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  1. Gerber, Lois MPH, BSN, RN

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"I LIVE WITH SLEEP DEPRIVATION every day; it makes me moody, angry, and unable to concentrate. It's a miserable way to live!" said Mr. H, 35 and single, sitting across from me in a local shelter. Homeless for 18 months, he was wearing ragged pants and a hooded sweatshirt, which he'd picked up at the Salvation Army. Although his clothes looked clean, his strong body odor permeated the air. Speaking in a soft monotone and avoiding eye contact, he clenched his fists and continued, "We're all different. I hate when people stereotype us as lazy, crazy, evil, or stupid. I have 3 years of college."

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Nurses working in any public, private, or veterans' hospital are responsible for providing homeless persons realistic plans for follow-up and appropriate referrals to community agencies on discharge. Nurses working in jails and prisons should develop discharge plans that include referrals for housing and healthcare before inmate release. The Joint Commission mandates all patients receive safe discharge from healthcare facilities.1


This article explores the health problems of homeless people like Mr. H, how these health problems can impact other people, and how nurses can best care for these vulnerable patients.


Sobering facts

Homelessness kills! This multidimensional problem harms the health of both homeless people and the general public. The many communicable diseases that homeless people contract may lead to outbreaks that later become serious public health hazards. Evidence suggests appropriate public health interventions can prevent and control the spread of disease.2


In 2011, about 636,000 people, more men than women, were homeless in the United States, a decrease of 1% from 2009.3 A report the same year reported 1 in 50 children was without a home.4 Over the last decade, the number of homeless families, many headed by single mothers in their 20s, has increased significantly. Many of these women have left a domestic situation because of physical and/or mental abuse.5,6 One study found about 25% of the gay and lesbian population and 15% of bisexuals reported homelessness compared with 3% of the heterosexual population.7


The prevalence of physical illnesses, including infectious diseases, among homeless persons ranges from 33% to 55%. Their average life expectancy is 44 years compared with 78 years for the general U.S. population.1 Their age-adjusted mortality is three to six times higher than for people with housing.1 Homelessness affects single people, families, and children in both urban and rural areas, although in farm communities, family and friends are more likely to offer temporary housing and other assistance.5


In urban renewal efforts to create more attractive neighborhoods, many single room occupancy (SRO) hotels were eliminated, which increased the number of homeless people. Deinstitutionalization of the chronically mentally ill from public psychiatric hospitals and the high unemployment rate both exacerbated the problem.5 For more insight into the root causes of homelessness, see Understanding two types of poverty.


Concurrent problems

The persistently homeless live in constant chaos, confusion, and fear. Trauma from head injuries, gunshot wounds, stab wounds, lacerations, and/or fractures is a significant cause of death and disability.5 Hypothermia in the winter and dehydration in the summer are of particular concern.


Homeless people also experience higher rates of chronic disease, comorbidities, and physical limitations than the general population. For example, many vision issues aren't addressed.8 Most homeless people have at least one chronic illness and untreated health problems to which they've adjusted. Many have adjusted to the functional disabilities of their chronic health problems.1,5,8 (See Zero in on chronic conditions.) For example, Ms. T, a middle-aged homeless woman visiting the shelter, spoke of long-term untreated digestive problems that she "just lives with."


From 20% to 25% of homeless people have mental health illnesses.9 Some deny mental illness and refuse treatment.


Substance abuse is a common comorbidity.11 Eighty-four percent of homeless men and 54% of homeless women have alcohol use disorders compared with 8% of the general population.1,10 Although 13% of the homeless are employed, physical and mental illnesses hinder the ability of most homeless people to earn enough to meet daily needs.6,7


Special populations, special concerns

Among the homeless, veterans, former convicts, and minority groups are disproportionately represented. Homeless pregnant women have high rates of sexually transmitted infections (STIs) and drug addiction and are at risk for complex health problems. Their infants are more likely to be born prematurely and have lower Apgar scores.5


Children younger than age 5 are at high risk for developmental delays and impaired brain development. Most homeless children have more physical, mental health, and learning problems than poor children who are housed.5


Homeless teens may be runaways attempting to escape physically or sexually abusive home environments. They may exchange sex for food, clothing, and shelter, which increases their risk for HIV/AIDS, STIs, and unintended pregnancy.5


Homeless youth come from all socioeconomic levels of society, not only from poor households, and are more likely to live outdoors than older homeless people. Many experience physical or sexual victimization after leaving their homes.12 Some are transitioning from foster care.3 Depression and suicidal ideation are common. These youth need reunification with families or supportive residential housing.12


Unique characteristics

All homeless people are vulnerable physically, socially, psychologically, and spiritually; they experience higher rates of violence, homicide, and suicide than the housed. Children, women, and older adults are the most defenseless.5,10,13


Many habits of homeless people, such as panhandling, infrequent bathing, and obtaining food from dumpsters, conflict with cultural norms. Often enduring conditions that would incapacitate others, homeless people may derive a sense of achievement from their survival skills they didn't experience in the mainstream world.


