# Presentation: 045161

## The Health and Behavioral Health Needs of Homeless Families  

- Linda Weinreb, M.D.
- Vice Chair and Professor
- Department of Family Medicine and Community Health
- University of Massachusetts Medical School
- Worcester, MA
- Homeless Families Policy Academy
- Houston, TX – April 20, 2005

- UMass Medical School

## Characteristics of Homeless Families

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

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## Characteristics of Homeless Families

- Average of 4 moves in 2 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.

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## 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*.*

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## Homeless Mothers: Health Issues*

- High rates of chronic illness
- Limited physical and role functioning
- High rates of adverse lifestyle practices
- 15% pregnant
- High levels adverse birth outcomes
- High rates of hospitalization and ED usage
- *Weinreb, Goldberg, Perloff.  *Journal of General Internal Medicine*, 1998.

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

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

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## 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

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## Homeless Children: Health Issues

- Poor health status more common
- High levels of acute and chronic illnesses
- More emergency department use
- Twice as many hospitalizations
- Weinreb et al.  *Pediatrics*, 1998.

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## 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.

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## 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
- Pediatrics, 1998;102:554-562.
- Developmental Psychology, 1999;35:246-257.
- J American Academy of Child and Adolescent Psychiatry, 1997;31(7):1-11.

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## Homelessness and Parenting

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

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## Ameliorate Risk Factors

Address mother’s emotional distress
Strengthen parenting practices
Prevent negative life events and traumas
Witness to violence
Physical and sexual abuse
Homelessness
Frequent moves

- _Ameliorate Risk Factors_
- Address mother’s emotional distress
- Strengthen parenting practices
- Prevent negative life events and traumas
- Witness to violence
- Physical and sexual abuse
- Homelessness
- Frequent moves

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## Utilize Prevention Approaches

Support resilience and protective factors
Strengthen adaptive and coping skills
Support parents’ active involvement
Address parental mental health, trauma, and substance use issues

- _Utilize Prevention Approaches_
- Support resilience and protective factors
- Strengthen adaptive and coping skills
- Support parents’ active involvement
- Address parental mental health, trauma, and substance use issues

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## Identify Problems Early

Take advantage of natural environments (e.g., health care, schools, Early Intervention, etc.)
Utilize screening approaches
Support participation in treatment

- _Identify Problems Early_
- Take advantage of natural environments (e.g., health care, schools, Early Intervention, etc.)
- Utilize screening approaches
- Support participation in treatment

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

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

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

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

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## 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 and non-English speaking
- Billing rules limit flexibility of services
- Behavioral health compliance rules push people out of care
- Limitations of traditional care models in meeting families’ needs
- Stigma reduces access to care

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## 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

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## 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 nonstigmatizing settings (e.g., primary health care, schools)
- Consider innovative delivery models (e.g., drop-in)
- Strengthen referral mechanisms and communication
- Redesign links with primary health care

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## 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

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## Improving the Responsiveness of Services

Take advantage of natural environments to identify problems early and to offer prevention services
Create opportunities for success by building on strengths
Offer trauma-specific and trauma-sensitive services

- _Improving the Responsiveness of Services_
- Take advantage of natural environments to identify problems early and to offer prevention services
- Create opportunities for success by building on strengths
- Offer trauma-specific and trauma-sensitive services

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## 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 ongoing quality monitoring/improvement

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## 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 rehousing 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

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