# Presentation: 045162

## The Health and Behavioral Health Needs of Homeless Families  

- Linda Weinreb, MD
- Vice Chair and Professor
- University of Massachusetts Medical School
- Department of Family Medicine and Community Health
- Homeless Families Policy Academy
- Miami, FL – January 27, 2004

- UMass Medical School

- November, 2003

## Characteristics of Homeless Families

- Most families headed by women
- Mothers in their late 20’s
- 2-3 children; average age 5
- Racial/ethnic minorities over-represented

- UMass Medical School

- November, 2003

## Characteristics of Homeless Families

- Average of 4 moves in two years*
- 89% doubled-up prior to shelter*
- 24-50% with more than one episode of homelessness**
-  *Bassuk, Weinreb, Buckner, Browne, et. al.  *JAMA. *1996.
- **Bassuk, et.al. Housing Policy Debate, 2001; Burt et. al. Housing Policy Debate, 2001.

- UMass Medical School

- November, 2003

## Characteristics of Homeless Mothers

- High Levels of Trauma*
- Lifetime physical/sexual violence		92%
- Childhood physical violence			67%
- Childhood sexual violence			43%
- Adult partner violence				63%
- *Bassuk, Weinreb, Buckner, Browne, et. al.  *JAMA,* 1996*.*

- UMass Medical School

- November, 2003

## Homeless Mothers:  Health Issues*

- High rates of chronic illness compared to general population (44% 1 or > chronic illness)
- Asthma  4X higher
- Anemia 10X higher
- Ulcer 4X higher
- Limited physical and role functioning
- High rate of adverse lifestyle practices
- High rate of HIV risk practices
- *Weinreb, Goldberg, Perloff.  *Journal of General Internal Medicine*, 1998.

- UMass Medical School

- November, 2003

## Homeless Mothers:  Health Services*

- Subgroup with no health insurance
- Barriers to care: no transportation; competing demands; unsure where to go; depressed
- Delays in routine preventative services
- High rates of emergency department use
- 16% hospitalized in past year
- *Weinreb, Goldberg, Perloff. *Journal of General Internal Medicine, *1998; Burt, et.al. 2001.

- UMass Medical School

- November, 2003

## Homeless Mothers:  Reproductive Health Issues

- 15% pregnant; 20% parenting newborn
- Delays in prenatal care compared to poor housed (39% vs. 15%)
- High-levels adverse birth outcomes
- *Weinreb, Gelberg, et.al. Disorders and Health Issues:  An Overview.  Encyclopedia on Homelessness. Berkshire Publishing Group.  MA  In press.

- UMass Medical School

- November, 2003

## Homeless Mothers:  Mental Health and			   Substance Abuse Disorders*

- 					         Lifetime	        One Month
- 				       	      Prevalence %    Prevalence %
- Any disorder			           72%		 38%
- Depression			           45%               10%
- Post-traumatic Stress Disorder     36%               18%
- Alcohol/Drug abuse                       41%                 5%
- *Bassuk, Weinreb, et. al. *JAMA,*1996.

- UMass Medical School

- November, 2003

## Characteristics of Homeless Children

- _Many Stressors_
- 25% have witnessed family violence
- 22% separated from family in past year
- Frequent moves in past year (mean = 3)
- More likely to be hungry or food insecure

- UMass Medical School

- November, 2003

## Homeless Children:   Health Issues

- Poor health status more common
- High levels of acute and chronic illnesses
- Asthma 3-4X higher
- More emergency department use
- 40% with 2+ visits/year
- Twice as many hospitalizations
- Weinreb, et. al.  *Pediatrics*, 1998.

- UMass Medical School

- November, 2003

## Homeless Children: Emotional and				   Behavioral Health

- 12% of preschoolers have emotional problems that require professional help
- 47% of school age children have anxiety, depression or withdrawal
- Mental health service use low among children in need
- Mother’s emotional status associated with behavioral outcomes
- Pediatrics, 1998;102:554-562; Devel Psychology, 1999;35:246-257; Jl Am Acad Child Adol Psychiatry, 1997;31(7):1-11.

- UMass Medical School

- November, 2003

## Homeless Children:  Learning Needs

- 45% do not attend school regularly
- 12% not enrolled in school
- More learning problems
- 4x more developmental delays
- 2x more learning disabilities
- 2x more likely to repeat a grade
- U.S. Dept Education, Education for Homeless Children and Youth.  Progress Report to Congress, 1999.