Those who value the common theme of self-survival have learned to rely on only themselves and their peers. Some lead a nomadic life and spend a large part of each day finding food and shelter with little thought or planning for the future.


Although detached from the broader community, they honor relationships with each other and tend to share resources among themselves. They may fear losing their street skills if they assimilate into the mainstream or accept societal assistance. Many blame fate or bad luck for their situations but hope for a change in their present circumstances.7,14


Nursing considerations

Nurses may feel powerless and frustrated when caring for homeless patients. These patients' frequent ED visits and poor adherence to discharge instructions can contribute to burnout in nurses.1 Yet nurses who learn about this culture's unique needs are in a pivotal position to improve healthcare for this population.


Nurses need to understand their personal values and beliefs before serving this population.5 The everyday lives of healthcare providers and the homeless are so different that they can become cultural strangers, often avoiding contact with each other because of mutual fears. Some healthcare providers prescribe treatment and offer professional advice in hospitals, clinics, or shelters without understanding a patient's lifestyle or knowing if the patient lives on the street, in a wooded area, under a bridge, or in an SRO, parked car, railcar, tent, abandoned building, or cave.5,11


According to R. Gonzales, director of operations of Halifax Urban Ministry, a multiservice agency serving the homeless in Daytona Beach, Fla., most homeless people protect the place where they live, even if it's outdoors, and carefully hide their things somewhere nearby.15


Ms. T said, "Waterproof backpacks are essential. And bikes. I sold my blood and an envelope of Keflex to buy a two-wheeler." Both items facilitate a homeless person's ability to move around within the community.15


Healthcare for the homeless is provided in various settings-shelters, hospital EDs, store-front clinics, churches, and mobile van units. Appointments shouldn't be required. Although it's not always feasible, the multidisciplinary team/case-management approach works best to prevent patient involvement with multiple providers and fragmentation of care.11


Outreach and case-finding is important. Building rapport is easier if patients are met on their own turf-shelters, soup kitchens, and on the street. Be aware of common factors that hinder treatment and work to overcome them. (See Barriers and obstacles to treatment.) Because the overall picture for each person, family, and community differs, care needs to be planned according to each person's potential.6,10


Take enough time and exercise patience to develop a trusting, nonjudgmental relationship that conveys respect, dignity, and value. Treat each person as an individual and avoid stereotyping. Follow up on promises. Be aware of the patient's body language and respond appropriately. Follow the patient's lead and respect his or her comfort level when making eye contact and entering personal space. Speak in a calm manner, especially if the patient appears tense or nervous. Communicate in the person's primary language; if necessary, use a medical interpreter.6,13


Listen to the patient's stories to find common themes. Storytelling helps people create their own identities and bring the past to the present. Often-repeated stories may offer clues to the patient's concerns and anxieties and alleviate feelings of confusion.16 On many occasions, Ms. T recounted anecdotes from her previous work experience as an administrative assistant to a business executive. These stories, whether they're true or not, illustrate her need for respect and validation of her intelligence and contributions to society.


Ask simple, open-ended questions with enough uninterrupted time for the patient to answer. An interesting way to start a conversation is, "What would make your day better right now?" Let the patient set the pace of the interaction and follow his or her lead, being aware of eye contact and personal space. Tailor questions to the patient's housing and behavioral situation. Establish clear guidelines and appropriate personal boundaries.1 Set limits on disrespectful comments, sexual innuendo, and obscene language. At times, making the hand gesture T signifying "time out" helps here. If not, make a firm statement. Personal safety is a concern for nurses working independently because some homeless people occasionally behave unpredictably.10


Physical and psychosocial assessment can be challenging. Focus first on basic life care needs. Pay special attention to the patient's teeth, skin, and feet because homeless people have limited access to dental care, bathing facilities, and food.1 Be alert for signs of substance abuse such as needle marks and nasal abnormalities.13 Assess for signs and symptoms of malnutrition, infectious diseases, lice, and scabies. Illicit drug use and risky sexual behaviors, including prostitution, increase the likelihood of infectious diseases such as HIV, hepatitis B and C, and STIs.


