Homelessness has become increasingly more prevalent over the last two decades. Between 1973 and 1993, 22 million low-rent units vanished from the housing market. By 1995, there was an estimated shortage of 4.4 million affordable housing units, and between 1991 and 1995, the medium rental cost paid by low-income renters increased 21 percent. This is coupled by a trend of falling or stagnant wages, less job security, and an overall decrease in benefits, including health insurance.

Each year, an estimated 3 million people in the United States experience homelessness: however, this figure is highly underestimated due to lack of visibility of this population, difficulty in locating persons experiencing short or intermittent episodes of homelessness, and the existence of those who do not identify as homeless. One study found that 26 million Americans, or 14 percent of the U.S. population, had been homeless at least once in their lifetime, with the majority having been homeless for more than one month.

Homelessness is not a state that exists simply as a result of low income and lack of public assistance programs. There are a number of co-existing conditions that contribute to the state of homelessness, ranging from substance abuse/addiction to mental illness to a history of emotional, physical and/or sexual abuse, making healthcare provision for the homeless uniquely difficult.

Individuals who experience homelessness are at increased risk of physical and behavioral health (mental illness and substance abuse) problems due to inconsistent and inadequate living conditions, poor nutrition, and limited access to mental health and primary healthcare services. In addition, the homeless are at greater risk of contracting infectious diseases and injuries, and are often victims of random violence – over half of homeless women have been sexually abused.

The emerging complex social and physical health needs of homeless patients can be challenging for clinicians. There are six characteristics that have been associated with “the difficult patient.” They are increased likelihood of mental disorder(s), more than five somatic symptoms, more severe symptoms, poorer functioning status, more unmet expectations/less satisfaction with care, and higher use of health services. All of these factors can play a significant role in shaping encounters with homeless patients, as all are exceedingly common in this population.

Many who are without stable housing have multiple diagnoses of behavioral health problem(s) and substance abuse. Mental illness is an individual factor that can increase a person’s risk for becoming homeless and staying homeless for longer periods of time. It is estimated that a third of homeless persons suffer from severe and persistent mental illness that prevents them from carrying out essential daily activities, such as self care, household management and successful engagement in interpersonal relationships. Often, their disease is active and untreated, which makes meeting even basic needs extremely difficult.

Also well documented in the existing literature is the fact that homeless persons suffer from a wide range of health problems, which contribute to high rates of mortality and morbidity. Those who are suffering from serious mental illness in addition to homelessness die, on average, 25 years earlier than the general population. Trauma, mental illness, alcoholism, chronic obstructive pulmonary disease, arthritis and musculoskeletal diseases, drug resistant tuberculosis, HIV/AIDS, peripheral vascular disease, nutritional deficiencies (such as pellagra and scurvy), and skin and foot disorders all have a much higher prevalence among the homeless.

“Our most common challenges are in the cases of diabetics and hypertensives [because] the common goal is ultimately therapeutic lifestyle changes. This can be a difficult task for this population due to finances, housing and adequate food selection,” says Adonica Franklin, RN, MSN, FNP-C. Delays in seeking medical attention, exposure to the environment, poor adherence to treatment and cognitive impairment highly impact the deterioration of health and, in turn cause disproportionately high utilization rates of health services, most commonly in emergency centers (EC).

Despite reporting high rates of EC use, most homeless patients report leaving dissatisfied with their care. A study on compassionate care and EC use found that 31 percent of homeless patients felt that they had been treated rudely by staff, 45 percent reported feeling that their medical issue was not taken seriously and 42 percent sought care at a later date for the same problem. Some critics have suggested that if patients perceive high quality care in the EC, then it may increase the rate of inappropriate use. Thus, improving patients’ satisfaction would increase the already overwhelming demand.

Redelmeier et al. conducted a study to test this theory and found that providing compassionate care increased patient satisfaction and, in fact, decreased the number of EC visits. They offer several explanations. According to Redelmeier, “Compassionate care may reinforce the reassurance [needed]; it may promote faith in the healthcare system…[and] it may increase trust and thereby lessen the tendency to seek additional care for a second opinion.”

There are many reasons for patients to be experienced as “difficult.” Patients may have poor hygiene and are unkempt. They may display behaviors that are inappropriate, for example, not respecting boundaries or acting out as a result of behavioral issues. Further, the encounter may evoke an awareness of difference is social class and other factors that contribute to feelings of alienation. However, research suggests that clinicians with more positive attitudes about psychosocial aspects of care experience less encounters as being “difficult” and are able to provide an atmosphere that allows patients to express their feelings and psychological distress.

Psychosocial intervention training and patient centered care models have proven effective in increasing successful encounters and health outcomes. Patient centered care models have long been used in social sciences, but are relatively new to medicine. They incorporate patients’ experiences with illness, psychosocial context and shared decision making and is based on the theory that patients, especially vulnerable ones, need to experience successes when working with others. Even small achievements can positively reinforce healthy behaviors. Homeless patients often reject help that is provided in traditional ways.


Goal negotiated care (GNC), a patient centered care model, aims to shape clinical encounters in a way that encourages positive decision making by placing the patient in a much more active role in the encounter. Traditional care models, which are largely clinician led and place patients in a relatively passive role, tend to reinforce learned helplessness and create a self-perpetuating cycle of hopelessness, low self-esteem, and repeated patterns of failure. They aim to identify the patient’s complaint(s) and then assign task/treatment in which the patient is to adhere – a “take two pills and call me in the morning” approach.

GNC, however, engages patients in a much different way. It entails identifying the patient’s goals (i.e. wanting to get a job). Next, identify the barriers to meeting that goal (i.e. the patient feels that back pain is what is preventing him from getting and holding a job). The clinician and the patient then work on formalizing goals to overcome this barrier by working backwards through their medical history and taking into account the overall goal of the patient.

The drastically increased rate of physical and behavioral health problems combined with complex social issues require a deeper understanding of the needs of this population. Undoubtedly, providing healthcare for the homeless comes with unique barriers and challenges; however, it also comes with its unique and deeply personal rewards.

“As a nurse practitioner working with the homeless population for almost seven years, there have been some unique challenges, one being the number of patients with mental illness and homelessness,” says Loretta King, RN, MSN, FNP-BC, a family nurse practicioner with Healthcare For the Homeless in Houston. “It can be challenging to adequately care for the patient due to lack of compliance with medication therapy, follow-up care and lack of shelter. Taking on these challenges requires a multidisciplinary approach, such case management and medical staff.

She continues: “The reward for me working with the homeless population is the sincere appreciation and ‘thank you’ that comes when we have provided a service such as dental and they have received a full set of dentures, when we have reached an optimal stable blood pressure or blood glucose level, when they have moved into their own place, when they have began working. That ‘smile’ is my reward for the work we do.”

If you would like to learn more about or support this work, please visit www.homeless-healthcare.org.

— Carlie Ann Brown has worked for health-related non-profit organizations since 2002 and is currently in the Department of Family and Community Medicine at Baylor College of Medicine serving as the lead project coordinator for Healthcare for the Homeless–Houston and the program director of the Houston-Galveston Schweitzer Fellows Program.

David S. Buck, MD, is the president and founder of Healthcare for the Homeless –Houston and an associate professor at Baylor College of Medicine in the Department of Family and Community Medicine.

Direct questions and comments to editorial@therapytimes.com.


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