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p 1
Ems
Committec on Health Care
for
Homeless People
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washinglon, D.C. 1988
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National Academy Press ~ 2101 Constitution Avenue, NW ~ Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board
of the National Research Council, whose members are drawn from the councils of the National
Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The
members of the committee responsible for the report were chosen for their special competences
and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures
approved by a Report Review Committee consisting of members of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to
enlist distinguished members of the appropriate professions in the examination of policy matters
pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863
congressional charter responsibility to be an adviser to the federal government and its own
initiative in identifying issues of medical care, research, and education.
The work on which this publication is based was performed pursuant to Contract No. 240-86-
0073 with the Health Resources and Services Administration of the Department of Health and
Human Services. Additional support for this study was contributed by the Veterans Adminis-
tration and the National Research Council (NRC) Fund. The NRC Fund is a pool of private,
discretionary, nonfederal funds that is used to support a program of Academy-initiated studies
of national issues in which science and technology figure significantly. The NRC Fund consists
of contributions from a consortium of private foundations including the Carnegie Corporation
of New York, the Charles E. Culpeper Foundation, the William and Flora Hewlett Foundation,
the John D. and Catherine T. MacArthur Foundation, the Andrew W. Mellon Foundation, the
Rockefeller Foundation, and the Alfred P. Sloan Foundation; the Academy Industry Program,
which seeks annual contributions from companies that are concerned with the health of U.S.
science and technology and with public policy issues with technology content; and the National
Academy of Sciences and the National Academy of Engineering endowments.
Library of Congress Cataloging-in-Publication Data
Institute of Medicine (U.S.). Committee on Health Care for Homeless
People.
Homelessness, health. and human needs / Committee on Health Care
for Homeless People. institute of Medicine.
P. cm.
Includes bibliographies and index.
1SBN 0-309-03835-9. 1SBN 0-309-03832-4 (pbk.)
1. Homelessness—Health aspects—United States. 2. Poor—Medical
care—United States. 1. Title.
[DNLM: l. Delivery of Health Care—United States. 2. Health
Services Accessibility—United States. 3. Homeless persons. WA
300 159h]
RA770.146 1988
362. 1 '08806942~c 1 9
DNLM/DLC
for Library of Congress
8-25466
CIP
Cover art by John Jenkins, a free-lance artist working in New York City, whose experience as
a homeless man in the shelter system provided the basis for this drawing. Reprinted, with
permission, from Working with Homeless People: A Guide for Staff and Volunteers (rev. ed.),
Amy Haus, editor. New York City: Columbia University Community Services, 1988.
Copyright ~ 1988 by the National Academy of Sciences
Printed in the United States of America
First Printing, September 1988
Second Printing, February 1989
Third Printing, May 1989
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Committee on Health Care for Homeless People
BRUCE C. VLADECK (Chairman),* President, United Hospital Fund of
New York, New York City
DREW ALTMAN, Commissioner, New Jersey Department of Human
Services, Trenton
ELLEN L. BASSUK, Associate Professor of Psychiatry, Harvard Medical
School
WILLIAM R. BREAKEY, Associate Professor, Department of Psychiatry
and Behavioral Sciences, Johns Hopkins University
A. ALAN FISCHER,* Professor and Chairman, Department of Family
Medicine, Indiana University School of Medicine
CHARLES R. HAEPERN,* Professor of Law, City University of New York
Law School at Queen's College
JUDITH R. LAVE, Professor, Department of Economics, University of
Pittsburgh
JACK A. MEYER, President, New Directions for Policy, Washington,
D.C.
GLORIA SMITH, Commissioner, Michigan Department of Public Health,
Lansing (currently Dean, College of Nursing, Wayne State
University)
LOUISA STARK, Adjunct Professor, Department of Anthropology,
Arizona State University
NATHAN STARK,* Kominers, Fort, Schlefer and Boyer, Washington,
D.C.
MARVIN TURCK, Associate Dean and Professor of Medicine, University
of Washington, and Medical Director, Harborview Medical Center,
Seattle
PHYLLIS WOLFE, Executive Director, Robert Wood Johnson/Pew
Memorial Trust Health Care for the Homeless Project, Washington,
D.C.
