Homelessness and Post-Acute Care: Myths, Facts, and SolutionsUrinary incontinence 48% Brown RT,...

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Margot Kushel, MDProfessor of Medicine, UCSF

Director, UCSF Center for Vulnerable Populations at ZSFGDirector, UCSF Benioff Homelessness and Housing Initiative

Homelessness and Post-Acute Care:Myths, Facts, and Solutions

@mkushel

2/26/2020Homelessness and Post-Acute Care: Myths, Facts and Solutions @mkushel2

Federal Definition of Homelessness (HEARTH Act) Individuals and families who:

• Lack a fixed, regular, and adequate nighttime residence (includes a subset for individuals who resided in an emergency shelter or a place not meant for human habitation, or who is exiting an institution where he or she temporarily resided);

• Will imminently lose their primary nighttime residence (within 14 days) [Court ordered eviction notice, OR notice to quit or terminate lease]; or

• Are fleeing, or are attempting to flee domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family member

Homelessness and Post-Acute Care: Myths, Facts and Solutions @mkushel3

Homeless Emergency Assistance and Rapid Transition to Housing: Defining “Homeless,” 24 C.F.R. § 91 & 576 (2010).Homeless Emergency Assistance and Rapid Transition to Housing: Defining “Homeless,” 75 Fed. Reg. 20541 (2010) (to be codified at 24 C.F.R. § 577).

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Federal Definition of Homelessness (HEARTH Act) (cont.)Unaccompanied youth and families with children who are defined as homeless under other federal statutes and who do not otherwise qualify as homeless under this definition


Homeless Emergency Assistance and Rapid Transition to Housing: Defining “Homeless,” 24 C.F.R. § 91 & 576 (2010).Homeless Emergency Assistance and Rapid Transition to Housing: Defining “Homeless,” 75 Fed. Reg. 20541 (2010) (to be codified at 24 C.F.R. § 577).

“The ache for home lives in all of us, the safe place where we can go as we are and not be questioned.”

- Maya Angelou


Question #1What causes homelessness?

1 Mental Health Problems2 Substance Use Problems3 None of the above


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Myth #1Homelessness is caused by substance use and mental health problems.


Why are people homeless?

Homelessness is an interaction between:• Structural Factors (i.e. affordable housing, jobs for low wage

workers, income inequality)• Individual vulnerabilities (i.e. mental health disabilities, substance

use disorders, adverse childhood experiences)And the presence or absence of a safety net (i.e. income support, safety-net healthcare, subsidized housing)

The less favorable the structural factors and availability of safety net is, the fewer individual vulnerabilities one needs to become homeless


Burt, M., Aron, L. Y. Lee, E. & Valente, J. (2001). Helping America’s homeless: emergency shelter or affordable housing? Washington DC: The Urban Institute.

California has 22 units available for every 100 extremely low-income households.


The Gap: A Shortage of Affordable Homes NLIHCMarch 2019 https://nlihc.org/sites/default/files/gap/gap-19_int/mobile/index.html

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Fewer than 1/4 low-income at-risk households receive rental assistance; 1/3 of elderly (low income, at-risk) households do.


HUD funding to California is decreasing.


California Department of Housing and Community Development, California’s Housing Future: Challenges and Opportunities

Loss of funding preceded homelessness rise.


California Department of Housing and Community Development, California’s Housing Future: Challenges and Opportunities

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Homelessness is a racial justice issue.Housing primary means of wealth-building Discrimination in home ownership

• Segregated neighborhoods• Redlining—restricted access to

mortgages in segregated neighborhoods

• Wealth gap 63x• Predatory lendingDiscrimination in rental marketCriminal justice, employment and

educational discrimination Black Americans at 3-4-fold increased

risk of homelessness


How many people are homeless in the U.S.?•2.3 – 3.5 million people homeless in a year (1996 U.S. estimate)•553,000 people experiencing homeless on a single night in 2017•130,000 people homeless single night in 2018 in CA• In 2016, 4.6 million people in poor households were doubled up with family and friends, a common precursor to becoming homeless


-The 2018 Annual Homeless Assessment Report (AHAR) to Congress-The State of Homelessness in America, National Alliance to End Homelessness (https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-report/ accessed 9/19/2018)The National Law Center on Homelessness and Poverty. “Homelessness in the United States and the Human Right to Housing,” (January, 2004).Urban Institute, The. A New Look at Homelessness in America.

