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1
Homelessness, Housing, and Health
Stephen Hwang, MD, MPHDivision of General Internal Medicine, University of Toronto
Centre for Research on Inner City Health, St. Michael’s Hospital
McGill University - Medical Grand Rounds
February 16, 2010
2
Educational Objectives• To increase understanding of the health
problems of homeless people and the impact of homelessness on the health care system.
• To understand how the social determinants of health are a critical factor in population health and clinical medicine.
• To assist health care providers to identify and use interventions that are effective in improving the health of homeless people
3
Question 1
• What is the probability that a 25-year old man living in a shelter or rooming house in Montreal will survive to age 75?
A) 32%
B) 42%
C) 52%
D) 62%
E) 72%
4
Question 2• A 45-year old woman with chronic paranoid schizophrenia
and occasional crack cocaine use has been living on the street for the last 10 years. Which intervention has the greatest chance of improving the health of this individual?
A) Encourage her to move into a homeless shelter immediatelyB) Urge her to get treatment for her mental illness and addiction, as a first step towards moving into a shelter, then transitional housing, and eventually into permanent housing.C) Provide her with immediate housing in a subsidized apartment, and give her the option of receiving intensive mental health support services.D) None of the above; the probability that this individual will achieve any significant improvement in her health is extremely low.
5
Case Study
• 40 year old man• Neurosurgery for subarachnoid hemorrhage
due to ruptured berry aneurysm 6 years ago• Perioperative left hemispheric stroke,
leading to right sided weakness, expressive aphasia, emotional lability
• Can be pleasant and cooperative, but frequent verbal outbursts with profanities
• Homeless x 5 years, living at various shelters
6
Case Study
• Depression, Rx mirtazapine• Musculoskeletal low back pain x 5 years,
Rx oxycodone/acetaminophen, ibuprofen, baclofen
• “Medical marijuana” use daily• Crack cocaine use, reportedly clean x 2 yrs
(confirmed by urine tox screen)• No alcohol abuse
7
Case Study
• Clinic visit for bed bug bites• Hospital admission for cellulitis of leg• On disability ($950 per month)• After a long wait, he obtained a subsidized
apartment (rent = 30% of monthly income)• Now housed x 6 months, doing well
8
Who are the homeless?
Streets, Parks, etc.
Shelters
Doubled Up with Friends or Family
Hospitals
Prisons & JailsPsychiatric
HospitalsStable
Housing
Adapted from S. Kertesz
Panhandlers
9
Homelessness in Canada
• An estimated 150,000 to 300,000 Canadians are homeless, living in shelters or on the streets
• On any given night, 40,000 people stay in homeless shelters
Homelessness Partnering Strategy, Government of Canada
10
Homelessness in Canada
• 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
Tompsett & Toro, 2002
11
Homelessness in Montreal
• 75% of Quebec’s homeless population lives in Montreal
• Estimate of “approximately 25,000 homeless Montrealers”
• Shelter beds for men: 570
• Shelter beds for women: 60
12
Homelessness in Other Canadian Cities
• Vancouver Homeless Count = 2,660
• Calgary Homeless Count = 4,060
• Toronto Homeless Count = 5,000– 3,800 in shelters– 800 on the street– 400 in health care & correctional facilities
13
Homelessness in Toronto
• 28,000 individuals use shelters each year– 50% single men– 20% single women– 20% parents with children– 10% youth (age 15-24)
14
Housing Transitions
Streets, Parks, etc.
Shelters
Doubled Up with Friends or Family
Hospitals
Prisons & JailsPsychiatric
HospitalsStable
Housing
Adapted from S. Kertesz
Panhandlers
15
Homelessness in Toronto Age distribution of shelter users
0
5
10
15
20
%
<= 14
15-1
9
20-2
4
25-2
9
30-3
4
35-3
9
40-4
4
45-4
9
50-5
4
55-5
9
60-6
4
65-6
9
70-7
4
75-7
6
Age (years)
16
Homelessness in Toronto Number of individuals using shelters, 1990-2005
0
5000
10000
15000
20000
25000
30000
35000
19901991
19921993
19941995
19961997
19981999
20002001
20022003
20042005
17
Homelessness and Health
• Some health problems precede and causally contribute to homelessness
• Other health problems are the result of being homeless
• Homelessness complicates the treatment of many illnesses
Homelessness, Health, and Human Needs, Institute of Medicine
18
What causes homelessness?
19
What causes obesity?
20
What causes homelessness?
21
• Individuals Failings
– ?Lifestyle choice
• Individual Vulnerabilities
– Mental illness
– Addictions
– Cognitive impairment
– Childhood environment
What causes homelessness?
22
• Social Forces– Lack of affordable housing– Lack of jobs for those with limited
skills– Inadequate welfare & disability rates– Ethnic & racial discrimination– Economic cycles of boom & bust
What causes homelessness?
