Abstract
The homeless are among vulnerable populations experiencing health disparities as a result of a lack of access to care. There are over 10 million adults not receiving treatment for mental illness or substance abuse due to a shortage of available resources (Huntley, 2015). The lack of resources including insurance creates the documented gap. As a result of environmental factors such as food and shelter, the homeless experience increased rates of mortality, mental illness, chronic conditions, and dental problems (Notaro et al., 2013). Additionally, 66% of the homeless population suffer from substance abuse (Huntley, 2015). Many times, substance abuse begins as a way of coping with life circumstances. The cost of addiction places a toll on families and society as a whole. Homeless addicts are among those responsible for frequent emergency department visits requiring hospital’s time, money, and resources (Althaus et al., 2011). Current efforts to alleviate addiction in the homeless including the Housing First model are neither effective or efficient. The use of multi-disciplinary teams, standardized screening tools, and technology have been found beneficial in alleviating addiction in the homeless. Additionally, the behavioral health continuum of care model and transtheoretical model of change including motivational interviewing are able to decrease the cost and duration of addiction treatment. A personal commitment by the addict and appropriate use of community resources contribute to long-term behavior change. The purpose of this paper is to present the gap in healthcare experienced by homeless addicts, identify underlying social inequalities, and introduce policies, interventions, and models to alleviate the health disparity.
Keywords: homeless, addiction, housing first
Addiction in the Homeless
Vulnerable populations are susceptible to adverse health outcomes. In the healthcare setting, homelessness is classified as a vulnerable population. The homeless suffer from a lack of housing, money and resources. The population naturally has a higher rate of common health conditions related to the lack of shelter and resources including balanced meals. More specifically, the homeless experience high rates of mortality, mental illness, chronic conditions, and dental problems (Notaro et al., 2013). These health disparities in the homeless can be traced back to a lack of health insurance. Many homeless individuals wrestle with drug and alcohol addiction. According to Huntley (2015) there are approximately 842,000 homeless individuals in the United States, and 66% of the population experience substance use related problems. These addictions frequently begin as a way of coping with life circumstances. Chronic addiction places a large monetary burden on families and communities (Collard, Lewinson, & Watkins, 2014). Many individuals eventually need medical interventions, but due to the health disparities, are unable to receive care. The purpose of this paper is to present the gap in healthcare experienced by homeless addicts, identify underlying social inequalities, and introduce policies, interventions, and models to alleviate the health disparities.
Documented Gaps
Due to the availability of healthcare resources, the homeless are left at a disadvantage when compared to the non-homeless. Increased rates of tuberculosis, hepatitis, anxiety, bipolar, diabetes, sinus problems, asthma, and depression are among the most common health problems experienced by the homeless (Notaro et al., 2013). As a disadvantaged population the homeless also have a higher rate of addiction (66%) over the non-homeless (7%) (Huntley, 2015). In turn, individuals with substance addiction, chronic physical disabilities and mental disabilities are at an increased risk for homelessness (Collard, Lewinson, & Watkins, 2014). A study conducted by Huntley (2015) used a series of surveys to research addiction severity among a non-random sample of 30 homeless and 30 non-homeless individuals. The severity of addiction was affected by mental status in both groups. However, among those that were homeless, mental health was a greater indicator of substance abuse over homelessness (Huntley, 2015).
Addiction is the most common psychiatric illness among the homeless and leads to further physiological health problems (Somers, Moniruzzaman & Palepu, 2015). As stated above, lack of money, insurance, food, and shelter are also among the leading factors contributing to the homeless’ increased rates of physiological health problems. With goals to address direct needs and alleviate homeless addiction, the Housing First (HF) model is the current national intervention in effect. The HF model is a non-profit program that supplies equitable housing for the homeless seeking recovery as a foundation to begin the recovery process. Without recovery, patients are more prone to develop chronic physical illness, premature death, longer time in homelessness, and poor treatment retention (Kirst, Zerger, Misir, Hwang, & Stergiopoulos, 2015). Kirst et al. (2015) conducted a 12-month randomized control trial, observing participants under HF and traditional therapy. Statistics show HF did not decrease rates of illicit drug use, but managed to decrease alcohol addiction (Kirst et al., 2015). Additionally, a 24-month randomized control trial was performed by Somers, Moniruzzaman and Palepu (2015) following HF and traditional recovering homeless individuals. Results showed that the daily substance abuse rate did not decrease among either group, concluding that the system now in place is neither effective or efficient.
