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Homelessness, Housing, and Health

Stephen Hwang, MD, MPHDivision 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

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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

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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%

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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 immediatelyB) 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.

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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

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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

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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

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Who are the homeless?

Streets, Parks, etc.

Shelters

Doubled Up with Friends or Family

Hospitals

Prisons & JailsPsychiatric

HospitalsStable

Housing

Adapted from S. Kertesz

Panhandlers

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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

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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

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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

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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

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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)

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Housing Transitions

Streets, Parks, etc.

Shelters

Doubled Up with Friends or Family

Hospitals

Prisons & JailsPsychiatric

HospitalsStable

Housing

Adapted from S. Kertesz

Panhandlers

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Homelessness in Toronto Age distribution of shelter users

0

5

10

15

20

%

<= 14

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

6

Age (years)

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

0

5000

10000

15000

20000

25000

30000

35000

19901991

19921993

19941995

19961997

19981999

20002001

20022003

20042005

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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

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What causes homelessness?

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What causes obesity?

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What causes homelessness?

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• Individuals Failings

– ?Lifestyle choice

• Individual Vulnerabilities

– Mental illness

– Addictions

– Cognitive impairment

– Childhood environment

What causes homelessness?

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• 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

What causes homelessness?

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What causes homelessness?

The Social Determinants of Health

The Clinical Perspective

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•  "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)

Is homelessness a lifestyle choice?

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• 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 Assessment2008 Metro Vancouver Homeless Count

Is homelessness a lifestyle choice?

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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

Is homelessness caused by a lack of affordable housing?

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• 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)

Mental Illness and Homelessness

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“Trans-institutionalization”

Streets, Parks, etc.

Shelters

Doubled Up with Friends or Family

Hospitals

Prisons & JailsPsychiatric

HospitalsStable

Housing

Adapted from S. Kertesz

Panhandlers

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• Mental health problem: 40-50%• Most common diagnosis: Depression• Schizophrenia: 6%• Bipolar Affective Disorder 5%

Sources: Toronto Pathways to Homelessness Study

Mental Illness and Homelessness

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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.

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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)

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Traumatic Brain Injury (TBI)

58

42

53

0102030405060708090

100

Per

cen

tag

e

Men Women Overall

Hwang, CMAJ 2008;179(8):779-84

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Severity of Traumatic Brain Injury

66

23

11Mild

Moderate orSevere

Unknown

Hwang, CMAJ 2008;179(8):779-84

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0

5

10

15

20

25

30

35

40+ 30 20 10 0 10 20 30+

Nu

mb

er

of

ind

ivid

ua

ls.

Years before first episode of homelessness Years after first episode of homelessness

Timing of first TBI relative tofirst episode of homelessness

Hwang, CMAJ 2008;179(8):779-84

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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

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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

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Infectious Diseases

• Community-acquired Pneumonia• Cellulitis & other soft tissue infections• Infestations (bed bugs, lice, scabies)• Tuberculosis• Hepatitis C• HIV / AIDS• Sexually Transmitted Infections

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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

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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

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Mortality Rate RatiosFigure 1. Mortality rate ratios for men and women who are homeless or living in marginal housing,

compared the total cohort and the poorest and richest income quintiles

0

1

2

3

4

5

6

25-34 35-44 45-54 55-64 65-74 75+ 25-34 35-44 45-54 55-64 65-74 75+

Age (years)

Rat

e ra

tio

vs. Richest quintile

vs. Total cohort

vs. Poorest quintile

Men Women

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Survival CurvesFigure 2. Probability of survival for men and women, conditional on survival to age 25

0

10

20

30

40

50

60

70

80

90

100

25 30 35 40 45 50 55 60 65 70 75 80 85 90 25 30 35 40 45 50 55 60 65 70 75 80 85 90

Age (years)

Pro

bab

ilit

y o

f su

rviv

al (

%)

