Homelessness 101 Under the Safety Net

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1 Homelessness 101 Under the Safety Net Matias J. Vega, M.D. Medical Director Albuquerque Health Care for the Homeless

2 Definition of Homelessness 1988 Definition Those without access to a conventional dwelling or residence including those marginally housed, in emergency shelters, or living in the streets.

3 Definition of Homelessness 2011 Definition Literally Homeless These include people who for various reasons have found it necessary to live in emergency shelters or transitional housing for some period of time. This category also includes unsheltered homeless people who sleep in places not meant for human habitation (for example, streets, parks, abandoned buildings, and subway tunnels) and who may also use shelters on an intermittent basis.

4 Definition of Homelessness 2011 Definition Precariously Housed These are people on the edge of becoming literally homeless who may be doubled up with friends and relatives or paying extremely high proportions of their resources for rent. The group is often characterized as being at imminent risk of becoming homeless. The McKinney-Vento Act s 2011 homeless definition specifically targets persons living in shelters or in places not meant for human habitation, but not people in precarious housing situations.

5 Definition of Homelessness Ø Obviously homeless situations on street, in vehicles, camping out in shelters, missions in transitional housing programs in Permanent Supportive Housing programs Ø Not so obviously homeless situations doubling up motels

6 Duration of Homelessness Ø Transiently homeless: short term (weeks to months) largest segment of HL community least visible, the hidden homeless usually don t self-identify as homeless easiest to help exit HLN Ø Episodically homeless: up yo 1-2 years Ø Chronically homeless: >1-2 years duration smallest number but most visible face of HLN higher incidence of SMI and addiction issues hardest to reach; most expensive to help exit HLN but still less expensive than the cost of doing nothing

7 What are the realities of homelessness in the United States?

8 Homelessness Ø Between 444,000 to 842,000 persons sleep on the streets or in shelters every night National Law Center on HLN and Poverty Ø Now estimated million people were homeless at some time during an average year Ø Approximately 12 million adults in the U.S. have experienced homelessness during their lifetime

9 Extent of Homelessness In the United States Survey of Adult Americans , 1994 Columbia University Ø 3.6% experienced homelessness million adults 1-2 million children Total of 7 million had been homeless 1 in 7 US households had experienced homelessness in 1990 survey 1 in 6 US households had been homeless in 1994 survey Ø 6.5% lifetime homelessness (12 million) Ø Much higher than point-in-time estimates Ø Reveals intermittent nature of homelessness

11 Housing According to the 2012 report from U.S. Conference of Mayors 25-city survey: Ø Lack of affordable housing #1 cause of HLN Ø Requests for assisted housing for individuals and families increased in 82% of cities Ø Average wait: 20 months for public housing; 30 months for Sec. 8 Certificates; 35 months for Sec. 8 Vouchers in 2008 Ø 59% of cities have stopped accepting applications for at least one assisted housing program due to excessive waiting list length in 2008

12 Homelessness According to the 2012 report from U.S. Conference of Mayors 25-city survey: Ø There was a 8% increase in family homelessness over the past year Ø Homelessness in individuals increased by 5% overall Ø 17% of homeless people needing assistance did not receive it due to lack of resources Ø Shelters in 64% of cities turned away families and in 60% of cities turned away individuals due to lack of space

13 Extent of Homelessness In New Mexico Ø NM has 17,000 individuals experiencing homelessness Based on 2005 homeless count New Mexico Coalition to End Homelessness Ø Based on street/shelter counts each January Used mandated HUD definitions of HLN which excludes doubled-up and motel categories entirely Disproportionately undercounts families with children Ø New Mexico has the second-worst poverty rate in the nation Ø NM is ranked 45 th in childhood homelessness Ø NM ranks 49 th in childhood poverty: 31% (2013)

14 Extent of Homelessness In Albuquerque Ø ABQ Point in Time Count 2009: : : 1170 Ø 12% increase in shelter demand in 2007 Ø Over 2000 homeless children in APS in 2007, ~ 7000 in 2012 APS Title I Homeless Project Ø Alternative view of HLN in ABQ: 10-20,000/year

15 Albuquerque Homelessness Ø In survey of 210 homeless people in 9/2007: 27.6% female 59.3% between years old 68.1% single 21% in families Ø Top reasons for homelessness 39.5% could not find affordable housing 35.2% did not make enough money to afford housing 27.6% did not have enough money for a deposit

