**[Slide 1]{.underline}**

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

**[Slide 2]{.underline}**

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

**[Slide 3]{.underline}**

Characteristics of Homeless Families (continued)

-   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.

**[Slide 4]{.underline}**

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*.*

**[Slide 5]{.underline}**

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

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-   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.

**[Slide 6]{.underline}**

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.

**[Slide 7]{.underline}**

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.

**[Slide 8]{.underline}**

Homeless Mothers: Mental Health and Substance Abuse Disorders\*

Lifetime Prevalence %

Any disorder 72%

Depression 45%

Post-traumatic Stress Disorder 36%

Alcohol/Drug abuse 41%

One Month Prevalence %

Any disorder 38%

Depression 10%

Post-traumatic Stress Disorder 18%

Alcohol/Drug abuse 5%

\*Bassuk, Weinreb, et. al. *JAMA,*1996.

**[Slide 9]{.underline}**

Characteristics of Homeless Children

[Many Stressors]{.underline}

-   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

**[Slide 10]{.underline}**

Homeless Children: Health Issues

-   Poor health status more common

    -   High levels of acute and chronic illnesses

    -   Asthma 3-4X higher

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-   More emergency department use

    -   40% with 2+ visits/year

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-   Twice as many hospitalizations

**[Slide 11]{.underline}**

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.

**[Slide 12]{.underline}**

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.

**[Slide 13]{.underline}**

Homelessness and Parenting

-   Parenting in public

-   Competing demands of parents

-   Relationship of mental health, substance abuse, and trauma to
    parenting

-   Opportunity for engagement

**[Slide 14]{.underline}**

Meeting the Health and Behavioral Health Needs of Homeless Families

[Issues and Challenges]{.underline}

1.  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

**[Slide 15]{.underline}**

Meeting the Health and Behavioral Health Needs of Homeless Families
(continued)

[Issues and Challenges]{.underline} (cont.)

2.  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

2.  Services often focus on adult or child, not families

3.  Limited evidence-based approaches

**[Slide 16]{.underline}**

Meeting the Health and Behavioral Health Needs of Homeless Families
(continued)

[Issues and Challenges]{.underline} (cont.)

5.  Access to mental health services limited

-   Inadequate capacity (i.e., psychiatry and counseling)

    -   Children

    -   Non-English speaking

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-   Cannot fund mental health services through third-party payment

    -   No show rate high

    -   Billing rules limit flexibility of services

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-   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

**[Slide 17]{.underline}**

Meeting the Health and Behavioral Health Needs of Homeless Families
(continued)

[Improving Access to Services]{.underline}

1.  Review and modify policies and practices at all levels that create
    barriers for families

2.  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

**[Slide 18]{.underline}**

Meeting the Health and Behavioral Health Needs of Homeless Families
(continued)

[Improving Access to Services]{.underline} (cont.)

3.  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

**[Slide 19]{.underline}**

Meeting the Health and Behavioral Health Needs of Homeless Families
(continued)

[Improving Access to Services]{.underline} (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

**[Slide 20]{.underline}**

Meeting the Health and Behavioral Health Needs of Homeless Families
(continued)

[Improving the Responsiveness of Systems ]{.underline}

-   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

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-   Develop and integrate evidence-based practices

-   Conduct on-going quality monitoring/improvement

**[Slide 21]{.underline}**

Meeting the Health and Behavioral Health Needs of Homeless Families
(continued)

[Trauma Specific and Trauma Sensitive Services]{.underline}

-   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

**[Slide 22]{.underline}**

Meeting the Health and Behavioral Health Needs of Homeless Families
(continued)

[Emerging Evidence-Based and Promising Practices]{.underline}

1.  Good evidence that housing subsidies and access to housing predict
    residential stability

2.  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

1.  Prevention strategies