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we're the best group

Katie Braschler

on 27 May 2014

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Transcript of Homelessness

Katie Braschler
Renath Hatungimana
Victor Lelm
Natasha Parsons
Molly Schieffelin
John Vienhage
Provide Education
Ann Marie
Justin & Anna
Ackley, B.J., and Ladwig, G.B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (10th ed.). Maryland Heights, Missouri: Mosby Elsevier.

Guadalupe Community Center and Shelter. (n/d). Introduction.
Catholic Charities: Archdiocese of Denver
. Retrieved April 19, 2014, from http://www.ccdenver.org/guadalupe-community-house-shelter

Hill, M., Granado, M., Opusunju, J., Peters, R., Ross, M. (2011). The impact of income, public assistance, and homelessness on seeking medical care.
American Journal of Health Studies, 26
(3), 174-181. 

Homeless Resource Network. (2012). Homelessness 101.
Homeless Resource Network
. Retrieved April 8, 2014, from http://homelessresourcenetwork.org/index.php/homelessness101/

National Alliance to End Homelessness. (2014). Cost of Homelessness.
National Alliance to End Homelessness
. Retrieved April 8th, 2014, from http://www.endhomelessness.org/pages/cost_of_homelessness

National Health Care for the Homeless Council. (2014, March). NHCHC Infographic.
National Health Care for the Homeless Council
. Retrieved April 8th, 2014, from http://www.nhchc.org/wp-content/uploads/2011/09/nhchc-infographic.pdf

"I'm not a bum, I'm a human being."
- If we can stand in their shoes, hear what they hear, see what they see, feel what they feel, then we will treat them differently
Photos Sources
Facebook. (2013).
. Retrieved from https://www.facebook.com/photo.php?fbid=433431990125976&set=pb.252006304935213.-2207520000.1398310409.&type=3&theater

Horvath, M. (2009). Ann Marie [Web log]. Retrieved from http://invisiblepeople.tv/blog/category/face-and-voice-of-homelessness/
Huff, S. (2008). My homeless project. Retrieved from http://www.stevehuffphoto.com/who-am-i/my-homeless-project/
Hwang, J. (2013). Beautiful photos of homeless people. Retrieved from http://www.ryot.org/beautiful-photos-homeless-people/451489

Jackson Nurse Professionals. (n.d.).
Why nurses choose JNP
[Photograph]. Retrieved from http://www.jacksonnursing.com/Who_We_Are/why_choose_jnp.php

Oprah. (2010).
Treat the homeless with dignity
[Photograph]. Retrieved from http://www.oprah.com/spirit/Treat-the-Homeless-with-Dignity-Every-Monday-Matters
Need a summary?
Take a look at your handout!
All our points and available resources for you can be found there.
As we know, education is a vital part of our jobs as nurses.

However, in this instance, it's not just our homeless patients who need education; it's also us - the nurses.
Nurse Education
Nurses need to be educated on how to treat the homeless population when they're directly under our care.
Tips for Good Care
Treat them with dignity and respect, just as you would any other patient. They are humans too and their life means just as much to them as your life means to you.
Put yourself in their shoes. Picture yourself going through their experiences, facing what they're facing, and see how your life would turn out. Would you make the same decisions? Would you be fighting the same battles?
Treat these patients with compassion. As you saw in the video earlier, homeless are often treated with disrespect.
The very word
stems from the word
, which means "to feed".
Take very good care of their "things". They don't have a lot of "things". So even if they have strange "things" that may not mean anything to us, they may be treasured possessions to our patients.
Be aware of their personal space. Homeless people may not be comfortable with people touching them/being so close to them.
Remember these people may have a lot on their plate. They may be dealing with addiction, loss of friends/family/job, mental illness, less education, etc. So don't assume they can handle as much as other patients. And don't assume they can't handle it either. It's a fine line between treating them like children and treating them like adults who have lost everything.
Finally, listen to them. Our homeless patients may have a lot to say, or they may have nothing to say at all. Listen in the silence and tend to their needs. Maybe all they need is another human to pay attention to them.

Patient Education
As we said before, health problems cause 60% of all bankruptcies. This puts a person at a higher risk for homelessness.

