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OBJECTIVE

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  • Define homelessness and identify risks for homelessness.

  • Describe the epidemiology of homelessness, including morbidity and mortality.

  • Review medical conditions common among the homeless.

  • Identify challenges to providing care to homeless patients.

  • Identify interventions to improve care, both at the provider and system levels.

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Mr. Jones rarely comes to clinic appointments and often leaves before being seen, as he is afraid of not getting a shelter bed in time. He has been homeless for years. He has schizophrenia, hypertension, and has difficulty controlling his diabetes.

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INTRODUCTION

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Being homeless has a profound effect on health. Homeless patients have higher rates of chronic illness, morbidity, and mortality than patients who have stable housing.1,2,3,4,5,6,7 Lacking insurance and transportation, their access to care is limited. Obtaining food and shelter are higher priorities for the homeless person than seeking health care.8,9 Homeless patients present for medical attention later in the course of their illness.10,11 Comorbid conditions such as mental illness and substance use can complicate adherence to treatment plans. Furthermore, providers often do not incorporate the challenges faced by homeless patients into management plans. This chapter explores the relevance of homelessness to health and health care and presents strategies to improve the care that homeless patients receive.

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EPIDEMIOLOGY

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In the United States in 2013, a total of 610,042 individuals were homeless on a single night and an estimated 2.5–3 million people experienced homelessness over the course of the year.12 Over one-third of individuals experiencing homelessness are persons in families and one-fourth of all Americans who are homeless are children.13 The median age of the homeless population is rising at a rate faster than that of the general population; the median age of homeless adults is now approximately 50 years.14 This rise in the age of this population is thought to be attributable to a cohort effect: individuals born in the second half of the baby boom (1954–1965) have had an elevated risk of homelessness throughout their lives.15 There is concern for another cohort effect, among those born in the 1990s.16

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DEFINITION AND PATTERN OF HOMELESSNESS

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The most commonly accepted definition of homelessness in the United States is from the Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act of 2009.17 The HEARTH Act updates the original Federal definition, the McKinney Act of 1987.18 The HEARTH Act defines a homeless individual as:

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An individual or family with a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation … living in a supervised publicly or privately operated shelter designated to provide temporary living arrangements; … individual who is exiting an institution where he or she ...

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