Study Staff, Division of Mental Health and Behavioral Medicine
ALAN R. SUTHERLAND, Study Director
DEBORAH S. SWANSBURG, Program Officer
JAMES R. BRUNER, Study Secretary/Project Assistant
FREDRIC SOLOMON, Director, Division of Mental Health and Behavioral
Medicine
ELIZABETH H. KITSINGER, Division Secretary
*Member, Institute of Medicine.
iii
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Preface
This study was undertaken at the request of the U.S. Congress as
stated in the Health Professionals Training Act of 1985 (P.L. 99-1291.
The act directed the secretary of the Department of Health and Human
Services to arrange with the National Academy of Sciences, through its
Institute of Medicine, for a study of the delivery of inpatient and outpatient
health care services to homeless people. That provision was one of
various legislative initiatives concerning the growing problem of home-
lessness that the Congress has considered in recent years (see Appendix
A). The congressional mandate in P.L. 99-129 was implemented in October
1986, when the Department of Health and Human Services, through its
Health Resources and Services Administration, entered into a contract
with the Institute of Medicine. Additional funding was provided by the
National Research Council and, subsequently, by the U.S. Veterans
Administration.
The study was directed at three tasks specified in P.L. 99-129: (1) an
evaluation of whether the eligibility requirements in existing health care
programs prevent homeless individuals from receiving health care ser-
vices; (2) an evaluation of the efficiency of the delivery of health care
services to homeless individuals; and (3) recommendations for activities
by federal, state, local, and private entities that would improve the
availability of health care service delivery to homeless individuals.
As in all studies done under the auspices of the National Academy of
Sciences, the first step in the process was to select a committee of
knowledgeable people to conduct the study. A 13-member panel was
drawn from the disciplines of anthropology, economics, epidemiology,
family and internal medicine, law, nursing, political science, psychiatry,
v
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Vi PREFACE
public administration, and social work. At its initial meeting in December
1986, the Committee on Health Care for Homeless People adopted the
following approach for the study.
Recognizing the limitations of the research literature on homeless
people, their health problems, and the health services they receive, the
committee directed a search of unpublished reports as well as published
studies and documents. To supplement the existing literature, the com-
mittee commissioned the following 10 papers written by experts on
subjects of special concern:
· "Legal Barriers to Access: The Unmet Health Care Needs of
Homeless People," Arlene Ranter;
· "A Critique of the Methodologies of Counting the Homeless,',
Charles Cowan, William Breakey, and Pamela Fischer;
· "Rural Homelessness," Lawrence Patton;
· "The Dynamics of Homelessness," Russell Schutt;
· "Homelessness: A Medical Viewpoint," William Vicic and Patricia
Doherty;
· "Shelter and Health Care of Homeless Families, Homeless Children,
Homeless Adult Individual Females, and Homeless Battered Women and
Their Children," Deborah Reisman Fink;
· "Ancillary Health Care Services for Homeless Persons: Availability
and Delivery," Marianne Gleason;
· "Mental Health and the Homeless Population," Andrew Ziegler;
· "Alcohol Problems Among the Contemporary American Homeless
Population: An Analytic Review of the Literature,'' Pamela Fischer; and
· "Illicit Substance Abuse Among the Homeless," Virginia Mulkern.
Significant findings from these papers are incorporated throughout this
report; two papers, those on the methodologies of counting the homeless
and on the homeless in rural areas, are included as Appendixes B and
C, respectively.
The committee regarded both the gaps in data and the desirability of
first-hand acquaintance with homelessness as reasons to conduct site
visits. Members of the committee, accompanied by Institute of Medicine
staff and consultants, visited 11 cities and (with separate funding from
the Department of Health and Human Services) rural areas in four states
to learn the characteristics of homelessness in those communities and
the nature of health services directed to homeless people. These sites
were selected not as a representative sample of programs for the homeless
but, rather, as potential models of service delivery. At the same time,
by interviewing both homeless individuals and people attempting to help
the homeless, committee members were able to assess the validity of
many findings that appear in the literature.
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PREFACE Vii
The committee benefited greatly from the assistance of the national
Health Care for the Homeless program of the Robert Wood Johnson
Foundation and the Pew Memorial Trust. The directors and staff members
of the 19 projects supported by these foundations provided much valuable
information for this report. In addition, the Social and Demographic
Research Institute of the University of Massachusetts at Amherst, which
is under contract with the Robert Wood Johnson and Pew foundations
to provide program monitoring and evaluation, generously shared its data
and undertook special analyses on the committee's behalf.