Shelters/lack of housing leads to poor hygiene, resulting in several health problems (i.e. cavities, gingivitis, halitosis, skin infections/conditions, viruses transmitted via fecal/oral route, parasitic infections, and STIs)

If we can disrupt this process at least a little bit, our patients may be able to keep their heads above water.
Educate our patients THOROUGHLY on their chronic disease. Teach them how to manage it, how to fit it into their lifestyle, how to continue working in the midst of it, how to be cost effective, and where they can find resources/support.
Refer "at risk" patients to financial services. We can't be the experts at everything all the time.
Thoroughly educate our patients in preventative care. Simply being homeless opens SO many doors to poor health. Tell them what they're at risk for!
Make them care about their health!
Don't forget to tend to every aspect of their health- not just the physical needs. There's also environmental, spiritual, emotional, and mental. For the homeless population, all five of these aspects may be lacking in sufficiency.
How do we do this?
Possible Nursing Diagnoses
Impaired home maintenance r/t cognitive or emotional functioning, inadequate support system, insufficient finances
Self-neglect r/t mental illness, substance abuse, cognitive impairment
Powerlessness r/t interpersonal interactions
Risk for trauma r/t being in a high-crime neighborhood, etc.
Deficient community health r/t lack of access to public health care providers, inadequate community support (pg. 406)
Risk-prone health behavior r/t excessive alcohol, inadequate comprehension, inadequate social support, low self-efficacy, low socioeconomic status, multiple stressors, smoking, negative attitude toward health care

Ineffective health maintenance r/t cognitive impairment, ineffective coping, insufficient resources
Risk for compromised human dignity r/t cultural incongruity, perceived dehumanizing treatment, perceived humiliation, perceived intrusion by clinicians, perceived invasion of privacy, stigmatizing label
Risk for loneliness/Social isolation r/t affectional deprivation, cathectic deprivation, physical isolation, social isolation
Risk for relocation stress syndrome r/t transfer from one environment to another, unpredictability of experiences, lack of adequate support system
Noncompliance r/t access to care, individual health coverage, provider regular follow-up, provider reimbursement, teaching skills of provider, complexity, cost, duration, intensity of care, deficient knowledge relevant to regimen, motivational forces (this nursing diagnosis is judgmental and places blame on the client. another option is Ineffective self-health management)
Imbalanced nutrition: less than body requirements r/t biological factors, economic factors, psychological factors
Post-trauma syndrome r/t any number of things

Risk for situational low self-esteem r/t decreased control over environment, failures, history of abandonment abuse or neglect, loss, physical illness, social role changes, lack of recognition
Risk for self-mutilation r/t any number of things
Impaired social interaction r/t communication barriers, environmental barriers, self-concept disturbance, sociocultural dissonance
Chronic sorrow r/t various crises
Spiritual distress r/t anxiety, chronic illness, death, life change, loneliness, self-alienation, social alienation, sociocultural deprivation

Stress overload r/t inadequate resources, intense/coexisting/repeated stressors
Risk for suicide r/t any number of things
Risk for thermal injury r/t exposure to extreme temperatures, lack of protective clothing, intoxication, unsafe environment
Powerlessness r/t illness-related regimen, unsatisfying interpersonal interactions, anxiety, deficient knowledge, economically disadvantaged, lack of social support, progressive debilitating disease, unpredictable course of illness

