Homelessness and health

1. 1
Homelessness and Health
Stephen Hwang, MD, MPH
email: hwangs@smh.ca
Centre for Research on Inner City Health,
St. Michael’s Hospital, Toronto, Canada
Division of General Internal Medicine,
University of Toronto
2010

2. 2
• 53 year old man – “Micah”
• Came to Canada on a visitor’s visa 18
years ago & never left
• Worked full-time as a cook at
restaurant, lived in basement apt.
• Drank alcohol
• Never used illicit drugs
• No mental illness
Homelessness: A Case Study

3. 3
Case Study: Micah
• Diabetes – treated with oral meds
• No health insurance – self-pay for
doctor’s visits and meds
• Stopped getting regular medical care,
went off meds
• June – Gangrene in left foot
• July – Admitted to hospital – Left foot
amputated

4. 4
Case Study: Micah
• Lost his basement apartment because
unable to work, not eligible for
benefits, no money to pay rent, no
wheelchair access to apartment
• Discharged from hospital to homeless
shelter
• No home care arranged
• “Follow-up with Dr. C. after insurance
issues are settled”

5. 5
Case Study: Micah
• Seen at shelter clinic 6 days later –
amputation site infected
• Admitted to hospital for 12 days for
intravenous antibiotics
• With close follow-up, wound eventually
healed
• 4 years later, Micah still lives at a
shelter

6. 6
Housing Transitions
HOMELESS
VULNERABLY HOUSED
Staying with
Friends/Family
Stable
Housing
Hospitals/
Drug
Treatment
Prisons/
Jails
Shelters Streets, Parks,
Vehicles, etc.
Pan
Handling
Adapted from S. Kertesz

7. 7
Homelessness in the U.S.
• More than 800,000 individuals
currently homeless
• About 5-8 million Americans have
experienced homelessness within the
last five years

8. 8
Homelessness in Canada
• 2002 Telephone survey
• 7.5% homeless in their lifetime
• 2% homeless in the last 5 years
• Extrapolates to 500,000 Canadians
homeless over last 5 years

9. 9
Homelessness in Toronto
• 28,000 individuals use shelters each year
• 5,000 people homeless each night

10. 10

11. 11
Shelters
(79%)
VAW Shelters (4%)
Homelessness in Toronto
Health/Treatment
Facilities (4%)
Correctional
Facilities (6%)
Outdoors (8%)
*
*
*
* Provincially Administered Services
Street Needs Assessment . City of Toronto, 2009.

12. 12
Single
Adults
(60%)
Youth
(12%)
Family
(27%)
Homelessness in Toronto
Street Needs Assessment . City of Toronto, 2009.

13. 13
Age of Homeless Individuals
in Toronto
0
5
10
15
20
%
<
=
1
4
1
5
-
1
9
2
0
-
2
4
2
5
-
2
9
3
0
-
3
4
3
5
-
3
9
4
0
-
4
4
4
5
-
4
9
5
0
-
5
4
5
5
-
5
9
6
0
-
6
4
6
5
-
6
9
7
0
-
7
4
7
5
-
7
6
Age (years)

14. 14
Mental Illness &
Substance Abuse
Mental
Illness
Substance
Abuse
20% 30%
30%
20%

15. 15
Mental Illness
• Major Depression: 37%
• Bipolar Disorder: 10%
• Schizophrenia: 6%

16. 16
Why do people become homeless?

17. 17
Why do people become homeless?
• Individual Risk Factors / Vulnerabilities
– Substance abuse
– Mental illness
– Childhood family environment
– Lack of job skills

18. 18
• Social Problems
– Lack of affordable housing
– Lack of jobs
– Inadequate levels of welfare &
disability payments
– Ethnic & racial discrimination
– Economic downturn
Why do people become homeless?

19. 19
Why do people become homeless?
Why is water
so salty,
causing the
iceberg float
so high in the
water?
This is the
population
health
perspective –
focus on
social forces
Why is this
part of the
iceberg
above the
water?
This is the
clinical
perspective –
focus on
individual risk
factors

20. 20
Approach B: Shift population
norm slightly upwards
Approach A: Focus on
improving conditions
for extreme groups
Homeless Poor Fair Moderate Good Excellent
Housing Quality
Frequency
in
Population
Are we focusing on the right group?

21. 21
Injuries and Assault
• Drug overdoses common
• 35% assaulted in last year
• 20% of women raped in last year
• 52% have had traumatic brain
injuries in their lifetime

22. 22
Chronic Medical Conditions
• Poorly controlled hypertension
• Poorly controlled diabetes
• Chronic pain
• Emphysema / bronchitis
• Seizures

23. 23
Infectious Diseases
• Pneumonia
• Infestations (body lice, scabies,
bed bugs)
• Tuberculosis
• Hepatitis C
• HIV / AIDS
• Sexually Transmitted Infections

24. 24
Homelessness and
the Health Care System
• Many barriers to obtaining care, but
high levels of disease
• High rate of Emergency Dept. visits
• High hospitalization rates
• Expensive hospital stays

25. 25
Emergency Department Use
by Homeless People
• Representative random sample of
homeless men in Toronto (N=587)
• Emergency Dept. use over 4 years:
• 0 visits: 138 (24%)
• 1 visit: 81 (14%)
• 2-3 visits: 109 (19%)
• 4-5 visits: 84 (14%)

26. 26
Emergency Department Use
by Homeless People
• Emergency Dept. use over 4 years:
• 25-50 visits: 30 (5%) = 1,016
• 51-75 visits: 8 (1%) = 475
• 76-100 visits: 4 (0.7%) = 364
• 101-125 visits: 2 (0.3%) = 250
• 44 men (7%) = 2,105 visits

27. 27
High Mortality among Residents of
Shelters, Rooming Houses, Hotels
Probability of survival for men and women, conditional on survival to age 25
0
10
20
30
40
50
60
70
80
90
100
25 30 35 40 45 50 55 60 65 70 75 80 85 90 25 30 35 40 45 50 55 60 65 70 75 80 85 90
Age (years)
Probability
of
survival
(%)
Richest income quintile
Total cohort
Poorest income quintile
Shelters, rooming houses, hotels
Men Women

28. 28
High Mortality among Residents of
Shelters, Rooming Houses, Hotels
Figure 3. Probability of survival to age 75, conditional on survival to age 25
0
10
20
30
40
50
60
70
80
90
100
Men Women
Probability
of
survival
(%)
Shelters, rooming houses, hotels
Poorest income quintile
Total cohort
Richest income quintile

29. 29
Leading Causes of Mortality
among Homeless People
• Injuries
• Drug Overdose
• Suicide
• HIV/AIDS
• Cancer
• Heart Disease

30. 30
Principles of Clinical Care for
Patients who are Homeless
• Patient-centered care
– Trust & listening
– The patient’s top concern, not yours
• Acute vs. Chronic (unmanaged) vs.
Chronic (managed) conditions
• Collateral history from clinicians and
pharmacists
• Promote continuity of care
• Understand the person’s life situation

31. 31
Bibliography
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33.
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• Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. JAMA. April 26,
2000;283:2152-57.
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Healthcare Encounters. Journal of General Internal Medicine. July 2007;22:1011-1017.
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