This report begins by trying to answer the question, "Who are the
homeless?" To dispel myths about homelessness and to provide infor-
mation about its causes, Chapter 2 discusses the dynamics of homeless-
ness. Chapter 3 describes the health problems of homeless people.
Chapter 4 describes the major barriers homeless people encounter in
their effort to obtain health care. Chapter 5 examines health care and
health-related service programs designed to meet the special needs of
homeless people. Chapter 6 summarizes the committee's findings and
sets forth its recommendations.
Two aspects of the work of the committee warrant further explanation.
First, although the committee's charge was fairly narrow, its examination
perforce was fairly broad. Early in the study, the committee determined
that the specific aspects of health and health care contained in the
congressional charge could not be separated from many aspects of
homelessness itself.
The second has to do with the relative amounts of attention, both in
the study and in the report, invested in specific health problems and
particular subpopulations of the homeless. Reports of studies of some
health problems common among homeless people, such as alcoholism or
mental illness, are numerous and readily available; these could be
summarized rather succinctly. Information on other types of health-
related problems, however, often was more anecdotal or based on very
recent data, some of which were provided especially for use in this study.
Therefore, parts of this report may appear to place greater or lesser
emphasis on certain problems than might seem to be warranted by their
actual proportion among the hardships of the homeless.
The report, in response to P.L. 99-129, is directed to the United States
Congress and to policymakers on the national, state, and local levels,
but the committee hopes it will also be of value to those who work
directly with the homeless and to the average citizen who has concern
for them.
*
* * * *
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viii PR E FA C E
As chairman of the committee responsible for this report, I want to
take this opportunity to thank my colleagues on the committee for their
dedication, patience, and extremely hard work on this study. I also wish
to acknowledge the many people outside the Institute of Medicine who
gave so generously of their time to help enrich our study (see Appendix
E). In addition to the authors of commissioned papers listed in the
Preface, we take particular note of the contributions of Pamela Fischer
of John Hopkins University; Deborah Franklin, a doctoral student in
history of science at the University of Pennsylvania; Max Michael of the
University of Alabama at Birmingham Medical Center; and James Wright
of the University of Massachusetts. I owe a particularly large debt of
personal gratitude to Susan Neibacher, director of the New York City
Health Care for the Homeless Program at the United Hospital Fund,
who generously served, with her customary great patience and tolerance,
as my personal guide through the thicket of issues the committee
encountered on homelessness.
None of these efforts, of course, would have produced a report without
the intensive labors of a dedicated professional staff at the Institute of
Medicine, especially the study director, Alan Sutherland, and his deputy,
Deborah Swansburg. An especially large thank you is owed to their
supervisor, Fredric Solomon, director of the Division of Mental Health
and Behavioral Medicine, and to the Institute's Associate Executive
Officer for Programs, Marian Osterweis.
BRUCE C. VLADECK, Chairman
Committee on Health Care for
Homeless People
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Contents
1 WHO ARE THE HOMELESS?
INTRODUCTION, 1
DEFINITION OF HOMELESS, 2
COUNTING THE HOMELESS, 2
STUDIES OF HOMELESSNESS, 4
CHARACTERISTICS OF HOMELESS PEOPLE, 5
Homeless Individual Adults, 6; Homeless Families, l l;
Homeless Runaway and Throwaway Youths, 14; Homeless
Elderly People, 15; The Rural Homeless, 17
SUMMARY, 17
REFERENCES, 18
2 DYNAMICS OF HOMELESSNESS
INTRODUCTION, 22
PATTERNS OF HOMELESSNESS, 23
HOUSING, 25
INCOME AND EMPLOYMENT, 26
DEINSTITUTIONALIZATION, 28
Mental Health System, 28; Other Systems, 31
SHELTERING THE HOMELESS, 32
Shelters, 32; Welfare Hotels and Motels, 34; Extent of the
Shelter System, 35
SUMMARY, 36
REFERENCES, 36
IX
1
22
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X CONTENTS
3 HEALTH PROBLEMS OF HOMELESS PEOPLE
TYPES OF INTERACTIONS BETWEEN HEALTH AND
HOMELESSNESS, 39
Health Problems That Cause Homelessness, 39; Health
Problems That Result from Being Homeless, 41; Homelessness
as a Complicating Factor in Health Care, 42
GENERAL HEALTH PROBLEMS OF HOMELESS
ADULTS, 43
Traumatic Disorders, 43; Disorders of Skin and Blood
Vessels, 45; Respiratory Illnesses, 47; Chronic Diseases, 49;
Miscellaneous Health Problems, 50
MENTAL ILLNESS, ALCOHOLISM, DRUG ABUSE, AND
COMORBIDITY OF HOMELESS ADULTS, 50
Mental Disorders, 50; Clinical Problems in Providing Mental
Health Care for the Homeless, 57; Alcoholism and Alcohol
Abuse, 60; Illness Associated with Abuse of Drugs Other
Than Alcohol, 63; Comorbidity, 65
HEALTH PROBLEMS OF HOMELESS FAMILIES,
CHILDREN, AND YOUTHS, 66
SUMMARY, 68
REFERENCES, 71
ACCESS TO HEALTH CARE SERVICES FOR
HOMELESS PEOPLE..................................
