Homelessness is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

Defined as (i) an individual who lacks a fixed, regular, and adequate nighttime residence; and (ii) an individual who has a primary nighttime residence that is (a) a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill); (b) an institution that provides a temporary residence for individuals intended to be institutionalized; and (c) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings

Epidemiology

Prevalence

In 2016, on any given night in January, there are 549,928 homeless individuals in the United States: 35% are homeless families; 15.6% are chronically homeless; and 22% are children (1).

  • From 2015 to 2016, overall homelessness decreased by 2.6% largely due to increases in available housing locations. Risk for becoming homeless remains high in certain populations (see “Risk Factors”) (1).
  • Although many homeless individuals reside in temporary housing or shelters, 32% live unsheltered (1).
  • Homelessness continues to decrease due to increases in targeted federal funding for rapid rehousing/permanent housing; 2016 fiscal year $5.5 billion (1,2)

Risk Factors

  • Economic factors
    • Poverty
      • 2017 federal poverty definition: $24,600 annual income for four-person household in the lower 48 states and District of Columbia, slightly higher in Alaska and Hawaii (3).
      • In 2015, 14.7% of the U.S. population fell below federal poverty definition (United States. Census Bureau).
    • Unemployment: U.S. rate 4.4% in June 2017 (U.S. Bureau of Labor Statistics)
    • Lack of affordable health care: In 2015, 13% of people in United States were without health insurance. This has decreased to 11.5% by the beginning of 2016 (4).
      • Young adults (ages 19 to 34 years) are disproportionately uninsured (27%) compared with the average for all ages (13%); the uninsured rate for ages 19 to 25 years decreased by 12% between 2009 and 2016, following Affordable Care Act provision allowing individuals in this age group to stay on parental insurance plans (4).
      • The number of uninsured nonelderly Americans has dropped 43% since October 2013 (4).
    • Lack of affordable housing: Housing is considered affordable if ≤30% of household income is devoted to housing costs.
      • An estimated 12 million households are “severely housing cost burdened” (≥50% of income is spent on housing).
  • Additional at-risk populations: intimate partner violence (IPV), victims of violence; youth (particularly those aging out of foster care); veterans; rural; addiction; psychiatric illness; disabled due to chronic medical disease, psychiatric illness, or substance use disorder; reentry after incarceration/prison
    • IPV: 12% of overall homeless population, and as many as 1 in 5 families, will have reported experiencing IPV; IPV leads directly to homelessness in many cases (2).
    • Youth: In 2016, Department of Housing and Urban Development (HUD) estimates 35,686 unaccompanied individual homeless youths (up to age 24 years), and another 9,800 persons in families where the parent is a youth (1). Approximately 550,000 youths in a year will experience homelessness lasting longer than a week (2).
    • Veterans: 9% of homeless adults; homelessness rate decreased between 2009 and 2016 (1).
    • Addiction disorders: 46% of homeless individuals report alcohol and/or drug use as a major factor contributing to homelessness (2).
    • Psychiatric illness: 45% of homeless report indicators of a mental health issue in the past year; 25% of homeless adults suffer from chronic mental illness (2).
    • Reentry after incarceration: Up to 50,000 people each year enter homeless shelters from jails or prisons (2).
  • Fundamental issues in homelessness and health care that require ongoing consideration:
    • Unstable housing, limited access to nutritious food and water, lack of transportation
    • Higher risk for abuse and violence
    • Physical/cognitive impairments, behavioral health problems
    • Developmental discrepancies for children: speech delay, chronic ear infection, insufficient opportunity to practice gross and fine motor skills
    • Higher risk for communicable disease
    • Lack of health insurance/resources, discontinuous/inaccessible health care, lack of a medical home, barriers to disability assistance
    • Cultural/linguistic barriers: racial and ethnic groups overrepresented in homeless population
    • Limited education/literacy
    • Lack of social supports: Alienation from family and friends precipitates homelessness.
    • Criminalization of homelessness: frequent arrests for loitering, sleeping in public places

General Prevention

  • Policy and funding for community programs to provide emergency/rapid housing, housing stabilization, and case management services
  • Increased Medicaid eligibility for homeless and expanded home and community-based services and case management to the homeless population (5)
  • HUD: increasing permanent supportive housing units, increasing services for veterans and those with disabilities (5)
  • 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
  • Worsening of chronic medical conditions: lack of healthy food, places to store medications, or medical equipment; lack of restful sleep; decreased health literacy
    • Infectious diseases
      • Tuberculosis (TB), HIV/AIDS, STI
      • Skin/nail infections and infestation (lice and scabies)
      • Liver disease (e.g., hepatitis B or C, or alcohol-related)
    • Cognitive impairment: traumatic brain injury (TBI), cerebrovascular accident (CVA), substance use
    • Dental problems
    • Exposure-related conditions (frostbite, heatstroke)
    • Psychiatric illness
    • Trauma: increased risk of assault, victims of hate crimes

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Citation

* When formatting your citation, note that all book, journal, and database titles should be italicized* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Homelessness ID - 116837 ED - Baldor,Robert A, ED - Domino,Frank J, ED - Golding,Jeremy, ED - Stephens,Mark B, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116837/all/Homelessness PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -