services and health care--but this may have been because many participants were accessed via these kinds of services. In an emergency, most said they would go to A&E or dial '999'.

Some of the participants reported having previously been discharged from hospital onto the streets:

They didn't find me anywhere to live, even though they said they would if I've been discharged on the streets.

I was beaten up and had stitches. Two o'clock in the morning, they're throwing me out. The following day I was vomiting blood.

The positive experiences described by participants included being discharged with enough medication for a week. However, some hospitals may be unaware of the national guidance on hospital discharge for homeless people.

Practitioners' needs

Community practitioners are committed and highly skilled professionals, but caring for this vulnerable population--often with multiple health issues and sometimes chaotic lives--presents many challenges. This may include institutional barriers such as a lack of understanding of homeless health issues by providers. Like their clients, practitioners may also be unsupported and marginalised, sometimes feeling stigmatised and undervalued. There can be insufficient support, resources and appropriate supervision, and restricted career opportunities. (10)

Inadequate understanding and prioritisation of homeless health issues in local health economies means that homeless services are often vulnerable to cuts. In addition, practitioners working in generic services may be unsupported in addressing homeless people's health needs. If there is no analysis of homeless people's local health needs, these can remain 'invisible'.

Imagine being a doctor in an emergency room, and you have a homeless patient to release, they are in bad shape, and you know they have no home. Would it be unethical to let him or her stay the night in a warm bed? It absolutely would, but at the same time if in the situation, I would imagine having a hard time releasing that person because of their circumstances. However, special treatment can not be given to every patient so where is the line drawn?


  1. http://find.galegroup.com.lesley.ezproxy.blackboard.com/gtx/retrieve.do?contentSet=IAC-Documents&resultListType=RESULT_LIST&qrySerId=Locale%28en%2C%2C%29%3AFQE%3D%28KE%2CNone%2C21%29health+care+homeless+%24&sgHitCountType=None&inPS=true&sort=DateDescend&searchType=BasicSearchForm&tabID=T002&prodId=HRCA&searchId=R4&currentPosition=5&userGroupName=les_main&docId=A186384504&docType=IAC

    link to article

  2. This is a great series of posts thus far -- this is a topic near to my heart. I can't wait to hear what our class colleagues have to say in response to your questions and the content of your posts. A great start!

    Dr. Amy R-R

  3. When it talks about homeless being discharged from the hospital and their negative and positive experiences. It is truly sad that a doctor would discharge a patient who is sick and would get sicker from not being in a warm or clean environment. I also find it very awful that they saw getting enough meds to last a week as a "positive" experience. A positive experience should be not leaving the hospital when you are still sick , you should not be allowed to leave until you are better.

  4. who would be paying for them to stay in the hospital until they are better? if they dont have health care and don't have enough money to pay for the care they need then you is the one that will responsible to over medical bills?

  5. Healthcare is a touchy subject. Reading all this makes me want to help all those in need have access to the same resources i'm lucky to have. However, at the same time i do not think it would be fair to other people who pay for their healthcare to give free services to the homeless. Especially, when many are struggling to afford healthcare.
    Not only the matter of fairness, but definately the matter that was brought up earlier on who is going to pay for all this?

  6. I feel that it is the responsibility of healthy fortunate Americans to help support and care for homeless Americans and help pay for healthcare for all. I have seen firsthand how mental health can lead a person from being well off to being homeless. My Great Aunt was a brilliant student at Cornell University. She was successful and was an executive at IBM after graduating. She then became mentally ill. She could not hold down a job and became homeless. My family members have paid for her housing and taken care of her since then. She was fortunate to have a family but not all mentally ill people are lucky like that. I feel that is it the responsibility of the healthy well off Americans to pay for medical intervention for mentally ill people who cannot afford it. I think that it is a cycle because once the mentally ill become homeless then they can become sicker and their mental illness can worsen. If healthy Americans helped pay for healthcare for the less fortunate especially preventative healthcare then we might not have as many homeless people in America and the mentally ill might not suffer as much from their mental illnesses.

    Taylor Faulkner