16 Who is homeless? Ø Predominantly male (58%) and non-white (61%) Ø 51% single men and 17% single women Ø 40% homeless families with children Ø 60% of homeless women and 41% of homeless men have minor children ages 0 17 Ø 24% of these children live with their homeless parent(s) Ø 71% of homeless families with minor children are headed by women Ø 71% of homeless clients are urban, 21% suburban, and 9% rural

17 What causes homelessness? Structural Causes Ø Increase in poverty (income decrease due to unemployment and under-employment; decrease in value or availability of public benefits) Personal Vulnerabilities Ø Physical or mental disability Ø Substance use disorders Ø Domestic violence Ø Lack of social supports Ø Decrease in affordable housing availability

18 Poverty & HLN 18

19 Housing & HLN Ø 80% reduction in federal subsidized housing budget from Ø $40 billion cut from HUD budget between Ø 200,000 private-sector rental units lost per year Ø 1.2 million unsubsidized affordable rental units lost between Ø Annual construction of HUD housing dropped from 129,490 in 1980 to 7,635 in 2002 Ø HUD funding for new public housing has been $0 since 1996 Ø 100,000 HUD units lost since 1996

20 Cost of Housing Ø Federal minimum wage is now $7.25 since 2009 Ø NM minimum wage is $7.50 since 2009 Ø National housing wage is $18.79 an hour Ø There is no state in the country where an individual can work 40 hours per week at the minimum wage and afford even a one-bedroom apartment at the local FMR. Ø The New Mexico housing wage is $14.42 and $15.00 in Albuquerque and Bernalilo County

21 Cost of Housing in Bernalillo County Ø A BC minimum wage earner earning $7.50 per hour cannot afford monthly rent over $390. Ø A SSI recipient (receiving $710 monthly) can afford monthly rent of no more than $213. Ø The BC Fair Market Rent for a two-bedroom unit is $780 and $637 for a one-bedroom unit Ø In BC, a worker earning the minimum wage must work 80 hours per week in order to afford a two-bedroom unit at the area s Fair Market Rent or 65 hours for a 1 bedroom unit Ø The Housing Wage in BC is $15.00 or 200% of the minimum wage for a 2 bedroom unit and $12.25 or 163% for a 1 bedroom unit

22 Effects of Homelessness on Health Ø Inadequate nutrition and uncertain diet Ø Chronic stress and sleep deprivation Ø Exposure to the elements/temperature extremes Ø Lack of access to facilities for daily hygiene Ø Lack of safety on the streets Ø Overcrowded shelters Ø Extreme poverty Ø Lack of health care and insurance

23 Common Medical Problems: Adults High Disease Burden & High Acuity Ø Trauma Ø Victimization Ø Respiratory illnesses/ TB Ø Infestations Ø Skin disorders Ø Poor nutrition Ø Dental disorders

24 What are the trends? Families with children are among the fastest growing segment of people experiencing homelessness

25 Homelessness is a dynamic state Children are homeless on average 10 months at a time 25% of homeless children are homeless more than once U.S. Department of Health & Human Services. Bureau of Primary Health Care. No Place to Call Home. April 2001.

26 Injury Homeless children live in less structured and less safe environments that may place them at risk of injury

27 Childhood Development Ø Delay in at least one Denver subscale 54% homeless vs. 16% housed Language and personal/social most significant Ø 180,000 homeless preschoolers not in school Source: National Health Care for the Homeless Council, Inc., and HCH Clinicians Network

28 Homeless Child Syndrome In summary, the typical homeless child problem list will include: poverty-related health problems immunization delays untreated or under-treated acute and chronic problems mental health, behavior and academic problems child abuse/neglect

29 Homelessness and Health: Pregnancy Ø Rate of pregnancy among adult homeless women is twice the national rate Ø Rate of sexual assault on homeless women is 20 times the rate among women in general Ø Higher infant mortality and morbidity rates

30 Street Youth Ø 730,000 to 1.3 million nationally Ø 25% chronically homeless Ø 50% runaway secondary to abuse Ø 75% engaged in illegal activity Ø 50% involved with prostitution Ø 50% abuse alcohol, 80% street drugs, 35% IDU

31 Alcohol, Drug and Mental Health Problems Ø 40 60% alcohol use problems Ø 25 50% drug use problems Ø 40 80% mental health problems 25% severe and persistent mental illness 250,000 nationwide Ø 20-30% co-occurring disorders Ø Cause or effect of homelessness?

