Health Care Services for Homeless People

 

Health Care Services for Homeless People

 

To the extent that homeless people have been able to obtain needed health care services, they have relied on emergency rooms, clinics, hospitals, and other facilities that serve the poor. Indigent people (with or without a home) experience many obstacles in obtaining health care. For homeless people there are additional barriers. Recognition of the special health care needs of homeless people has encouraged the development of special services for them. In observing and describing these health care and health care-related services, one must be mindful of the heterogeneous nature of the homeless population, as well as the structure of the communities in which such services have developed. Regardless of differences among homeless people or regional variations in services, however, homeless people are more susceptible to certain diseases, have greater difficulty getting health care, and are harder to treat than other people, all because they lack a home. Similarly, attempts to provide health and mental health care services, regardless of variations in such areas as history, funding levels, and nature of support, also have certain common elements. They arose in response to a crisis rather than developing as part of a well thought out plan. They generally brought services to homeless people rather than waiting for them to come in; increasingly, they rely on public funding because the problem has grown beyond a level that the private sector can support.

 

 Characteristics of homeless people that affect the provision of treatment and the planning of health care services:

 

Daily Activities—Some homeless people live under circumstances that pose particular problems for developing a treatment plan. For many, it may be difficult to keep a supply of medication while living on the street. For an alcoholic trying to stay sober, a homeless existence may present too many opportunities for drinking. Some former patients complain that neuroleptic medications, prescribed for a schizophrenic illness, may make them too drowsy and interfere with their alertness against the dangers on the streets.

 

Multiplicity of Needs—In addition to physical and mental health problems and difficulties with such things as housing and income maintenance, homeless people often also suffer from drug or alcohol abuse. Any health care program for homeless adults should expect that 25 to 40 percent of patients will suffer from serious alcohol or drug abuse problems (Fischer and Breakey, 1986).

 

Disaffiliation—Although many homeless people establish individual support networks outside a family structure, some homeless people typically lack those networks that enable most people to sustain themselves in society. Such isolation often causes (and sometimes is caused by) a limited capacity to establish supportive relationships with other people. Difficulties in establishing and maintaining relationships can militate against the development of cooperation with health care providers and may be an important factor in explaining what is often inaccurately described as a "lack of motivation."

 

Distrust—In addition to their distrust of authority, many homeless people are disenchanted with health and mental health care providers. Some have had bad experiences with medications, hospitals, doctors, and other human service professionals and are leery of further involvement.

 

 

Several program models were developed to provide health care services to homeless people

 

Shelter-Based Clinics

Shelter-based clinics provide the types of services most frequently found throughout the country. Recognizing a need to bring services to where homeless people can be found, those involved with shelters or health care have developed on-site clinics at shelter locations.

 

Rescue Missions

The committee visited volunteer clinics located at rescue missions in Kansas City, Los Angeles, Nashville, and San Diego. These rescue missions are coordinated on the national level by the International Union of Gospel Missions, but there is an even greater strength of coordination locally. Having served the homeless for extended periods, they are known to the community and have substantial access to existing networks of, for example, health care services, housing, and social services. The clinics tend to be staffed by volunteer doctors and nurses and rely heavily on private donations, both of cash and pharmaceutical and medical supplies (although some have begun to accept limited financial support from local governments). However, because of the religious aspects of the organizations that operate these clinics, not every homeless person is willing to go to them.

 

Non-sectarian Programs

Non-sectarian programs, such as the clinic at the Pine Street Inn in Boston, operate similarly to the religious rescue missions. They have developed strong sources of financial support, frequently from among local businesses, charitable organizations, and foundations. In the absence of any national coordinating or controlling body, they tend to reflect the characteristics and needs of the city in which they are located.

 

 

Health Care Services in Day Programs

Day programs, which are similar to the shelter-based clinics identified above, provide services where homeless people can be found, but they differ from shelter-based clinics in that the sites are independent of residential programs. One good example is St. Francis House in Boston, which has been described by its staff as "a shopping mall of services to the homeless." Various mental health and vocational guidance services are provided to homeless people in a single building located in what was once known as the "combat zone"³ of Boston. Included in these services is a health clinic for homeless people that is staffed by volunteers and paid employees

 

 

Specialized Health Care Approaches

Various other programs address the special needs of homeless people or the problems of specific subpopulations among the homeless.

 

Respite and Convalescent Care

One of the most serious issues facing those who work with homeless people is that many standard forms of treatment assume that the patient has a home; when that is not true, treatment is extraordinarily difficult. Convalescent (or respite) services allow a homeless person to recover from an illness or an injury that does not require (or no longer requires) care in a hospital but that is of such severity that the homeless person should not return to a regular shelter setting

 

Residential Placement

Many homeless people with physical disabilities, mental disabilities, or both who cannot live independently require supportive living settings. One program that attempts to meet this need is the Veterans Administration (VA) community placement program, which secures supervised housing for mentally or physically disabled veterans who are facing discharge from a VA medical centre and who would be at extreme risk of becoming homeless. Members of the committee visited four such placement sites in Lexington, Kentucky. Three were private homes in which the individual homeowner contracted with the VA to accept patients from the medical centre (the largest program accepted up to eight men) for supervised residential living. The fourth program was a personal care home licensed by the Commonwealth of Kentucky. The personal care home received clients from the state agencies serving the mentally ill and the mentally retarded, as well as from the VA medical centre. This facility is larger (over 15 beds) and was specifically designed to serve a population in greater need of medical and nursing care. Although the residences were supervised and certified by government agencies, the actual funding for the individual veterans comes from their own VA benefits.

 

Range of Health Care Services

The experience of the Johnson-Pew projects and other providers of health care services for homeless people suggests that a wide range of services is needed. The range and the extent to which each service should be developed in a given city may be based upon such factors as the numbers of homeless people and the proportions of the various homeless subpopulations. An assumption of these health care services is that provision of social services is an integral component of health care.

Although many of these services are appropriate for all people (homeless or not) and are especially important for the medically indigent, they are of even greater importance to homeless people because of the high level of debilitation seen in that population. The following range of services could be considered basic primary health care for homeless people.

 1. Outreach to people where they are, including the streets.

 2. General medical assessment and treatment for chronic and acute illnesses.

 3. Specific screening, treatment, and follow-up for such health problems as high bloodpressure.

 4. Paediatric services (including well-baby clinics, immunizations, and screening for lead poisoning) and diagnostic and psychosocial intervention programs for both preschool and school-age children to address emotional disability and developmental delays.

5.Ancillary services (dentistry, podiatry, optometry, and specialized diets).

6.Access to mental health care and substance abuse services, including access to specialized housing.

7.Referral and access to convalescent care, as well as long-term medical and nursing care for catastrophic illness.

8.Gynaecological services.

9.Prenatal care.

10.Educational services, primarily with regard to family planning and the prevention of sexually transmitted