National experts have called out the aging of the homeless population as an impending crisis. [1] This demographic shift is happening rapidly, mirroring general population trends. Nationwide, currently half of single homeless adults are aged 50 or older, compared to 11% in 1990. [2] Moreover, according to a white paper prepared by the Corporation for Supportive Housing (CSH) and presented to a New York City coalition studying ways to address the aging of the homeless population, “not only are those on the streets getting older, but their health is deteriorating at rates much faster than the general population.” [3] The paper cites research showing that homeless adults over 50 had a higher prevalence of geriatric conditions than that seen in housed adults 20 years older. [4] Another study showed that older homeless adults were 3.6 times as likely to have a chronic medical condition as homeless adults under 50. [5] Such findings clearly indicate a pressing need for housing and services that specifically address geriatric conditions among older homeless adults living across varied environments. [6]
I began learning about the impact of these trends on the capacity of shelter and housing providers to meet client needs while leading Public Health-Seattle and King County’s Health Care for the Homeless Network (HCHN). My program management team [7] and I engaged homeless housing leaders around this aging trend and discovered significant challenges aligned with those cited in national literature. They also aligned with calls for assistance that HCHN received from its physicians, nurses, behavioral health professionals, and outreach workers stationed at Permanent Supportive Housing sites. In Seattle and nationally, housing agencies find themselves ill-equipped to address widespread issues related to memory loss and other conditions that impact residents’ ability to independently perform activities of daily living (ADLs) as well as end-of-life care needs. Statistically, these issues and needs impact the homeless population at a much earlier age than the general population, so homeless housing programs with an increasing proportion of residents over 50 years old have begun grappling with complex and difficult questions about resident health and safety.
The Permanent Supportive Housing (PSH) model offers distinct advantages in terms of meeting the needs of older and other vulnerable people who have experienced homelessness, but many of the challenges older PSH residents experience are testing the adequacy of the supportive services historically provided in these programs. For numerous reasons, homeless housing agencies encounter significant barriers to referring PSH residents with intensive health-related support needs to nursing homes, adult family homes, or other residential alternatives specifically designed to address such needs. At the same time, these homeless housing agencies are generally not staffed to provide anything approaching the intensity of services available in such facilities. In addition, PSH residents often prefer to age in place rather than move, but housing and health care providers in Seattle point to significant difficulties in efficiently and cost-effectively bringing needed chore workers or other state-funded resources into homeless housing buildings.
Background: The National Picture
PSH is defined by the Corporation for Supportive Housing (CSH) as a model of affordable housing connected to supportive services typically targeted at individuals or families experiencing or at-risk of homelessness and who are likely unable to retain permanent housing without ongoing supports. According to CSH, supportive housing should not be thought of as a separate and distinct intervention, but rather a combination of:
- affordable housing with deep subsidies and tolerant landlords/property management;
- care management (services engagement, motivational client-centered counseling, goal-setting and services planning, services coordination, and connection to mainstream services); and
- evidence-based service models rooted in cognitive behavioral and family systems approaches.
Overall, PSH has proven extremely effective in helping to stabilize the lives of people with significant vulnerabilities related to their homelessness as well as chronic behavioral health and medical conditions, but most PSH program models were not designed with the special needs of seniors in mind. On one hand, numerous studies, including some conducted in Seattle, indicate that a combination of supportive housing best practices can appreciably improve a person’s health after they have experienced the trauma of homelessness. [8] On the other, late life needs are significant, as nearly half of all adults in the U.S. over age 65 have difficulty, or receive help, with daily activities. [9] To respond to the intensity of support required by many older residents with advanced needs as well as the overall aging of the PSH resident population, PSH providers and their partners need specialized interventions that go well beyond the supports that most residents are typically provided. [10]
Ending Homelessness among Older Adults and Elders through Permanent Supportive Housing, published by CSH and Hearth, Inc., a Boston-based non-profit organization dedicated to the elimination of homelessness among the elderly, provides an excellent overview of these needed specialized interventions. The paper suggests that:
A wide range of age appropriate services, often onsite, are needed by homeless older adults and elders in supportive housing. These services include: specialized outreach services, assistance with activities of daily living, 24-hour crisis assistance, physical health care, mental health care, substance use treatment, transportation services, payee services, care coordination with community providers, nutrition and meal services, and community building activities aimed at reducing isolation. This requires individualized health treatment plans that take into account the interplay of the chronic, often co-occurring, health conditions along with the normal physical and psychological changes that come with age. Making use of multidisciplinary service teams that can provide “one stop” access, and facilitate coordination, has been found to be a successful approach. Providers have also found that offering services on-site is ideal for older tenants who might have difficulty traveling to off-site services. [11]
Challenges for PSH Operators in Washington State
HCHN conducted key informant interviews with the two local PSH operators represented on its community advisory board. Both Plymouth Housing Group and Compass Housing Alliance have experienced a significant increase in the number of PSH residents and candidates with intensive service needs related to dementia, other cognitive impairments, behavioral health issues and various late-stage chronic diseases. HCHN data shows that its contracted health care provider partners have seen a dramatic increase in older patients, so this observation is not surprising. Staff at both agencies interviewed indicated that they frequently feel ill-equipped to meet these clients’ needs but see few options because of the dearth of assisted living and nursing home operators who are willing and able to work effectively with people who have been chronically homeless.