Homeless Typology•“Household” structure•Duration/Pattern•Living situation


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Chronic homelessness: Federal Definition•Homeless for one or more years OR 4 or more separate occasions in prior three years that together are > 1 year AND

•A disabling condition (diagnosable substance use disorder, cognitive impairment, mental health problem, traumatic brain injury, disabling condition, or chronic physical illness)


The homeless population is aging; health is getting worse

Proportion of single homeless adults ≥50 in San Francisco:‒1990 11% ‒2003 37%‒Today ~50%‒Median age increased 0.66

years for every calendar year 1990-2003


Hahn J et aPopulation JGIM 2006l. The Aging of the Homeless

Generational EffectAmericans born in the second half of the baby boom (1955-1965) have had elevated risk of homelessness throughout their lifetime.


“The Emerging Crisis of Aged Homelessness” Culhane, Treglia, Byrne, Metraux, Kuhn, Doran, Johns, Schretzman https://www.aisp.upenn.edu/wp-content/uploads/2019/01/Emerging-Crisis-of-Aged-Homelessness.pdf

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“The Emerging Crisis of Aged Homelessness” Culhane, Treglia, Byrne, Metraux, Kuhn, Doran, Johns, Schretzmanhttps://www.aisp.upenn.edu/wp-content/uploads/2019/01/Emerging-Crisis-of-Aged-Homelessness.pdf

44% with first episode of homelessness after age 50.


Poor health in every measure

56% report health as fair or poor


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High proportion with functional impairments

0%

10%

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30%

40%

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60%

Activities of Daily Living Instrumental Activities ofDaily Living

2 or more impairments

1 impairment


Brown RT, Hemati K, Riley ED, Lee CT, Ponath C, Tieu L, Guzman D, Kushel MB. Geriatric Conditions in a Population-Based Sample of Older Homeless Adults. Gerontologist. 2016 Feb 26. pii: gnw011. PubMed PMID: 26920935

High prevalence of cognitive impairment

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3MS Trails B


Hurstak E, Johnson JK, Tieu L, Guzman D, Ponath C, Lee CT, Jamora CW, Kushel M. Factors associated with cognitive impairment in a cohort of older homelessadults: Results from the HOPE HOME study. Drug Alcohol Depend. 2017 Sep 1;178:562-570.

(measures global impairments) (measures executive function)

High prevalence of all geriatric conditions

Mobility impairment 27%One or more falls (6 months) 34%Visual impairment 45%Hearing impairment 36%Urinary incontinence 48%

Brown RT, Hemati K, Riley ED, Lee CT, Ponath C, Tieu L, Guzman D, Kushel MB. Geriatric Conditions in a Population-Based Sample of Older Homeless Adults. Gerontologist. 2016 Feb 26. pii: gnw011. [Epub ahead of print] PubMed PMID: 26920935.


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Overall Poor Functional Status

“50 is the new 75”

Median age of sample: 57Prevalence of geriatric conditions worse than those in general population samples in their 70s and 80s.


Alcohol and Drug Use Problems are Common

65% with moderate or greater severity of drug use symptoms• Cocaine (43%), cannabis (39%), and opioids (13%) moderate or

severe use symptoms

26% moderate or greater severity alcohol use symptoms• 15% severe symptoms


Mental Health Problems are Common

0%

5%

10%

15%

20%

25%

30%

35%

40%

Depression(moderate-severe)

PTSD Psychiatrichospitalization ever

Psychiatrichospitalization last 6

months


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Elevated Age-Adjusted Mortality Rates of Homeless Adults; Causes Vary by AgeAge 25 to 44

• Drug overdose, heart disease, substance use disorders, HIV• Mortality rates 9x-10x higher than general populationAge 45 to 84

• Cancer, heart disease• Mortality rates 4x-5x higher than general population


Baggett TP, Hwang SW, O’Connell JJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013 Feb 11;173(3):189-95. doi: 10.1001/jamainternmed.2013.1604. PMID: 23318302.

