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1 Homelessness, Housing, and Health Stephen Hwang, MD, MPH Division of General Internal Medicine, University of Toronto Centre for Research on Inner City.

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Presentation on theme: "1 Homelessness, Housing, and Health Stephen Hwang, MD, MPH Division of General Internal Medicine, University of Toronto Centre for Research on Inner City."— Presentation transcript:

1 1 Homelessness, Housing, and Health Stephen Hwang, MD, MPH Division 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 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 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 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 immediately B) 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 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 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 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 8 Who are the homeless? Streets, Parks, etc. Shelters Doubled Up with Friends or Family Hospitals Prisons & Jails Psychiatric Hospitals Stable Housing Adapted from S. Kertesz Panhandlers

9 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 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 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 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 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 14 Housing Transitions Streets, Parks, etc. Shelters Doubled Up with Friends or Family Hospitals Prisons & Jails Psychiatric Hospitals Stable Housing Adapted from S. Kertesz Panhandlers

15 15 Homelessness in Toronto Age distribution of shelter users

16 16 Homelessness in Toronto Number of individuals using shelters,

17 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 18 What causes homelessness?

19 19 What causes obesity?

20 20 What causes homelessness?

21 21 Individuals Failings –?Lifestyle choice Individual Vulnerabilities –Mental illness –Addictions –Cognitive impairment –Childhood environment What causes homelessness?

22 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 23 What causes homelessness? The Social Determinants of Health The Clinical Perspective

24 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 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 Assessment 2008 Metro Vancouver Homeless Count Is homelessness a lifestyle choice?

26 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 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 28 “Trans-institutionalization” Streets, Parks, etc. Shelters Doubled Up with Friends or Family Hospitals Prisons & Jails Psychiatric Hospitals Stable Housing Adapted from S. Kertesz Panhandlers

29 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 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;

31 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 32 Traumatic Brain Injury (TBI) Hwang, CMAJ 2008;179(8):779-84

33 33 Severity of Traumatic Brain Injury Hwang, CMAJ 2008;179(8):779-84

34 34 Years before first episode of homelessnessYears after first episode of homelessness Timing of first TBI relative to first episode of homelessness Hwang, CMAJ 2008;179(8):779-84

35 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 36 Chronic Medical Conditions Poorly controlled hypertension & diabetes Chronic pain COPD Asthma Seizures Lee & Hwang, Circulation 2005;111: Bugeja & Hwang, CMAJ 2000;163(2):161-5

37 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 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 39 Canada Census Mortality Study Shelters 1,500 Rooming Houses 7,800 Hotels 5,800 Total15,100 General Population 2,735,000 Hwang et al, BMJ 2009;339:b4036

40 40 Mortality Rate Ratios

41 41 Survival Curves

42 42 Probability of Survival to 75

43 43 Mortality Rate Ratios

44 44 Differences in Cause of Death - Men CauseRatioDifference Total (all causes)2.01,238 Cancer Lung cancer Heart attack Stroke1.965

45 45 Differences in Cause of Death - Men CauseRatioDifference Pneumonia2.345 Bronchitis, emphysema Digestive system disease2.851 Cirrhosis of liver3.737

46 46 Differences in Cause of Death - Men CauseRatioDifference External causes Motor vehicle1.79 Suicide2.330 Falls3.127 Homicide Overdose10.330

47 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 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 49 Emergency Department Use by Homeless People Emergency Dept. use over 4 years: visits: 30 (5%) = 1, visits: 8 (1%) = visits: 4 (0.7%)= visits: 2 (0.3%)= men (7%) = 2,105 visits

50 50 Hospitalization Costs of Homeless People Admissions to Medicine at St. Michael’s Hospital, ,314 Housed vs. 1,758 Homeless patients Crude costs: $11,741 vs. $13,611 Homeless + $1,870

51 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 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 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:

54 54 Housing First Streets, Parks, etc. Shelters Doubled Up with Friends or Family Hospitals Prisons & Jails Psychiatric Hospitals Stable Housing Adapted from S. Kertesz Panhandlers

55 55 Housing First Tsemberis. AJPH 2004

56 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 immediately B) 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 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)

58 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:

59 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 Frequency in Population Intervention at two possible levels

60 60

61 61 Thank you!

62 62 Differences in Cause of Death - Men CauseRatioDifference Smoking-related Alcohol-related6.481 Drug-related11.548

63 63 Economic Booms & Busts

64 64 Source: Calgary Homeless Foundation Economic Booms & Busts Calgary


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