Sunrise Family Clinic
44% uninsured
39% medicaid
7% private
6% child health plan
4 % medicare
primary medical and dental care
behavioral health sciences
WIC, nutrition, and health education
specialty services
outreach services
Sunrise Offers:
97% live at or below 200% of poverty level (family of 4 earning <$46,000/yr)
71% live at or below 100% of poverty level
(family of 4 earning <$22,050/yr)
overnight emergency shelter
transitional housing shelter
daily meals
clean linens/basic toiletries
case management and referrals
computer resource room
medical screenings/referrals to Sunrise
Guadalupe Center
served 555 individuals
14,927 nights of shelter
65% of clients were able to secure sustainable housing after leaving the shelter
Guadalupe Statistics
Emergency Food Box Program
any resident is eligible (ID, SS)
don't need proof of income
non perishable & available perishable from food room
Weld County Food Bank
Weld County Food Bank
Mobile Food Pantry
Taking food directly to the people in need
Delivers: fresh produce, dairy products, meat, bakery, and dry goods
Pinpoint areas with the highest need
Other programs:
Commodity supplemental food program
Kid's programs
*Physiological & Safety needs*
What can we do?
Q & A with Karen Hessler
Q: Does your care change when you have a homeless or transitional homeless patient?
NP volunteers for Sunrise
A: "It changes everything"
many are transitional, living in a friend's, parent's, or acquaintance's house
must prescribe and treat in cheapest and most cost-effective manner
socially - can they pay $4 for medication, can they get to appointments
Q: Is there any advice you would give student nurses in preparation of caring for these patients
A: Meet them on their level
they are intelligent - usually they are this way due to abnormal circumstances and have just fallen down on their luck
"they aren't losers," break the stereotype
reach each person with a caring attitude
do not be judgemental - these patients see a lot before they get to you
Q: How does Sunrise work with the people that cannot afford care?
A: Many of the providers are volunteer, there is a sliding scale payment system, they accept Medicaid and Medicare
working here has really changed her attitude toward the word "poor."
psych disorders
mental health: self esteem, embarrassment, shame, self worth

Causes of Homelessness

Nowhere in the 50 states can a person work a full-time, minimum wage job and afford fair market rent, even for a one-bedroom apartment
Health problems cause 60% of all personal bankruptcies, which frequently leads to homelessness

Compared to non-homeless, psych disorders occur 3-4x as frequently, and co-occurring substance abuse occurs 5x as often
Whether occurring before or after, mental illness significantly handicaps a person’s ability to reintegrate into society and find work
Many homeless individuals would be able to hold down a job if they had access to healthcare and medications
A Sample from the Street
On any given night, more than 636,000 individuals in the U.S. have no place to sleep
On the streets, there are 2 males for every 1 female
40% are Caucasian, 40% are African American
20% are <18, 20% are in their 20’s, and 40% are between 30 &50

At-Risk Populations
In a year, 1,500,000 children experience homelessness...alone
50% of youth experienced physical abuse, and 30% sexual abuse, that resulted in homelessness
These youth often remain homeless chronically because they lack the education necessary to market themselves for a job; this in turn puts their health in dire straits
Women & Children
40% of the homeless population is made of families with children - 80% are single mothers
90% of homeless mothers have been physically and/or sexually abused
50% of mothers developed major clinical depression AFTER becoming homeless

Unaccompanied Youth
African-American Men
Culturally, the man bears the responsibility of financial provision for the family, no matter the cost
Delaying personal medical needs in order to provide for the family is expected in this culture
A significant proportion of men in low-income African-American families leave in order to allow their families to qualify for public assistance and have a chance at survival
as studied by Hill, et al. 2011
Financial Situation
Mental Illness & Substance Abuse
The Health of the Homeless
Exposure to infections and
communicable diseases
Shelters or lack of housing result in poor hygiene and frequent human contact, leading to easy pathogen transmission
Homeless are more likely to suffer from:
Parasitic skin infections and conditions
GI illnesses
Respiratory infections, esp TB
Increased incidence of chronic disease

Nearly 50% of homeless suffer from a chronic health condition
Stress, diet, drug use, disability, and mental illness all increase their risk of developing chronic illness
As expected, high rates of diabetes, obesity, anemia, asthma, HTN, COPD, PVD, and chronic liver and renal disease is reported among homeless
It is difficult to determine whether the illness caused or followed homelessness
Increased incidence of
psychosocial problems
Within the chronically homeless population, 60% suffer from a severe psych condition and 80% are consumed by drug/alcohol issues
Mental illness exacerbates the physical effects of communicable and chronic disease
Limited access to health services
Preventative services – immunizations, cancer screening, prenatal care
Medical & surgical care
Prescription medications
Chronic disease management & follow-up care
Mental health care & follow-up
Eye & dental care
Emergency Department
20-30% of all ED visits are made by homeless individuals
ED is overused by this population because all healthcare is either treated as emergent or is nonexistent
80% of ED visits by homeless people could have been prevented with primary care provided free of charge or at reduced rates
Homeless individuals are admitted from the ED to inpatient units 5x as frequently as non-homeless
Homeless individuals spend, on average, 4 days longer per hospital visit than non-homeless
The rate of psychiatric hospitalization for homeless is 100x that of non-homeless
Seeking Healthcare
Chronic homelessness – On the streets for a year or longer without reprieve

