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The Aging of the Homeless Population:  Fourteen-year Trends in San Francisco

Explore the changing demographics and health needs of San Francisco's homeless population over 14 years, highlighting the challenges of aging without stable housing.

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The Aging of the Homeless Population:  Fourteen-year Trends in San Francisco

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  1. The Aging of the Homeless Population:  Fourteen-year Trends in San Francisco Judy Hahn, Margot Kushel, David Bangsberg, Elise Riley, Andrew Moss

  2. Background Changes in homelessness in the US • 1930’s • Young transient men in search of work • 1950’s to 1970’s: • “Skid row”, single older low income white men, unstable housing (flophouses, SROs, missions) • 1980’s onward: • Loss of SRO hotels and affordable housing in urban centers • Shelter capacities nationwide increased • More families and minorities, younger • Poorer living conditions compared to Skid row Rossi, American Psychologist 1990

  3. Background In San Francisco, • Continued decline in the number of low cost housing and SRO units in the 1990s • Units lost due to earthquakes, fires and gentrification • The response to homelessness • Establishment of emergency shelters and soup kitchens and large shelters with services (1980s) • Policing programs (mid 1990s) • Supportive housing (some late 1990s, most starting 2004), leveraging Federal $ Ilene Lelchuk, San Francisco Chronicle September 7, 2003.

  4. Objectives • We have studied HIV and TB in the homeless and marginally housed in San Francisco from 1990 to 2003. • In this analysis, we sought to examine changes in the homeless population over time in: • Demographics – age, race, sex • Housing • Health status • Health service utilization • Drug use

  5. Methods • Four cross sectional studies (“waves”) conducted at shelters and free meal programs Wave 1: 1990-1994 Wave 2: 1996-1997 Wave 3: 1998-2000 Wave 4: 2003 • Over the entire study period we conducted sampling at a total of 13 shelters and 8 free meal programs

  6. Methods • Inclusion criterion: Age 18 and older • 45 minute interviewer-administered survey • HIV antibody testing and counseling, TB testing (waves 1 and 2) • $10-$20 remuneration for participating • Anonymous

  7. Analysis We included in this analysis: • Shelters and meal programs that were sampled in at least ¾ of the “waves” • 4 shelters and 2 free meal programs (78% of those sampled) • Study participants who were “literally homeless” in the prior year • 87% of those sampled

  8. RESULTS Demographics (n=3534) Male 77% Race African American 52% Caucasian 33% Other, or mixed race 15% Veterans (of the men) 33%

  9. Substance use and mental illness Psychiatric hospitalization, ever 23% Crack use, ever 63% Injection drug use, ever 38% Heavy alcohol use, prior 30 days 35% At least one of the above 80% Two or more of the above 49%

  10. Age trends

  11. Age trends by group 1% overall >= age 65

  12. Demographics

  13. Housing

  14. Self-reported health

  15. Hospital utilization

  16. Drug/alcohol use

  17. Aging in 6 cities

  18. Conclusions and Implications • The homeless population is getting older. • This aging indicates that the homeless population is static and not regenerating itself in time. • A dynamic population would have as many new young people joining the population as old people leaving the population and would have a constant age over time. • Good news: resources spent on housing the homeless now may be finite.

  19. Conclusions and Implications • Of concern: the homeless will increasingly need health care services -- either to control their chronic disease or to treat the more serious outcomes of unmanaged chronic disease. • Control of chronic disease will be very difficult to deliver to persons not in housing.

  20. Recommendations • Provide supportive housing with onsite medical services for those age 50 and older in order to intervene in the course of chronic disease early • Base on the model of San Francisco Department of Public Health’s Direct Access to Housing • Houses 1000 people in 12 buildings • 3 buildings dedicated to seniors • Psychiatrists, nurses, physicians assistants • Case worker : resident ratio: 1:20 • 80% stay at least 1 year

  21. Acknowledgments REACH field staff and study participants Grants: NIH 5R01DA004363, 1R01MH054907, R01DA010164, and K08HS11415. Contact info: Judy Hahn, Ph.D. Assistant Professor EPI-Center, Department of Medicine University of California, San Francisco San Francisco, CA 94143-1372 jhahn@epi-center.ucsf.edu

  22. Bonus data!Younger vs. older homeless 2003 data wave *p<0.05

  23. Younger vs. older homeless Housing *p<0.05

  24. Younger vs. older homeless Health *p<0.05

  25. Younger vs. older homeless Substance use *p<0.05

  26. Summary of bonus data • Many older homeless persons are using drugs or drinking heavy amounts of alcohol, though somewhat fewer than younger homeless persons • Older homeless persons have the same rate of ED visits and inpatient hospitalizations though higher rates of chronic disease

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