Underlying Social Inequalities
Both addiction and homelessness are associated with a stigma in society. In turn, the discrimination experienced contributes to a disparity in health care. Kulesza et al. (2016) conducted a study testing society’s attitude towards addiction. The most popular belief was people with addiction should be punished rather than be helped (Kulesza et al., 2016). Contributing to the advantage gap, society believes addicts should be punished for their actions rather than given an opportunity to receive help. However, withholding the opportunity for homeless addicts to recover would in turn place a larger toll on society as a whole (Kulesza et al., 2016). The financial burden of addiction could directly prolong or increase overall homeless rates.
Homeless addicts are among those responsible for the majority of frequent Emergency Department (ED) visits (Althaus et al., 2011). Frequent ED use reflects the need for long-term treatment and places a costly burden on the population and healthcare system. Increased levels of physical resources and money are needed to compensate for such chronic diseases. Homelessness creates a discrepancy for compensation due to the lack of financial resources. Case management intervention has been used to address the needs of homeless addicts and in turn decrease the frequency of ED visits (Althaus et al., 2011). However, the main limitation to case management is availability of resources. A homeless addict may need rehab services, however, there may be no programs available in the area. Community outreach programs play a large role in providing rehab to the homeless in the community setting (Althaus et al., 2011). Some homeless addicts may receive Medicaid through the government, where others may have no insurance at all. In the hospital setting, case managers play the largest role in alleviating addiction in the homeless.
Many studies have been conducted on social inequalities experienced by homeless addicts from an external perspective. Daiski (2007) conducted a study from an internal perspective centered around the homeless’ personal concerns including physical illness, mental health, violence in shelters, addictions and stress. Participants felt emotional distress over unequitable social exclusion and depersonalization. Participants wanted to work and be housed, yet felt trapped in a dehumanizing system (Daiski, 2007). Community nurses have the opportunity to collaborate with homeless patients to advocate for changes in public policies regarding national housing, addiction treatment policies, and services to smooth the process of social reintegration.
Policies and Interventions
A continual increase in alcohol-related hospital admission rates places a significant burden on hospital resources and challenging public health and social care systems. Understanding and efficiently managing patients with complex alcohol needs requires an integrated approach. A community of practice or team-based care brings together frontline practitioners working between homeless, health and substance use (Whiteford & Byrne, 2015). Using inter-professional practice at the local level could provide holistic care and alleviate homeless addiction. In order to achieve this goal, teams should address all areas of homeless re-integration including: safe affordable housing, job counselling, treatment of addictions and employment (Daiski, 2007).
According to The National Guideline Clearinghouse (NGC) (2016b), to provide equitable care the provider should listen to patients concerns in a non-judgmental way and build mutual trust. A homeless person’s health history should additionally include “current living situation, history of homelessness, behavioral health history, nutrition, and hydration (NGC, 2016a, p. 2).” Documentation should be completed thoroughly to ensure efficiency and proper coordination of care. The plan of care should include: “an interdisciplinary team, basic needs, governmental assistance, communication, and verification of patient’s understanding of course of treatment (NGC, 2016c, p.5).” Outreach services and intensive case management can facilitate increased patient engagement in care.
The homeless population is disadvantaged in all five social determinants of health addressed in Healthy People 2020. Nuruzzaman et al., (2015) conducted a study recommending that social determinant screening should become a routine part of healthcare. The NGC (2016b) also recommends the use of standardized screening tools for addiction to determine the level of intervention needed. Screening tools for this population should include “housing, domestic violence, risky alcohol use, risky drug use and mental illness (Nuruzzaman et al., 2015, p. 322).” Utilizing standardized screening tools allows patients to receive the highest level of individualized care available. According to NGC (2016b) alcohol addiction should be treated pharmacologically by the use of acamprosate, disulfiram, altrexone, and topiramate. Recommendations are also made for the use of psychosocial interventions including: behavioral couple’s therapy, cognitive behavioral therapy, community reinforcement approach, and motivational enhancement therapy (NGC, 2016b). However, with a lack of insurance, it is difficult for homeless individuals to receive the medication and therapies they need.