Health Care Utilization

High rates of ED use and hospitalizations by homeless• 40% report ED visit in past year, compared with 11% general

population• Homeless over 50: even higher (~ 50% of HOPE HOME

participants had visited an ED (confirmed) in prior six months)• Small group (<7%) account for over half of all ED visitsHigh utilizersHigh rates of substance use, mental health problems,

violence/victimizationLow rates of non-ED ambulatory care


High mortality rate and institutional care

53 confirmed deaths out of 350 participants in HOPE HOME since cohort began (July 2013-June 2014)

(8 additional deaths among 100 recruited last year)

Those first homeless >50 2x as likely to have died as those with earlier onset homelessness

>40 confirmed nursing home stays


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Question # 3True or False

People who are frequent utilizers are LESS likely to have a primary care provider?

1 True2 False


How Homelessness Affects Health Care UtilizationMore frequent hospital staysLonger hospital stays

• More hospitalization for potentially preventable causes• Lowered admission thresholds• More difficult to dischargeHomeless were 3x more likely to be readmitted (22.2 %

versus 7.0 %)


Saab D, Nisenbaum R, Dhalla I, Hwang SW. Hospital Readmissions in a Community-based Sample of Homeless Adults: a Matched-cohort Study. J Gen Intern Med. doi:10.1007/s11606-016-3680-8.

What can health care providers do?

Screen for and document homelessness and risk of homelessness


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National Association Community Health Centers Screening Tool: PRAPARE*What is your housing situation today? I have housing I do not have housing (staying with others, in a hotel, in a shelter, living

outside on the street, on a beach, in a car, or in a park) I choose not to answer this question

Are you worried about losing your housing? (Yes, No, Choose not to answer)What address do you live at? (include street and zip code)

*ZSFG has chosen this to incorporate into EPIC


National Health Care for the Homeless Council. (August 2016.) Ask & Code: Documenting Homelessness Throughout the Health Care System (Authors: Barbara DiPietro, Senior Director of Policy, and Sabrina Edgington Director of Special Projects.Available at: https://www.nhchc.org/policyadvocacy/reform/nhchchealthreformmaterials/

Accountable Health Communities Health Related Social Needs Screening Tool What is your housing situation today?

• I don’t have housing• I have housing today but worried about losing housing in the future• I have housingThink about the place you live. Do you have trouble with any of the

following? (Circle all that apply)• Bug infestation, mold, lead paint or pipes, inadequate heat, oven or stove

not working, no or not working smoke detectors, water leaks, none of the above


United States, U.S. Department of Health and Human Services Medicare and Medicaid Services. (2017, September 05). Accountable Health Communities Model. https://innovation.cms.gov/initiatives/ahcm

VA Screener

1. In the past two months, have you been living in stable housing that you own, rent, or stay in as part of a household? (“No” indicates homelessness.)2. Are you worried or concerned that in the next two months you may NOT have stable housing that you own, rent, or stay in as part of a household? (“Yes” indicates risk.)Answer to either requires follow-up


Montgomery AE, Fargo JD, Kane V, Culhane DP. Development and validation of an instrument to assess imminent risk of homelessness among veterans. Public Health Rep. 2014 Sep-Oct;129(5):428-36. PubMed PMID: 25177054; PubMed Central PMCID: PMC4116370.

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My questions:

Ask questions to assess both homelessness and risk of homelessnessDo not ask “are you homeless?”

• “Many of our patients are finding it difficult to have a regular place to stay.”

• “Have you been without a regular place to stay in the past month? Have you stayed in a shelter/outdoors/car?”

• If staying with friends/family ask: “Can you stay there as long as you would like? Do you stay the same place every day?”


Code it! But Be Sensitive to Stigma

Housing Circumstance Affecting Care Z59.9Homelessness Z59.0


Myth #2

We cannot solve homelessness.

Fact: Of course we can. The solution to homelessness is housing.