23
What causes homelessness?
The Social Determinants of Health
The Clinical Perspective
24
• "You can't help those who simply will not be helped. One problem that we've had, even in the best of times, is people who are sleeping on the grates, the homeless who are homeless, you might say, by choice."
• President Ronald Reagan (1984)
Is homelessness a lifestyle choice?
25
• Toronto: Do you want to live in permanent housing?– In shelters: 86%– On the street: 86%
• Vancouver: Main reason don’t have own place = “Don’t want a home”– In shelters: 2%– On the street: 6%
2006 Toronto Street Needs Assessment2008 Metro Vancouver Homeless Count
Is homelessness a lifestyle choice?
26
Welfare* Rent**
• Montreal, QC $ 590 $ 514
• Toronto, ON $ 585 $ 767
• Calgary, AB $ 690 $ 775
• Vancouver, BC$ 610 $ 779
* for a single adult
** average rent for a bachelor unit
Is homelessness caused by a lack of affordable housing?
27
• Did the de-institutionalization of people with serious mental illness cause the homelessness that we see today?
Dear & Wolch, Landscapes of Despair:
From Deinstitutionalization to Homelessness (1987)
Mental Illness and Homelessness
28
“Trans-institutionalization”
Streets, Parks, etc.
Shelters
Doubled Up with Friends or Family
Hospitals
Prisons & JailsPsychiatric
HospitalsStable
Housing
Adapted from S. Kertesz
Panhandlers
29
• Mental health problem: 40-50%• Most common diagnosis: Depression• Schizophrenia: 6%• Bipolar Affective Disorder 5%
Sources: Toronto Pathways to Homelessness Study
Mental Illness and Homelessness
30
Homelessness and Addictions
• Homeless people in Toronto• Current alcohol problem: 29%• Current drug problem: 40%
• Single men: 53%• Single women: 41%• Women with children: 11%
• Most frequent drugs used in Toronto: marijuana, crack cocaine
Grinman & Hwang, BMC Public Health, in press.Chiu & Hwang, J Epidemiol Community Health, 2009;63;943-948.
31
Injuries and Assault
• Homeless adults in Toronto assaulted in the last year:
• 35% of shelter residents
• 50% of street dwellers
Zakrison & Hwang, Journal of Urban Health 2004; 81(4)
32
Traumatic Brain Injury (TBI)
58
42
53
0102030405060708090
100
Per
cen
tag
e
Men Women Overall
Hwang, CMAJ 2008;179(8):779-84
33
Severity of Traumatic Brain Injury
66
23
11Mild
Moderate orSevere
Unknown
Hwang, CMAJ 2008;179(8):779-84
34
0
5
10
15
20
25
30
35
40+ 30 20 10 0 10 20 30+
Nu
mb
er
of
ind
ivid
ua
ls.
Years before first episode of homelessness Years after first episode of homelessness
Timing of first TBI relative tofirst episode of homelessness
Hwang, CMAJ 2008;179(8):779-84
35
Homelessness and Health
• Some health problems precede and causally contribute to homelessness
• Other health problems are the result of being homeless
• Homelessness complicates the treatment of many illnesses
Homelessness, Health, and Human Needs, Institute of Medicine
36
Chronic Medical Conditions
• Poorly controlled hypertension & diabetes
• Chronic pain
• COPD
• Asthma
• Seizures
Lee & Hwang, Circulation 2005;111:2629-2635.
Bugeja & Hwang, CMAJ 2000;163(2):161-5
37
Infectious Diseases
• Community-acquired Pneumonia• Cellulitis & other soft tissue infections• Infestations (bed bugs, lice, scabies)• Tuberculosis• Hepatitis C• HIV / AIDS• Sexually Transmitted Infections
38
Life Expectancy
• Canadian census mortality study– 15% of general population (1991)– Shelters and hostels for the homeless, missions,
and YMCA/YWCA facilities (“shelters”)– Rooming and lodging houses (“rooming houses”)– Hotels, motels, and tourist homes (“hotels”)
• 11 years of follow-up for deaths
Hwang et al, BMJ 2009;339:b4036
39
Canada Census Mortality Study
Shelters 1,500
Rooming Houses 7,800
Hotels 5,800
Total 15,100
General Population 2,735,000
Hwang et al, BMJ 2009;339:b4036
40
Mortality Rate RatiosFigure 1. Mortality rate ratios for men and women who are homeless or living in marginal housing,
compared the total cohort and the poorest and richest income quintiles
0
1
2
3
4
5
6
25-34 35-44 45-54 55-64 65-74 75+ 25-34 35-44 45-54 55-64 65-74 75+
Age (years)
Rat
e ra
tio
vs. Richest quintile
vs. Total cohort
vs. Poorest quintile
Men Women
41
Survival CurvesFigure 2. 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)
Pro
bab
ilit
y o
f su
rviv
al (
%)
Richest income quintile
Total cohort
Poorest income quintile
Shelters, rooming houses, hotels
Men Women
42
Probability of Survival to 75
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
Pro
bab
ilit
y o
f su
rviv
al
(%) Shelters, rooming houses, hotels
Poorest income quintile
Total cohort
Richest income quintile
43
Mortality Rate RatiosFigure 4. Mortality rate ratios for men and women living in shelters, rooming houses, and hotels,
compared to the entire cohort
0
1
2
3
4
5
6
7
25-34 35-44 45-54 55-64 65-74 75+ 25-34 35-44 45-54 55-64 65-74 75+
Age (years)
Rat
e ra
tio
Shelters
Rooming houses
Hotels
Note: Shelters include hostels, missions, and YMCA/YWCA facilities. Rooming houses include lodging houses. Hotels include motels and tourist homes.