For homeless individuals with access to medications they need, medication adherence is one of the many challenges of managing his or her long-term illness. Negligence or lack of access leads to additional negative health outcomes. A study conducted by Burda, Haack, Duarte, and Alemi (2012) confirms the benefits of using daily cell phone reminders to increase medication adherence in homeless individuals taking psychotropic medications for substance and psychiatric disorders. Participants from the Baltimore City Health Care for the Homeless were given a cell phone with daily medication reminders for 45 days. Patients responded positively towards the implementation of technology, as 93% of patients were reached every day and reported taking his or her medication (Burda, Haack, Duarte, and Alemi, 2012). Although patient engagement could be hindered in practice by a lack of access to cell phones, potential commitment was supported through this study. Kim et al. (2016) also conducted a randomized control trial supporting the use of technology to improve patient engagement. During the 52-week study on recovering addicts the control group received standard counseling, where 30 minutes of the experimental group’s counseling was replaced with personalized computer-based content tailored specifically to the patient (Kim et al., 2016). Upon completion of the study, computer-based treatment was more effective on patient engagement than standard treatment alone. Finally, technology-based assessments have also been able to positively impact homeless addiction treatment. Technology has the ability to enhance established evidence-based interventions and focus on standardization while remaining cost-effective (Marsch, 2012). Technology-based programs tailor to the specific needs of individuals, and engage patients by linking them to other services available in the community.
Model or Strategy to Address Health Equality
The Substance Abuse and Mental Health Services Administration (SAMHSA) is an organization that works alongside the federal government to help implement evidence behavioral interventions across the United States (Lynsen, 2018). Helplines and links to private programs are available through the SAMHSA for those in need. The majority of the program referrals require payment, creating a disadvantage for homeless individuals. However, the homeless can benefit from community coalitions that are formed through the SAMHSA to implement tailored programs and impact the long-term health of the local community. The SAMHSA follows the behavioral health continuum of care model which includes: promotion, prevention, treatment, and recovery (Lynsen, 2018). Cost-benefit ratios place a heavy focus on early intervention as one dollar invested in prevention programs is equivalent to two dollars to $10 of traditional treatment cost (Lynsen, 2018). Addiction results in hefty costs to families, employers and health systems. Providing initial equitable care has the power to alleviate additional future costs.
Additionally, it is important to engage the community in decreasing modifiable risk factors to avoid additional illnesses and diseases. Richardson (2012) examines what it takes to make people change. The Transtheoretical Model of Change includes six stages of change that are applicable to addiction recovery: precontemplation, contemplation, preparation, action, maintenance, and possibly relapse (Richardson, 2012). Many addicts see short term satisfaction as more appealing than long-term harm. Many are also afraid of the consequences of changing his or her actions. The use of evidence-based motivational interviewing, an element of the transtheoretical model of change, has been found beneficial when encouraging patients to correct harmful habits (Richardson, 2012). Motivational interviewing was created with the idea of treating addiction behaviors (Richardson, 2012). The practitioner should intently listen to the patient and his or her concerns. Change is a process and relapse is a strong possibility (Richardson, 2012). A person will only truly change when he or she make the personal decision and commitment to follow through with treatment.
Summary
The homeless are a vulnerable population with high rates of addiction and increased levels of additional physiological illnesses. A lack of resources including insurance leads to a financial burden on families and the community. The Housing First model attempts to alleviate addiction in the homeless, however is neither effective or efficient. The homeless feel trapped in a dehumanizing system, reflecting the need for additional outreach services. Implementing the behavioral health continuum of care model has the power to decrease costs of long-term care. Additionally, the use of the transtheoretical model of change and motivational interviewing is able to motivate patients to commit to long-term behavior change.