Homelessness

BASICS

DESCRIPTION

  • Lacking a fixed, regular, and adequate nighttime residence.
  • Chronic homelessness: lacking fixed, regular housing for at least 1 year, or at least four episodes of being unhoused in the past 3 years for a combined length of at least 1 year.
  • People struggling with homelessness often have complex and chronic medical illnesses such as mental illness, substance use disorders, and physical disabilities (1).

EPIDEMIOLOGY

Incidence

  • Increasing since 2017 nationwide; 6% overall increase year-to-year, expect for this past year which showed >12% increase over the previous year. This marked the largest increase since data collection began in 2007.
  • The COVID-19 pandemic disrupted accounting of unsheltered people, but conditions during the pandemic may have increased the incidence (1).

Prevalence

In 2023, 0.19% of the U.S. population (approximately 653,100 individuals) experienced homelessness on any given night: 61% in sheltered locations and 39% in unsheltered locations (1).

  • 5% are veterans, 28% are families with children, 5% are unaccompanied youth (age <25 years) and 22% are chronically homeless individuals.
  • 50% of the homeless population is white.

RISK FACTORS

  • Poverty
    • 2024 federal poverty level: $31,200 annual income for four-person household in the lower 48 states and District of Columbia, slightly higher in Alaska and Hawaii (2)
    • In 2022, 11.5% of U.S. population below federal poverty line
  • Unemployment: U.S. rate 4.3% in July 2024 (U.S. Bureau of Labor Statistics)
  • Lack of affordable health care: In 2023, 7.7% of U.S. population (334 million) were uninsured for the entire calendar year (3).
  • Lack of affordable housing: <30% of gross income for housing costs, including utilities; roughly 40.9 million U.S. households spend >30% on housing costs; 19 million households spend ≥50% of income on housing.
  • Intimate partner violence (IPV): 12% of overall persons experiencing homelessness and about 20% of families experiencing homelessness report IPV; IPV often involves exertion of psychological and financial control that leaves survivors with poor credit, limited support, and few resources.
  • Veterans: decreasing due to policy changes; decreased by 50% over a decade (2010 to 2020) (2)
  • Transgender individuals: 0.6% identify as transgender and 0.6% as gender nonconforming (2)
  • Addiction disorders: 46% report substance use as a major factor contributing to homelessness (1).
  • Psychiatric illness: 25% of adults experiencing homelessness (1)
  • Postincarceration: 50,000 people each year enter homeless shelters from jails/prisons (1).

GENERAL PREVENTION

  • Policy and funding for community programs to provide emergency/rapid housing, housing stabilization, and case management services; the CARES Act of 2020 and the American Rescue Plan Act of 2021 provide funding for permanent housing. Over the past 5 years, the fastest growing forms of assistance include rapid rehousing and “other permanent housing.”
  • Increased Medicaid eligibility, expanded home- and community-based services, and case management for people experiencing homelessness.
  • HUD: increasing permanent supportive housing units; increasing services for veterans, families with children, and those with disabilities
  • Social justice policy recommendations: permanent affordable housing; foreclosure and homelessness prevention; increased funds for HUD McKinney-Vento programs (emergency, transitional, and permanent housing) and National Housing Trust Fund, rural homeless assistance, universal health care, universal livable income, employment/workforce services; prevention of hate crimes against the homeless, decriminalization of homelessness

COMMONLY ASSOCIATED CONDITIONS

  • Hunger and malnutrition
  • Exposure-related conditions (frostbite, heatstroke)
  • Substance use disorders and their associated conditions
    • Liver disease (alcohol, hepatitis B and C)
    • Abscesses (intravenous drug use)
    • Overdose
  • Dental problems
  • Psychiatric illness
  • Trauma (increased risk of assault, victims of hate crime)
  • Infectious diseases
    • Skin/nail infection and infestation (lice, bedbugs, and scabies)
    • Tuberculosis, HIV/AIDS, STI
  • Worsening of chronic medical conditions; lack of healthy food, places to store medications, or medical equipment; lack of restful sleep; decreased health literacy; limited transportation to appointments