Men Women
44
Differences in Cause of Death - Men
Cause Ratio Difference
Total (all causes) 2.0 1,238
Cancer 1.6 219
Lung cancer 1.9 107
Heart attack 1.6 182
Stroke 1.9 65
45
Differences in Cause of Death - Men
Cause Ratio Difference
Pneumonia 2.3 45
Bronchitis, emphysema 2.9 119
Digestive system disease 2.8 51
Cirrhosis of liver 3.7 37
46
Differences in Cause of Death - Men
Cause Ratio Difference
External causes 3.3 158
Motor vehicle 1.7 9
Suicide 2.3 30
Falls 3.1 27
Homicide 11.3 18
Overdose 10.3 30
47
Homelessness and the Health Care System
• High levels of morbidity, but many barriers to obtaining appropriate care
• Patient factors, provider factors, health care system factors
48
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%)
49
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
50
Hospitalization Costs of Homeless People
• Admissions to Medicine at St. Michael’s Hospital, 2002-7
• 40,314 Housed vs. 1,758 Homeless patients
• Crude costs: $11,741 vs. $13,611
• Homeless + $1,870
51
Hospitalization Costs of Homeless People
• Adjust for age, sex, complexity: +$2,188
• Adjust for acute days: +$1,458
• Adjust for alternate level of care days: +$529 (not significant)
52
Interventions to Improve the Health of Homeless People
• Many interventions are effective!• Respite Care• Housing First & Mental Health
Services• Improving Health Care Experiences
Hwang, Am J Preventive Med 2005;29(4):311–319
53
Respite Care
• 225 homeless patients discharged from hospitals in Chicago
• 161 respite vs. 64 wait-list controls
• Hospital days over next 12 months: 3.7 vs. 8.3 days (p=0.002)
Buchanan, Am J Pub Health 2006;96:1278-81.
54
Housing First
Streets, Parks, etc.
Shelters
Doubled Up with Friends or Family
Hospitals
Prisons & JailsPsychiatric
HospitalsStable
Housing
Adapted from S. Kertesz
Panhandlers
55
Housing First
Tsemberis. AJPH 2004
56
Question 2• A 45-year old woman with chronic paranoid schizophrenia
and occasional crack cocaine use has been living on the street for the last 10 years. Which intervention has the greatest chance of improving the health of this individual?
A) Encourage her to move into a homeless shelter immediatelyB) Urge her to get treatment for her mental illness and addiction, as a first step towards moving into a shelter, then transitional housing, and eventually into permanent housing.C) Provide her with immediate housing in a subsidized apartment, and give her the option of receiving intensive mental health support services.D) None of the above; the probability that this individual will achieve any significant improvement in her health is extremely low.
57
At Home/Chez Soi Project
• Randomized controlled trial of Housing First and mental health services
• Homeless & serious mental illness• Mental Health Commission of Canada• Montreal PI: Dr. Eric Latimer (Douglas
Institute)• www.mentalhealthcommission.ca
58
Improving Homeless People’s Health Care Experiences
• Qualitative study
• Experiences of unwelcomeness perceived as acts of discrimination
• Feeling objectified/dehumanized vs. valued as a person/listened to
Wen & Hwang, J General Int Med 2007;22:1011-7.
59
Approach B: Shift population norm slightly upwards
Approach A: Focus on improving conditions for extreme groups
Homeless Poor Fair Moderate Good Excellent
Housing Quality
Fre
qu
en
cy in
Pop
ula
tion
Intervention at two possible levels
60
61
Thank you!
62
Differences in Cause of Death - Men
Cause Ratio Difference
Smoking-related 2.4 281
Alcohol-related 6.4 81
Drug-related 11.5 48
63
Economic Booms & Busts
64
Source: Calgary Homeless Foundation
Economic Booms & Busts
0
2
4
6
8
10
12
2008 2009
Unemployment(%)Vacancy (%)
Rent x $100
Calgary