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

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

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

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.

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

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

PROGNOSIS

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

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)