People residing in overcrowded living conditions have a higher incidence of airborne infections, especially tuberculosis and influenza.2,6 An uncommon but serious transmissible relapsing illness is Bartonella quintana, a louse-borne disease that causes fever, rash, bone pain, and splenomegaly. Complications include bacteremia and endocarditis.2,17


Assessment and intervention

Assess the patient's mental health for clarity of thought, emotional affect, and aggressive tendencies. Identify areas of self-esteem, self-empowerment, and assertiveness, no matter how small, and determine the patient's personal, social, and day-to-day living skills. Focus and build on the patient's talents and strengths rather than on weaknesses. Identify coping skills and areas of resilience-what worked before and what didn't. Prioritize problems.6,10


Create viable care plans that are individualized and interdisciplinary. For acutely ill patients, coordinate appropriate intervention with medical facilities, mental health crisis units, or detoxification care.1


For those not needing immediate care, develop patient-centered goals, expressed in the patient's language and frame of reference. The goals should belong to the patient, not the nurse. Make initial goals simple, concrete, and short term. A very basic goal would be a return visit to the clinic the following day. Registering for an identification card this afternoon is another example. Start at the beginning of the process instead of the hoped-for end result.10 Patients must understand the goals and believe they're attainable. Many homeless people may not be able to sustain interest in long-range endeavors. Their focus is the present day.


Chronic and infectious diseases should be managed with clear-cut treatment plans and medication schedules. Be aware that the patient may sell his or her prescribed medications on the streets. Offer regular infectious disease screenings in shelters using multidisciplinary teams. Some of these screenings should be unannounced to cover people who'd stay away because they're afraid or reluctant to interact with healthcare workers. If possible, give patients with terminal illnesses the opportunity for shelter and hospice-type interventions to relieve pain and suffering in a supervised setting.2,10,18


Coordination of care is imperative. Obtain previous records and identify any support persons in the patient's life.10 Services shouldn't conflict or duplicate each other; "one-stop shopping" and follow-up with an assigned case manager is optimal.13 If that's not possible, link services together to avoid fragmentation. Using the electronic medical record and following Health Insurance Portability and Accountability Act guidelines, patient health information can be shared with all providers so that treatment plans and patient progress toward goals are managed more effectively.6,13


If available, use telehealth tools to communicate patient-specific data from mobile clinics to hospitals and healthcare provider offices.19 The U.S. Department of Housing and Urban Development's software program, Homeless Management Information System, can be used to record and store information about homeless people.20


Investigate and network with the various disciplines and social service agencies that offer emergency overnight shelter, food, hygiene products, and clothing, such as the Salvation Army, United Way, churches, and soup kitchens.5,6 Coordinate services with city and county health departments, churches, and volunteer groups such as the Interfaith Hospitality Network. Refer homeless patients and those living in poverty to these community agencies.


The paperwork maze is a tremendous problem. Give patients detailed information about required paperwork, as well as agency locations, travel options, and the name of a contact person. Simply providing food, a safe place for 7 or 8 hours of uninterrupted sleep, and an opportunity to shower improves patients' receptiveness to these services.5,6,14


Learn about educational opportunities, job training programs, and free legal services. Refer patients to appropriate housing programs (emergency, transitional, or permanent). If appropriate, contact Habitat for Humanity and religious groups in the community. Agencies with comprehensive housing plans to address homelessness provide various options-emergency overnight shelter, transitional housing, permanent housing, and supportive housing (subsidized living arrangements with supportive services in place to meet the patients' needs).5,21,22


Counsel patients to apply for state and federal programs such as Medicare, Medicaid, welfare, Head Start, Supplemental Security Income (SSI) program, and food stamps. Typically, identification cards validating the person's name, birth date, and Social Security number are required.21 Some city governments or programs working directly with the homeless provide these free of charge.


Monies from the McKinney-Vento Homeless Assistance Act, a federal program providing funds for outpatient health services, may be available. Families with children are eligible to receive shelter and nutritional assistance from the Women, Infants and Children (or WIC) program, a federal program from the U.S. Department of Agriculture.5 Temporary Assistance to Needy Families is a further resource. Serious psychiatric and physical disability can qualify patients for SSI.11 The Homeless Emergency and Rapid Transition to Housing (or HEARTH) Act, signed into law in May 2009, consolidates the government's competitive grant programs and increases resources to prevent homelessness.20 (See Tapping resources for more information.)