Transitional homelessness – Temporary, one-time stay, usually in a shelter, before returning to society

Episodic homelessness – Teetering between life on the streets and life within society, often due to poverty
Types of Homelessness
Overview of the Homeless
Why THIS group?
- Our goal is to understand who they are and the reality of their lives, as none of us have experienced this culture
- The homeless compose a diverse group regarding gender, race, and age - it is hard to provide care for a group we have little in common with
- We want to be prepared in case we encounter the culture of homelessness in the future
- This group has significant risks in terms of health issues, making them an important focus for nurses
Adapting to Homelessness
Nursing Focus
- For this group, attention should be paid not only to the illness, but also to the person's situation in life
-Our goal should be to increase the well-being of our patients in terms of helping them to recover from their illnesses
- Homeless individuals tend to be misjudged and misunderstood, and this impacts their access to healthcare
- The culture of the homeless is one of adaptation - while people enter homelessness with their own norms and customs, these must change in order to meet their needs
- The move into homelessness can be gradual or sudden, affecting how they adapt to their new environment
- Gradual transitions appear to be somewhat less jarring by allowing the opportunity to mentally prepare for the change
- Individuals can form close-knit groups in order to meet the needs of the population as whole, uniting people with nothing more in common than their homelessness
Rank & Hierarchy
- Just as with other cultures, a rank system emerges among homeless individuals as well
- The values that create the leader in the homeless population are the opposite of what establishes power in mainstream culture
- Respect is awarded to those who have experienced the most trauma and survived the longest on the streets
- Pain and trauma become badges of honor, with women touting the number of times they have been raped, or criminal records advertised to demonstrate strength
- With homelessness comes isolation from mainstream society, and strong bonds are created amongst members of the homeless culture to compensate
- Due to the circumstances of homelessness, having few ways to spend their time, and constant contact with other people, friendships can form amongst even un-similar individuals
- Friendships that arise between homeless people have a quality of empathy and understanding that they may not have received from mainstream society
- They are able to relate to life circumstances and support one another
- They build trust through shared life experiences and the knowledge that the other will not pass judgment upon them
Values & Characteristics
- Distrust & breakdown of personal control
- Safety & survival - focus on the environment & how it affects them
- Present time orientation - daily existence rather than looking ahead or looking back
- Self-focused existence - despite friendships, the most important person is himself/herself
- Altered perception of ethics - all is permissible if done for the sake of survival, whether theft, murder, prostitution, etc.
- Resentment & anger against society - because of their place outside of it
- Violence - seen as an acceptable way to fix a problem between two or more people
- Accept their definition of family and friends - ask who should be allowed in their room & who can access their medical records
- Adjust our interactions & recommendations to account for limited access to food and housing
Culture of the Homeless

Lobby, lobby, and more lobbying
Lobbyists are typically employed by interest groups that want public policies to favor them and their causes. The goal of healthcare lobbyists is to impact healthcare policy to facilitate effective use of human and financial resources.

The process of lobbying involves an active constituency to make elected official accountable for their vote. Advocacy!

Lobbyists most often use verbal persuasion to try to influence public officials. Interest groups may hold a formal meeting where information is shared that supports their position on a topic.

A lobbyist might try to befriend public officials in various ways, such as by taking them out to dinner, throwing parties or providing entertainment. Unfortunately some might resort to more unethical or even illegal practices, such as bribery.
Strategic Political Influence


Democrats/Democratic leaners

The economy
Poverty and homelessness
Healthcare policy
Social Security and Medicare
Distribution of income/wealth
The environment
Gun policy
Republicans/Republican leaners

