Health Needs and Permanent Supportive Housing

Do all chronically homeless people have health issues requiring permanent supportive housing? No. But the design and delivery of PSH needs to heed the health needs of chronically homeless people, while avoiding the pitfalls of a solely medical model in service delivery.

Homeless individuals have poorer health than the general population[1]. However, these individuals with poor physical and mental health and substance use issues can achieve stable housing[2]. Research from Toronto indicates that 72% of people in a Housing First program report improved physical health once moved into housing; however, while people with longer-term homelessness were likely to report improvements in mental health after moving into scattered-site housing with supports, they were less likely to report improvements in physical health[3].

There are statistically significant differences in self-reported physical health and self-reported mental health amongst homeless people, with homeless people fairing worse than the general population[4]. Length of homelessness has a direct link to the severity of the health issues, with people experiencing homelessness 5 or more years much more likely to have chronic health issues, and multiple chronic health issues much more prevalent amongst those homeless for a long time[5]. This would seem to suggest that PSH should first focus on those that have been homeless for longer periods of time with co-occurring health issues rather than focusing solely on health issues in the assessment.

The various types of specific health issues confronted by homeless people are numerous. For example, cardiovascular disease is more frequent than the general population[6], and can be compounded by the high propensity of cigarette smokers (almost 9 out of 10 according to self-reports) within the homeless population. Serious health conditions found to be statistically significant in difference from the general population include: Heart Disease (5 times greater than the general population), Diabetes (2 times greater than the general population), Arthritis or Rheumatism (3 times greater than the general population), Epilepsy (20 times more likely than the general population), Liver Disease, Hepatitis C (30 times greater than the general population), Hepatitis B, Cancer (4 times greater than the general population), Stomach or Intestinal Ulcers, Allergies (other than food allergies), and Migraines[7].

Tolomiczenko and Goering almost 25 years ago demonstrated that mental illness does not usually cause homelessness[8]. While not a precipitating factor, it can be exacerbated by the experience of homelessness. Stereotypes of the homeless population infiltrated with high rates of psychosis like schizophrenia are unfounded. While there will always be a smaller percentage of homeless people that experience schizophrenia – 6% lifetime prevalence amongst the homeless population in Canada and 10-13% found amongst rigorous US studies[9], the truth is that depression and anxiety disorders with alarming rates of suicidal ideation and suicide attempts are more common[10].

The costs and service use impacts of mental illness on emergency rooms amongst homeless persons, however, warrants attention. According to CIHI more than 50% of emergency room visits and hospitalizations amongst homeless people in any given year are a result of mental illness[11]. Given reported improvements in mental health and wellness after a housing intervention in Housing First[12], emphasis on housing is warranted to decrease these expensive health utilization costs to address compromised mental wellness experienced while homeless.

There is a high rate of brain injury amongst homeless people[13], but interestingly this often happens younger in life and predates their homelessness – as high as 58% amongst homeless men and 42% amongst homeless women[14]. Recent research on youth homelessness has also demonstrated that more than 50% of youth that experience homelessness have experienced a brain injury[15]. Given cognitive limitations and issues with impulse control that happen amongst people with brain injuries, different housing models can be necessary within PSH to provide a supportive environment that is attuned to the behaviours that these conditions may present.

Frequency of alcohol use and abstinence rates are not particularly dissimilar between the homeless and non-homeless populations[16]. However, instances of heavy drinking (5 or more drinks on one occasion) and rates of substance addiction are higher amongst the homeless population, as is the consumption of non-beverage alcohol where almost 10% of the homeless population uses daily[17]. Problems with alcohol use disorders are between 6-7 times more prevalent amongst the homeless population, and especially prevalent amongst homeless men where upwards of 60% will have an alcohol use disorder[18]. Use of tobacco is prevalent in almost 90% of the homeless population compared to 18% of the general population[19], which also needs to be taken into account when designing housing and service options – a rate that is most likely going to remain high even with the availability of cessation programs. While it is difficult to accurately and comprehensively quantify the depth and breadth of the use of other drugs amongst the homeless population (illicit drugs), US research from a couple of decades ago found the median prevalence of drug use disorders to be 30%[20]. The “drug of choice” within the homeless population is usually influenced by geography and ebbs and flows in popularity relative to availability and price. It would seem, however, that for several decades alcohol (including non-palatable alcohol), crack cocaine, marijuana, oxy and methamphetamine have been popular. Given the propensity for mental illness and substance use disorders to happen concurrently, it is important for PSH to take this into consideration. Moreover, given the rate of substance use there is a compelling case for PSH to embrace a harm reduction framework relative to substance use – neither condoning nor supporting, but accepting the rate of use as fact and commonplace.