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Effective Solutions

House people as quickly as possibleDivert people from imminent homelessness as quickly as possibleWe must design solutions to be anti-racist


Role of Shelter?

NOT a destination (shelter ≠ housing)Part of the process to get people housedShelter is LOW barrier

• Pets, partners, possessions, privacyStaffed appropriately to get people into housing Length of stay short; no returns to homelessness


Coordinated Entry

HUD mandated way to prioritize who is at highest riskUses different risk scores

• NOT validated


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Extremely Low Income (ELI) Housing

Expand and preserve affordable housingELI (extremely low income) housing: target towards those who

make <30% AMI• Cutbacks in HUD threaten development• Good sources of information for national legislative efforts:National Low-Income Housing Coalition CA


Housing Assistance

Housing Choice Vouchers: In Family Options Study, Vouchers outperformed every other optionEstimate would cost $31B a year to fully fund vouchers (US spends $12B a year in shelter, even though large proportion unsheltered)


PreventionNot enough effort on preventing homelessnessPrevention efforts need to be both EFFICIENT and EFFECTIVESome increased action on eviction protection Individuals without a lease are at highest risk

• HOME BASE in NYHOME SAFE

• Targeting prevention funds for APS involved older adults in CAMost benefit is to target those at highest risk!


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To be efficient—target those at highest risk


Shinn et al 2013

ED and hospital use peak immediately before episode of homelessness: Role for hospitals in prevention?


Day of shelter entry: 28.1 ED visits and 15.4 hospitalizations per 1,000 entrants (1 year before: 2.72/0.67; week before 7.6/1.9

Treglia et al Health Affairs 2019

Homelessness and Post-Acute Care: Myths, Facts and Solutions @mkushel

Emergency Housing Assistance

Families who called when housing assistance available 76% less likely to enter shelter at six months• Absolute decrease 1.6%One-time payments up to $1500Average cost per caller referred $720; cost of homeless

spell averted $10,300Limiting to very low-income callers reduce cost per

episode averted to $6800


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Rapid Re-Housing Connects families and individuals to permanent housing via tailored

package of assistance. Can serve as bridge to longer-term support (i.e. rental vouchers)• Time-limited rental assistance • Targeted supportive servicesHousing identificationRent and move-in assistance (typically 6 months or less)Case management and services

Expand concept to use for problem solving, early intervention to shorten homelessness episodes


Myth #3You can’t house people with substance use disorder before you treat the disorder.

FACT: You CAN and you MUST


Permanent Supportive Housing

Permanent supportive housing for those with chronic homelessness/disabling conditions:

• Subsidized housing • Linked supportive services that are voluntary• Housing First model − start with the housing• Shown to be highly effective at keeping people housed• Need to adapt for needs of older adults


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Challenges: Affordable Housing and Prevention

Enormous shortage of deeply affordable housing• Difficult to build for those most at-risk

Need to stop in-flow into homelessness • Difficult to target resources


Challenges: Aging PopulationLoss of residential care facilities throughout CA

• “Board and Care”PSH faced with providing services for aging population

• Adaptations for functional impairmentsCAPABLE model

• Provision of personal careHomebridgePACE programs aligned with PSH

• Advance Care Planning• Dementia Care


Health Systems Responding to Homelessness


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What Can Health Care Providers/Systems Do?

Advocate• Understand the underlying structural factors that create and

sustain homelessness• Push back against individual narrativeWe know how to treat SMI!

• Use your voice to advocate for real solutionsHealth effects of homelessness“There is NO medicine as powerful as housing”


Concluding thoughts…CrisisSuffering immenseHigh prevalence morbidity and mortalityChaotic use of health care systemHomelessness caused by longstanding policy failures, disinvestment in affordable housing, and structural racismHealth care providers and systems have important role to play in ending crisis


Questions?

Raise your hand or submit a question at www.menti.com and enter code 80 39 38

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Thank You

Margot Kushel, MDProfessor of Medicine, Director of UCSF Center for Vulnerable Populations, Director UCSF Benioff Homelessness and Housing [email protected]

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Homelessness and Post-Acute Care: Myths, Facts, and SolutionsUrinary incontinence 48% Brown RT,...

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