Measure progress, provide positive reinforcement, and adjust goals when necessary in a nonjudgmental way. Evaluate the success of the care plan objectives in measurable terms using evidence-based practice criteria.10,13


Nurse-managed health clinics (NMHC), especially those that serve only the homeless, provide a cost-effective solution for delivering healthcare to this population. Primary healthcare providers may be NPs with prescriptive authority, well prepared for the role.11 Other team members include dentists, physicians, substance abuse counselors, pharmacists, and psychologists. Nurses working in outreach and case management can act as liaisons between the homeless and NMHC staff. These one-on-one relationships will increase the patients' participation in health screening and health promotion programs. NHMCs can provide clinical sites for nursing students and may operate under the aegis of hospitals, universities, or community colleges.1,23 The Patient Protection and Affordable Care Act of 2010 includes funding for nurse-managed centers.13


Community health nurses can act as case-finders and referral sources for the homeless and near-homeless. School nurses can identify and intervene with homeless students or those at risk and can offer educational programs on the needs of this population to the student body. Parish nurses can act as a resource for persons needing shelter and educate the church congregation on the characteristics of this elusive culture.


Focus on prevention

For most people, mental, physical, and financial problems precede homelessness; homelessness rarely comes first.6 In 2011, the federal poverty guideline was $22,350 for a family of four.5 To reduce the risk of homelessness, identify and intervene with individuals and families living in poverty and marginal situations, such as families residing together in "doubled up" situations.3 Assess for insect, mouse, or rat infestation; lack of running water; inadequate heating and air conditioning; malfunctioning plumbing; and the absence of a telephone. Refer patients to emergency assistance programs for help with rent and/or utility bills. Teach health promotion behaviors, such as using condoms, and screen for such diseases as tuberculosis, anemia, diabetes, and hypertension.5,24


Advocacy is important. Volunteer.14 Talk to members of professional nursing organizations, political leaders, and the general public about the needs of the homeless and strategies to provide health screening and care in a humanitarian and cost-effective manner. Mobile units with multidisciplinary teams are one option; another is accessible and convenient "brick and mortar" locations.25 Many homeless people prefer to remain in their own neighborhoods.


Each chronically homeless person who cycles in and out of homelessness and institutional care costs tens of thousands of dollars annually.25 Offer documentation to local leaders showing that permanent supportive housing coupled with supportive care saves money because of the decreased financial burden on hospitals, mental health services, police and criminal justice resources, and substance abuse detoxification and treatment centers.25 Government block grants are available.


Crossing the divide

Homelessness today is a multifaceted public health problem. The Department of Health and Human Services outlined several goals related to homelessness in Healthy People 2020: achieve health equity, eliminate disparities, and create healthy social and physical environments.26 Even though future research is essential to determine nursing's role in how to best reach these goals, nurses have the skills and abilities to address this serious issue in a humanitarian and cost-effective manner.14 Bridging the divide between the housed and the homeless will improve the health and well-being of society at large.


Now what about Mr. H, the man in the shelter? Toward the end of my conversation with him, he jammed his fists in his sweatshirt pockets, saying, "I've gotta get out of here," as he stomped out the door. Unfortunately, residents in the community where he lives may experience the fallout from his anger and anxiety. I hope he'll return to the shelter for healthcare, counseling, and outreach services. Nursing care of the homeless must focus on both the needs of the individual patient and the population at large.6


Understanding two types of poverty5

The poverty of homelessness can be broken down into two subtypes: crisis poverty and persistent poverty.


* Crisis poverty impacts people whose lives are riddled with hardship and struggle; their homelessness is transient with episodic stays in shelters and temporary housing. The root causes of crisis poverty are lack of employment opportunities, obsolete job skills, lack of education, and domestic violence.


* Persistent poverty refers to chronically homeless people who are likely to have mental and physical disabilities, which often exist along with alcohol and drug abuse, family estrangement, lack of a high school education, and poor social skills.



Zero in on chronic conditions

Homeless people have disproportionately high rates of these chronic conditions:


* arthritis


* asthma


* chronic obstructive pulmonary disease


* diabetes




* hypertension


* peripheral vascular disease


* pneumonia


* STIs


* tuberculosis (TB).5,6,10



The mental health diagnoses most often identified in the homeless are the following:


* bipolar disorder


* dementia


* depression


* personality disorder


* posttraumatic stress disorder


* schizophrenia.5,6



Barriers and obstacles to treatment5,6,10

Keep in mind that a homeless patient may face these hurdles:


* lack of transportation


* lack of telephone service


* alienation from the healthcare system


* lack of preventive care


* literacy difficulties


* poor nutrition


* feelings of stigma


* multiple day-to-day stressors


* disorganization


* difficulty keeping appointments and adhering to medical plans


* immigration issues.



Tapping resources for more information

Check out these websites for more ways to help homeless patients:


* National Alliance to End Homelessness: http://www.endhomelessness.org


* National Health Care for the Homeless Council: http://nhchc.org


* U.S. Department of Housing and Urban Development: http://portal.hud.gov.





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