Overall, mortality rates are much higher amongst homeless people than the general population. For example, a study from the late 1990s showed homeless youth in Montreal have a mortality rate 9 times higher for males and 31 times higher for women than other youth in Quebec[21]. A frequently cited study by Dr. Stephen Hwang[22], demonstrates that amongst the shelter using population in Toronto that mortality rates are 8.3 times higher than the mean for 18-24 year olds; 3.7 times higher than the mean for 25-44 year olds; and, 2.3 times higher than the mean for 45-64 year olds.  Higher mortality rates and advanced ageing can be improved upon through PSH that offers safety and security to its residents with access to care that people may have been unable to access while homeless…or at least not sustainably or proactively or intensely access while homeless.

It is important to consider that street homeless individuals (sometimes referred to as “rough sleepers”) have poorer health than their shelter-using peers[23]. It is amongst the street homeless population that there is a greater incidence of chronic homelessness. Offers of PSH must keep this in mind in some respects when considering prospective tenants. If PSH looks solely to shelter environments it will likely miss some clients that would most benefit from what is being offered. Links between PSH and street outreach can be very important and effective in service delivery.

But health isn’t the only consideration. We don’t want PSH to become parallel health care providers to the mainstream health services. Health services, however, should be integrated as part of the service delivery, not the sole focus of service delivery. A more holistic view that also encompasses the need for the likes of meaningful daily activities, social networks, self care, avoidance of high risk and exploitive situations, etc are also beneficial in a PSH environment for it to be as health as possible.

[1] See for example: Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health; Hwang, SW. “The health and housing in transition study.” International Journal of Public Health. 011 Dec;56(6):609-23. Epub 2011 Aug 20; Wilkens, R et al. “Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study.” British Medical Journal. 2009 Oct 26;339; Tolomiczenko G. et al “Multidimensional social support and the health of homeless individuals.” Journal of Urban Health. 2009 Sep;86(5):791-803; Dunn JR et al. “Housing as a socio-economic determinant of health: findings of a national needs, gaps and opportunities assessment.” Canadian Journal of Public Health. 2006 Sep-Oct; Hwang SW et al. “Interventions to improve the health of the homeless: a systematic review.” American Journal of Preventive Medicine. 2005 Nov;29(4):311-9.

[2] Hwang, SW et al. “Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program”. Journal of Urban Health. 2011 Dec; 88(6):1076-90; Raine L and T Marcellin. “What Housing First Means” City of Toronto, 2007.

[3] Raine L and T Marcellin. “What Housing First Means” City of Toronto, 2007.

[4] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[5] Ibid.

[6] Marmot M. and Wilkinson R. Eds. 2003. Social Determinants of health: the solid facts. 2nd edition. Copenhagen: World Health Organization (WHO); Frankish CJ, et al 2005. Homelessness and health in Canada: research lessons and priorities. Canadian Journal of Public Health. 96(Supplement 2):S23-S29.

[7] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[8] Tolomiczenko G, Goering P. 1998. Pathways into homelessness: Broadening the perspective. Psychiatry Rounds. 2(8). Toronto: Centre for Addiction and Mental Health.

[9] Mental Health Policy Research Group. Mental illness and pathways into homelessness: proceedings and recommendations. Toronto: Canadian Mental Health Association; 1998; Fischer PJ WR Breakey. The epidemiology of alcohol, drug, and mental disorders among homeless persons. American Psychology 1991;46:1115-28.

[10] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[11] Canadian Institute for Health and Information. (August, 2007). Improving the Health of Canadians: Mental Health and Homelessness.

[12] Raine, L and T Marcellin. What Housing First Means. City of Toronto, 2007.

[13] Highley, JL. Traumatic Brain Injury Amongst Homeless Persons. National Health Care for the Homeless Council. 2008.

[14] Hwang SW et al. “The effect of traumatic brain injury on the health of homeless people.” Canadian Medical Association Journal, 2008; 179: 779-784.

[15] Forchuk, C et al. Service Preferences of Homeless Youth with Mental Illness. University of Western Ontario, 2012.

[16] Health Canada. Canada Alcohol and Drug Use Monitoring Survey. Ottawa, 2011. Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[17] Raine, L and T Marcellin. What Housing First Means. City of Toronto, 2007; Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[18] Fischer PJ WR Breakey. The epidemiology of alcohol, drug, and mental disorders among homeless persons. American Psychology 1991;46:1115-28.

[19] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[20] Lehman AF and DS Cordray. Prevalence of alcohol, drug, and mental disorders among the homeless. Contemporary Drug Problems 1993;20:355-83.

[21] Roy E, et al. Mortality among street youth. Lancet 1998;352:32.

[22] Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. Journal of the American Medical Association 2000:283:2152-7

[23] Gelberg L and LS Linn. Assessing the physical health of homeless adults. Journal of the American Medical Association 1989;262:1973-9.