INTRODUCTION, 76
HEALTH CARE OF THE INDIGENT, 77
MEDICAID, 82
Eligibility, 83; Benefits, 88; Medicaid and the Homeless, 89
THE INDIGENT CARE SYSTEM, 89
Hospitals, 90; Clinics, 92; The National Health Service
Corps, 93; Categorical Programs, 93
ADDITIONAL BARRIERS TO ACCESS FOR HOMELESS
PEOPLE, 94
MENTAL HEALTH CARE, 96
VETERANS, 98
SUMMARY, 100
REFERENCES, 100
...... 39
76
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CONTENTS Xi
5 HEALTH CARE SERVICES FOR HOMELESS
PEOPLE . e ~ · · e ~ e e e e e e e e e e e e e e e e e e e e e e e e e ~ e e e e e e e e e e e e e e e
INTRODUCTION, 103
PRE-JOHNSON-PEW MODELS, 106
Shelter-Based Clinics, 106; Health Care Services in Day
Programs, 107; Free-Standing Clinics, 108
SPECIALIZED HEALTH CARE APPROACHES, 109
Respite and Convalescent Care, 109; Residential Placement, 110
THE JOHNSON-PEW HEALTH CARE FOR THE
HOMELESS PROJECTS, 110
Structure of the Johnson-Pew Projects, 111; Common Elements
of Health Care Programs for the Homeless, 112; Issues
Raised by the Johnson-Pew Project Models, 116
TARGETED SERVICES FOR POPULATIONS WITH
SPECIAL NEEDS, 118
The Chronically Mentally Ill, 118; Alcohol and Drug
Abuse, 123; AIDS, 124; Homeless Individual Women, Families,
and Youths, 124
OTHER ISSUES IN HEALTH SERVICES FOR THE
HOMELESS, 127
Coordinated Efforts in Non-Johnson-Pew Cities, 127; Range of
Health Care Services, 129; Discharge Planning, 130; Case
Management, 131; Liability Insurance Coverage for Providers,
132; Personnel, 133
SUMMARY, 134
REFERENCES, 135
6 SUMMARY AND RECOMMENDATIONS
ORIGIN OF THIS STUDY, 136
STUDY PROCESS, 137
WHAT WAS LEARNED, 138
Who Are the Homeless?, 138; Why Do People Become
Homeless?, 139; What Are the Health Problems of the
Homeless?, 139; What Other Problems Do Homeless People
Have with Health Care?, 140; What Is Being Done About
the Health Problems of Homeless People?, 141
CONCLUSIONS AND RECOMMENDATIONS, 141
Five Critical Observations, 141; Preventing and Reducing
Homelessness and Its Related Health Problems, 144; Health
Care and Related Services, 148; Special Needs of Homeless
Children and Their Parents, 156; Shelters, 157; Volunteer
Efforts, 158; Research, 159
REFERENCES, 161
103
.136
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·—
All CONTENTS
APPENDIXES
A. Legislative Efforts to Aid the Homeless, 165
B. The Methodology of Counting the Homeless, 169
Charles D. Cowan, William R. Breakey, and Pamela J.
Fischer
The Rural Homeless, 183
Larry T. Patton
D. Site Visits and Meetings with Local Providers of Services
to the Homeless, 218
E. Acknowledgments, 223
F. Biographical Notes on Committee Members, 225
INDEX
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Homelessness
Health'
argot Human Needs
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