The economy
The military and national defense
Healthcare policy
Social Security and Medicare
World affairs
Poverty and homelessness
Top 10 Priority Issues, by Party Identification
These results are from Gallup's annual Mood of the Nation survey conducted January 5-8, 2014. They are based on telephone interviews conducted with a random sample of 1,018 adults ages 18 and older, living in all 50 U.S. states and the District of Columbia.
Affordable Care Act
Mental Health America
National Coalition for the Homeless (2008). Factsheet for college students.
National Coalition for the Homeless
. Retrieved April 8th, 2014, from http://www.nationalhomeless.org/factsheets/Fact%20Sheet%20for%20CollegeStudents.pdf
Phillips, K. (2012). Homelessness: Causes, culture, and community development as a solution.
Pell Scholars and Senior Theses, 88
. Retrieved from http://digitalcommons.salve.edu/pell_theses/88

Potter, P. A., Perry, A. G., Stockert, P. A., Hall, A. M. (2013). Fundamentals of nursing (8th ed.). St. Louis, Missouri: Elsevier Mosby.

Roos, D. (2012, June 19). How Lobbying Works.
. Retrieved April 23, 2014, from http://people.howstuffworks.com/lobbying.htm
Shanzer, B., Dominguez, B., Shrout, P. E., Caton, C. (2007). Homelessness, health status, and healthcare use.
American Journal of Public Health, 97
(3). 464-469. doi: 10.2105/AJPH.2005.076190

Shelton, K. H., Taylor, P. J., Bonner, A., van den Bree, M. (2009). Risk factors for homelessness: Evidence from a population-based study.
Psychiatry Services, 60
(4), 465-472. doi: 10.1176/appi.ps.60.4.465

Staff, MHA. (n.d.). Policy & Advocacy.
Mental Health America
. Retrieved April 23, 2014, from http://mentalhealthamerica.net/policy-advocacy
Substance Abuse and Mental Health Services Administration. (2011, July). Current statistics on the prevalence and characteristics of people experiencing homelessness in the united states. Substance Abuse and Mental Health Services Administration. Retrieved April 8th, 2014, from http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf

Sunrise Community Health. (n/d). Comprehensive health.
Sunrise Community Health
. Retrieved April 19, 2014, from http://www.sunrisecommunityhealth.org/

Weld Food Bank. (n/d). Programs.
Weld Food Bank
. Retrieved April 19, 2014, from http://www.weldfoodbank.org/

Wilke, J., and Newport, F. (2014, January 28). Democrats and Republicans Differ on Top Priorities for Gov't.
GALLUP Politics
. Retrieved April 23, 2014, from http://www.gallup.com/poll/167084/democrats-republicans-differ-top-priorities-gov.aspx
Affordable Care Act 101: Expanding Mental Health and Addiction Coverage

Expanding coverage:
No one can be denied insurance coverage based on preexisting conditions
Medicaid expanded to 133% of the federal poverty level which is about $14,000/year
Mental Health and Substance Use: (essential benefits)
Preventive services:
For adults: alcohol misuse screening and counseling, depression screening, and tobacco use screening and cessation intervention
For women: domestic and interpersonal violence screening and counseling, expanded tobacco use, and counseling for pregnant women
For children: behavioral assessments, depression screening for adolescents, and alcohol and drug use assessments
MHA is the nation's leading community-based network dedicated to helping Americans achieve wellness by living mentally healthier lives

MHA advocates for changes in mental health and wellness policy, educates the public, and delivers urgently needed mental health and wellness programs and services (counseling, screening)

Capitol Hill Day May 7, 2014 in Washington, D.C.
Mental Health America is partnering with the National Council for Behavioral Health to advocate for mental health
Star speakers, informational workshops, and a chance to meet with your Members of Congress
Lobby, lobby, and more lobbying
Usually interest groups that lobby for increases in homeless healthcare are volunteer or non-profit organizations. These groups have less lobbying power than other companies/groups because of the fact they have less money. When competing for votes it is beneficial to have more money.

Eight tips for a successful lobby visit:
Make an appointment
Prepare for the visit
Be punctual and positive
Focus the meeting
Listen and gather information
Make a specific request
Follow up
Express your thanks
We're supposed to leave our personal judgments at the door.

That is especially important in this case because of the sheer amount of negative prejudices that homeless people face. We don't want these ideas to get in the way of patient care.

However, we need to use our judgments to ASSESS as nurses. Assess the needs of our patients based off of what you're seeing and experiencing with each patient.

And finally, make sure our patients know how to take care of themselves when they go home- wherever that may be.
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