DIAGNOSIS

HISTORY

  • Living conditions: location, access to food, restrooms, place to store medicines, safety
  • Prior homelessness: causes and circumstances
  • Family members, especially dependent children
  • Medications: OTC medication, dietary supplements, medication “borrowed” from others
  • Prior providers: oral health, primary and specialty care, current medical home
  • Mental health: stress, anxiety, appetite, sleep, concentration, mood, speech, memory, thought process and content, auditory/visual hallucinations, suicidal/homicidal ideation, insight, judgment, impulse control, social interactions; symptoms of brain injury (headaches, seizures, memory loss, irritability, dizziness, insomnia, poor organizational/decision-making skills), trauma history
  • Alcohol/nicotine/drug use: amount, frequency, duration
  • Gender identity/orientation, behaviors, rape, pregnancies, hepatitis, HIV/AIDS, other STIs
  • History of or current abuse: emotional, physical, sexual; patient safety
  • Legal problems/violence: history of incarceration
  • Activities: routines (treatment feasibility); level of strenuous activity
  • Work: previous types of jobs, length held, veteran status, occupational injuries/toxic exposures; vocational skills, interest
  • Education: highest level; ever in special education; assess ability to read/language skills/English fluency.
  • Nutrition/hydration: diet, food resources, preparation skills, liquid intake
  • Cultural heritage/affiliations: family, friends, faith community, other sources of support
  • Strengths: coping skills, job skills, resourcefulness, abilities, interests

PHYSICAL EXAM

  • Comprehensive exam: height, weight, BMI, especially abdominal, cardiopulmonary, dermatologic, oral, feet, neurologic, mental status
  • Focused exams: for patients uncomfortable with full-body, unclothed exam at first visit
  • Dental assessment: age-appropriate teeth, obvious caries, dental/referred pain, diabetes, CVD

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • Mental health: Patient Health Questionnaire (PHQ-9, PHQ-2), MHS-III, MDQ, GAD-7
  • Cognitive assessment: Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MOCA), Traumatic Brain Injury Questionnaire (TBIQ), Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
  • Developmental assessment: Ages & Stages Questionnaires, Parents’ Evaluation of Developmental Status (PEDS), Denver II, or other screening tool
  • Interpersonal violence: IPV, sexual assault, TBI
  • Forensic evaluation: if indicated by history
  • Baseline labs: as needed to address suspected medical concerns
  • TB screening: PPD or T-SPOT.TB/QuantiFERON-TB Gold if available
  • STI screening: HIV/AIDS, chlamydia, gonorrhea, syphilis, hepatitis B, hepatitis C, trichomonas
  • Substance abuse: Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD), urine drug screen

Follow-Up Tests & Special Considerations

  • Reproductive health care and STIs: Obtain detailed sexual history (sexual identity, orientation, behaviors/sexual practices, number of partners). Consider patient exploitation, especially if mental illness/developmental disability suspected. Communicate willingness to initiate contraception first visit without exam. Genital exam recommended, but be sensitive to patient, especially if there is a possible sexual abuse history. If pelvic exam is refused, consider self-collected testing and/or empiric treatment for STI (and possibility of multiple orifice infection). Dispense medications on site; facilitate partner treatment.
  • Consider access to facilities, even if residing at a shelter. For example, patient may not have access to restroom for colonoscopy bowel prep.
  • Pediatric care: complete exam every visit; use each visit to identify/address problems and provide vaccinations because homeless families may not see a medical provider unless child is sick. Vision and hearing screening at every visit. Facilitate referrals as able.