Richest income quintile

Total cohort

Poorest income quintile

Shelters, rooming houses, hotels

Men Women

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Probability of Survival to 75

Figure 3. Probability of survival to age 75, conditional on survival to age 25

0

10

20

30

40

50

60

70

80

90

100

Men Women

Pro

bab

ilit

y o

f su

rviv

al

(%) Shelters, rooming houses, hotels

Poorest income quintile

Total cohort

Richest income quintile

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Mortality Rate RatiosFigure 4. Mortality rate ratios for men and women living in shelters, rooming houses, and hotels,

compared to the entire cohort

0

1

2

3

4

5

6

7

25-34 35-44 45-54 55-64 65-74 75+ 25-34 35-44 45-54 55-64 65-74 75+

Age (years)

Rat

e ra

tio

Shelters

Rooming houses

Hotels

Note: Shelters include hostels, missions, and YMCA/YWCA facilities. Rooming houses include lodging houses. Hotels include motels and tourist homes.

Men Women

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Differences in Cause of Death - Men

Cause Ratio Difference

Total (all causes) 2.0 1,238

Cancer 1.6 219

Lung cancer 1.9 107

Heart attack 1.6 182

Stroke 1.9 65

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Differences in Cause of Death - Men

Cause Ratio Difference

Pneumonia 2.3 45

Bronchitis, emphysema 2.9 119

Digestive system disease 2.8 51

Cirrhosis of liver 3.7 37

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Differences in Cause of Death - Men

Cause Ratio Difference

External causes 3.3 158

Motor vehicle 1.7 9

Suicide 2.3 30

Falls 3.1 27

Homicide 11.3 18

Overdose 10.3 30

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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

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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%)

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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

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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

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Hospitalization Costs of Homeless People

• Adjust for age, sex, complexity: +$2,188

• Adjust for acute days: +$1,458

• Adjust for alternate level of care days: +$529 (not significant)

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Interventions to Improve the Health of Homeless People

• Many interventions are effective!• Respite Care• Housing First & Mental Health

Services• Improving Health Care Experiences

Hwang, Am J Preventive Med 2005;29(4):311–319

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Respite Care

• 225 homeless patients discharged from hospitals in Chicago

• 161 respite vs. 64 wait-list controls

• Hospital days over next 12 months: 3.7 vs. 8.3 days (p=0.002)

Buchanan, Am J Pub Health 2006;96:1278-81.

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Housing First

Streets, Parks, etc.

Shelters

Doubled Up with Friends or Family

Hospitals

Prisons & JailsPsychiatric

HospitalsStable

Housing

Adapted from S. Kertesz

Panhandlers

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Housing First

Tsemberis. AJPH 2004

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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 immediatelyB) 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.

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At Home/Chez Soi Project

• Randomized controlled trial of Housing First and mental health services

• Homeless & serious mental illness• Mental Health Commission of Canada• Montreal PI: Dr. Eric Latimer (Douglas

Institute)• www.mentalhealthcommission.ca

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Improving Homeless People’s Health Care Experiences

• Qualitative study

• Experiences of unwelcomeness perceived as acts of discrimination

• Feeling objectified/dehumanized vs. valued as a person/listened to

Wen & Hwang, J General Int Med 2007;22:1011-7.

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Approach B: Shift population norm slightly upwards

Approach A: Focus on improving conditions for extreme groups

Homeless Poor Fair Moderate Good Excellent

Housing Quality

Fre

qu

en

cy in

Pop

ula

tion

Intervention at two possible levels

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61

Thank you!

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Differences in Cause of Death - Men

Cause Ratio Difference

Smoking-related 2.4 281

Alcohol-related 6.4 81

Drug-related 11.5 48

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Economic Booms & Busts

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Source: Calgary Homeless Foundation

Economic Booms & Busts

0

2

4

6

8

10

12

2008 2009

Unemployment(%)Vacancy (%)

Rent x $100

Calgary