Homelessness, Housing, and Health

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. 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. 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. 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. 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. 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. 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. Who are the homeless? Panhandlers Shelters Streets, Parks, etc. Doubled Up with Friends or Family Prisons & Jails Psychiatric Hospitals Stable Housing Hospitals Adapted from S. Kertesz

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

15. Homelessness in Toronto Age distribution of shelter users

16. Homelessness in Toronto Number of individuals using shelters, 1990-2005

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. What causes homelessness?

19. What causes obesity?

20. What causes homelessness?

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

22. What causes homelessness? • 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

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

24. Is homelessness a lifestyle choice? •  "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)

25. Is homelessness a lifestyle choice? • 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

26. Is homelessness caused by a lack of affordable housing? 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

27. Mental Illness and Homelessness • 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)

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

29. Mental Illness and Homelessness • Mental health problem: 40-50% • Most common diagnosis: Depression • Schizophrenia: 6% • Bipolar Affective Disorder 5% Sources: Toronto Pathways to Homelessness Study

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;943-948.

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

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

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

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. Chronic Medical Conditions • Poorly controlled hypertension & diabetes • Chronic pain • COPD • Asthma • Seizures Lee & Hwang, Circulation 2005;111:2629-2635. Bugeja & Hwang, CMAJ 2000;163(2):161-5

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. 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. Canada Census Mortality Study Shelters 1,500 Rooming Houses 7,800 Hotels 5,800 Total 15,100 General Population 2,735,000 Hwang et al, BMJ 2009;339:b4036

40. Mortality Rate Ratios

41. Survival Curves

42. Probability of Survival to 75

43. Mortality Rate Ratios

44. Differences in Cause of Death - Men

45. Differences in Cause of Death - Men

46. Differences in Cause of Death - Men

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. 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. Emergency Department Use by Homeless People • Emergency Dept. use over 4 years: • 25-50 visits: 30 (5%) = 1,016 • 51-75 visits: 8 (1%) = 475 • 76-100 visits: 4 (0.7%) = 364 • 101-125 visits: 2 (0.3%) = 250 • 44 men (7%) = 2,105 visits

50. Hospitalization Costs of Homeless People • Admissions to Medicine at St. Michael’s Hospital, 2002-7 • 40,314 Housed vs. 1,758 Homeless patients • Crude costs: $11,741 vs. $13,611 • Homeless + $1,870