- UMass Medical School

- November, 2003

## Homelessness and Parenting

- Parenting in public
- Competing demands of parents
- Relationship of mental health, substance abuse, and trauma to parenting
- Opportunity for engagement

- UMass Medical School

- November, 2003

## Meeting the Health and Behavioral Health Needs of Homeless Families

- _Issues and Challenges_
- Complex needs met in multiple systems and service settings
- Competing mandates, policies, practices, and outcomes across systems create barriers
- Lack of coordination and collaboration across and within systems
- Limited cross-agency information management systems

- UMass Medical School

- November, 2003

## Meeting the Health and Behavioral Health Needs of Homeless Families

- _Issues and Challenges_ (cont.)
- Financing and reimbursement mechanisms
- Significant subgroup uninsured
- Funds not flexible; may not support service goals
- Few, if any, resources for collaboration and collateral communication
- Case management not reimbursable in some states
- Limited funds for prevention and early intervention
- Services often focus on adult or child, not families
- Limited evidence-based approaches

- UMass Medical School

- November, 2003

## Meeting the Health and Behavioral Health Needs of Homeless Families

- _Issues and Challenges_ (cont.)
- Access to mental health services limited
- Inadequate capacity (i.e., psychiatry and counseling)
- Children
- Non-English speaking
- Cannot fund mental health services through third-party payment
- No show rate high
- Billing rules limit flexibility of services
- Variations in referral and pharmacy guidelines
- Behavioral health compliance rules push people out of care
- Limitations of traditional care models in meeting families’ needs
- Stigma reduces access to care

- UMass Medical School

- November, 2003

## Meeting the Health and Behavioral Health Needs of Homeless Families

- _Improving Access to Services_
- Review and modify policies and practices at all levels that create barriers for families
- Develop funding mechanisms to respond to families’ needs
- Review current barriers in funding structures
- Blended or coordinated financing
- Flexible funding to support service goals
- Review funding options for case management
- Funding collaboration/collateral contact
- Incentives for good care

- UMass Medical School

- November, 2003

## Meeting the Health and Behavioral Health Needs of Homeless Families

- _Improving Access to Services_ (cont.)
- Activate mental health services to be more available and responsive
- Increase services for children; non-English speakers
- Provide mental health/behavioral health services in non-stigmatizing settings (e.g., primary health care, schools)
- Consider innovative delivery models (e.g., drop-in)
- Strengthen referral mechanisms and communication
- Re-design links with primary health care
- Simplify pharmacy guidelines

- UMass Medical School

- November, 2003

## Meeting the Health and Behavioral Health Needs of Homeless Families

- _Improving Access to Services_ (cont.)
*Engaging Families in the Health Care Setting*
- Ideal gateway from which to organize provision of comprehensive services
- Facilitates earlier identification of mental health/substance abuse/trauma issues within context of health care delivery
- Facilitates engagement due to reduced stigma
- Proven success of collaborative models addressing mental health needs in primary care

- UMass Medical School

- November, 2003

## Meeting the Health and Behavioral Health Needs of Homeless Families

- _Improving the Responsiveness of Systems _
- Collaboration across and within systems and agencies at policy, management, and service levels
- Family-centered services
- Interagency service planning and monitoring
- Integrated adult and child services
- Develop and integrate evidence-based practices
- Conduct on-going quality monitoring/improvement

- UMass Medical School

- November, 2003

## Meeting the Health and Behavioral Health Needs of Homeless Families

_*Trauma Specific and Trauma Sensitive Services*_
- Most homeless mothers are survivors
- Service and shelter settings can re-traumatize survivors
- Requires deliberate strategies to address
- Review and modify procedures and forms
- Time for team and collateral contacts
- Commitment to staff training and support
- Impact on parenting and child outcomes

- UMass Medical School

- November, 2003

## Meeting the Health and Behavioral Health Needs of Homeless Families

- _Emerging Evidence-Based and Promising Practices_
- Good evidence that housing subsidies and access to housing predict residential stability
- Promising practices
- Rapid re-housing with case management support
- Intensive case management/Family critical time intervention
- Collaborative model in primary care with mental health, substance abuse and trauma services
- Prevention strategies

- UMass Medical School

- November, 2003