TREATMENT

MEDICATION

  • Simple regimen: low pill count, once-daily dosing
  • Dispensing: small amounts on site to promote follow-up, decrease loss/theft/misuse; determine resources for written prescriptions.
  • Storage of medications: If no access, avoid medications requiring refrigeration.
  • Patient assistance: free/low-cost drugs depending on available local options
  • Aids to adherence: harm reduction, outreach/case management, directly observed therapy
  • Side effects: Primary reason for medication nonadherence are drugs causing diarrhea, polyuria, nausea, and/or disorientation.
  • Analgesia/symptomatic treatment: Consider pain contract, single provider for pain medication refills.
  • Dietary supplements: multivitamins with minerals, nutritional supplements
  • Managed care: generics, if possible; assistance getting prescription filled.
  • Lab monitoring: Monitor patients on antipsychotic medications for metabolic disorders using available laboratory resources.

ADDITIONAL THERAPIES

  • Associated problems/complications
    • Fragmented care: multiple providers; use electronic medical record (EMR) as possible; list prescribed medication on wallet-sized card.
    • Masked symptoms/misdiagnosis: for example, weight loss, dementia, edema, lactic acidosis
    • Focus on immediate concerns, not possible future consequences.
    • Integrated treatment for concurrent mental illness/substance use disorders
    • Support for parent of child abused by others and for abused parent
    • Large appointment burdens: specialty care may be difficult to obtain.
  • Follow-up
    • Reliable phone/email contact for patient/friend/family/case manager
    • Frequent follow-up, incentives, nonjudgmental care regardless of adherence
    • Anticipate/accommodate unscheduled clinic visits.
    • Provide car fare, tokens, and help with transportation services.
    • Monitor school attendance and address health/developmental problems with family/school.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

  • Admission is beneficial if living conditions are not conducive to treatment of medical, psychiatric, and substance use disorders.
  • Discharge considerations:
    • Acute or chronic wound care: Bed rest, extended periods of elevation, rest, or icing are not feasible in most instances.
    • Need for durable medical equipment (DME): Portable oxygen tanks and nebulizers may not be covered by the hospital and may be cumbersome to use in absence of stable housing.
    • Medications: It is preferable to fill prescriptions at hospital outpatient pharmacy.
    • Outpatient follow-up: Transportation to appointments should be arranged if possible.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Patients with a history of nonadherence need additional support (e.g., case manager, outreach) to succeed in ongoing care after hospital discharge.
  • Limited telephone access to schedule appointments; may be unable to receive telephone messages with test results or rescheduled appointment times; some social service agencies will provide phone, mail, email, Internet, and laundry services.
  • Arrange appointments prior to discharge.
  • Document the best way to contact the individual.
  • Work with experienced health care agency designed to address physical/mental health services and substance use treatment.

PATIENT EDUCATION

PROGNOSIS

Mortality rates are 3 to 4 times higher than general U.S. population.

Authors

Dana Sprute, MD, MPH, FAAFP
Madeline Elaine Huff, MD, MS

REFERENCES

  1. National Alliance to End Homelessness. State of homelessness: 2024 edition. https://endhomelessness.org/homelessness-in-america/homlessness-statistics.... Accessed August 27, 2024.
  2. U.S. Department of Health and Human Services. Annual update of the HHS poverty guidelines. https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines. Accessed August 27, 2024.
  3. de Sousa T, Andrichik A, Prestera E, et al; for Abt Associates. The 2023 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: Point-in-Time Estimates of Homelessness: December 2023. U.S. Department of Housing and Urban Development, Office of Community Planning and Development; 2023.

CODES

ICD10

  • Z59.0 Homelessness
  • Z59.1 Inadequate housing
  • Z59.8 Other problems related to housing and economic circumstances
  • Z59.9 Problem related to housing and economic circumstances, unsp
  • Z59.3 Problems related to living in residential institution

SNOMED

  • 32911000 homeless (finding)
  • 266935003 Housing lack
  • 365510008 Temporary shelter arrangements - finding
  • 160700001 Homeless single person (finding)
  • 105526001 Homeless family (finding)

CLINICAL PEARLS

Last Updated: 2026

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