32 THE 8 AMERICAS AMERICA DESCRIPTION AVERAGE LIFE EXPECTANCY 1 Asian 84.9 years 2 Northland low-income rural white Middle America Low-income whites in Appalachia and Mississippi Valley Western Native American Black Middle America Southern low-income rural black High-risk urban black 71.1

33 THE NINTH AMERICA: HOMELESSNESS Ø Average age at death is ~ 53 for both men and women Ø Death rate among homeless people is 3 to 4 times that of the general population Ø Leading causes of death in homeless people ü Accidents & trauma ü Homicide ü Alcohol/drug use and sequelae Ø Less prevalent causes of death in homeless persons ü Cancer: dependent on age group ü CV disease: dependent on age group

34 CAUSES OF DEATH 28,000 ADULTS SEEN BY BOSTON HCH Age Age Age Male Female Male Female Male Female OD OD Cancer Cancer Cancer Cancer Cardiac Cardiac Cardiac Cardiac Cardiac Cardiac Drugs/ Alcohol HIV OD OD Lung disease Diabetes HIV Drugs/ Alcohol Drugs/ Alcohol Liver disease Stroke Suicide Liver disease Liver disease HIV Infections

35 MORTALITY & HOMELESSNESS Ø 2X increased mortality in Caucasians than Hispanics or African Americans Ø Caucasians over-represented in OD and drug/alcohol related deaths Ø Could be related to racial differences in causes of homelessness: In Caucasians, more related to drugs/alcohol, mental health and medical issues In minorities, more related to employment status and poverty Ø Many deaths are immediately post-er, post-hospitalization and post-detox Ø Triple-diagnoses (addiction, mental health and medical) have much more potent effect on mortality than dual-diagnosis

36 Healthy People 2020 Guidelines: Reflections on HCH Reality Ø HP 2020 guidelines based on assumptions that may not be applicable to homeless community Ø HP/DP screening and intervention guidelines assume: ü at least 10 years of remaining life-span ü social stability, i.e. housing Ø Can we assume this in the homeless community? Ø USPTF finally adds housing to guidelines: 2020

37 Healthy People 2020 Guidelines Reflections on HCH Reality Ø Differences between homeless and housed populations ü Mortality causes are different ü Age at death is lower ü Years of remaining life are lower Ø All of above vary between different HL subpopulations ü Male vs. Female ü Unattached adults vs. Families ü Adults vs. Children ü Street vs. Sheltered ü Age < 45 vs. Age > 45 ü Racial Differences

38 Healthy People 2020 Guidelines Reflections on HCH Reality Ø Effects of homelessness obliterates gender differences in causes of death ü Even when HL people die of heart disease, there is no gender protective effect Ø Adaptations for homeless health care: ü Screen for addictions, mental illness and social determinants of health ü Less attention to tobacco use, obesity and exercise based on age ü Lipid level screening less important Ø All of this changes when become housed

39 Current Challenges Facing HCH Programs Ø Persistence and increase of homelessness Ø Increasing amount/acuity of health care problems Ø High rates of uninsurance Ø Increase in undocumented immigrants Ø Partnering with mainstream health care programs Ø Continued focus on temporary rather than long-term solutions Ø Concerns regarding institutionalization of HLN/ HCH

40 Homelessness & Health Care Ø Homelessness and chronic poverty Ø Safety net is not a net at all Ø Homelessness and health are mutually exclusive Ø Housing is health care Ø Housing is a right; no need to earn it Ø Goal is to end homelessness

41 Ending Homelessness Is About Justice Health Housing Economic Education Civil rights Work at local/state/national levels Ø In collaboration with others Ø As caregivers and as advocates

42 Solutions to Homelessness Address urgent needs while working on systemic solutions Ø Low Income Housing ü Increase supply and affordability ü Fund the National Housing Trust Fund Ø Income ü Universal living wage ü Adequate income supports ü Education and job training Ø Health Care ü Universal access/coverage/insurance

Changes in the HUD Definition of Homeless

Changes in the HUD Definition of Homeless HUD has issued a draft regulation to implement changes to the definition of homelessness contained in the Homeless Emergency Assistance and Rapid Transition to