In addition, these PSH operators, as well as health care providers who partner with PSH programs, point to significant challenges in making Washington State’s Community Options Program Entry System (COPES) work for older residents with dementia and other cognitive impairments. COPES is a Washington State Medicaid (Apple Health) program designed to enable individuals who require nursing home level care to receive that care in their home or community living environment. PSH operators report that their case managers encounter difficulties in advocating on behalf of their clients within the COPES intake process, for example when their client’s cognitive impairment complicates the assessment process. In addition, case managers struggle with the COPES process for scheduling cluster care visits during which one COPES worker can visit multiple residents during the same day. As a result, a method of providing services that could be a very efficient avenue for meeting the needs of multiple residents with COPES service needs is underutilized. Given the limited capacity of the PSH case managers, these challenges can create unnecessary barriers to care that increase the risk for poor health outcomes and premature exits from PSH.
Prioritized Chronic and Geriatric Conditions Impacting the Aging Homeless Population
Discussions with HCHN health care provider partners and a review of national literature suggests the prioritization of the following conditions:
Dementia and other cognitive impairments
- A review of 12 studies on the prevalence of cognitive impairment among homeless persons suggests that as many as 80% of homeless persons tested displayed marked deficits in cognitive functioning in at least one domain: language, immediate memory, delayed memory, visuospatial/constructional, or attention. [12]
- Older homeless adults are more likely than younger homeless adults to have cognitive impairments. [13] Such impairments may result from dementia. Dementia describes a series of symptoms of decline in memory or other thinking skills that affect someone’s everyday life. Symptoms include memory loss, problems with language, faulty reasoning, and impaired judgment.
- Other cognitive impairments may result from depression, long-term effects of alcohol abuse, traumatic brain injuries, or be caused by health conditions such as cardiovascular problems. [14] Regardless of the cause, cognitive impairments can impact a person’s ability to follow medical recommendations, successfully seek out healthcare services and navigate the systems that provide public benefits, services and housing opportunities.
Mental health and substance use
- Though the physical healthcare needs of this population are considerable, like other people who have been homeless for long periods of time, older homeless persons frequently also have co-occurring mental illnesses and/or substance abuse disorders. While experts estimate that 30% of the general homeless population has a mental health condition, [15] close to 70% of residents at Plymouth Place, a Seattle PSH building operated by Plymouth Housing Group, reported having one or more diagnosed mental health conditions and almost 60% reported chemical dependency problems.
- PSH operators and their health care provider partners report that mental health and substance use disorders frequently represent the most significant barriers to success in referring PSH residents to assisted living facilities and nursing homes.
- About 40% of Hearth, Inc. residents in Boston, MA reported past alcohol or drug problems along with chronic health conditions that include 69% with heart or circulatory problems, 61% with high blood pressure, 52% with diabetes and 52% living with arthritis. [16] These characteristics are typical of older adults experiencing homelessness. [17]
Building on PSH’s Solid Foundation
Notwithstanding the gaps in typical PSH service arrays that impact the health and safety of residents with the highest degree of debilitation related to chronic and geriatric conditions, the PSH model offers some distinct advantages over other strategies for addressing the formidable challenges of an aging homeless population. In fact the national literature points to promising adaptations of existing PSH programs to specifically address these gaps. Here a few of the examples that HCHN found in its review:
- According to researchers Hahn, et. al, “New programs that integrate health care with more stable housing, such as supportive housing, may be important steps for avoiding end stage disease and institutionalization in older homeless persons with complex medical regimens needing frequent office visits.” [18] A case study by National Church Residences found that the cumulative annual cost savings for one of their buildings, the Commons at Buckingham, was greater than $800,000 based on 18 residents who had moved into the permanent supportive housing development from skilled nursing care and group homes.
- Brooklyn Community Housing and Services’ (BCHS) aging program brought on a part-time onsite nurse for a walk-in clinic, added case management and medical and senior-specific programming as well as a geriatric case manager with a smaller, targeted caseload to provide additional case management services for residents 55 and over and developed several social and wellness groups for aging residents including movie nights and peer led groups on nutrition. As a result of these program changes, inpatient hospitalizations decreased by 92% and resulted in annual savings of over $400,000. When the program first started in 2007, there were 415 days of in-patient medical stays. By 2013, there were only 30 days of in-patient medical stays which resulted in greater housing stability. [19]
Opportunities
King County has numerous successful PSH programs operated by a variety of agencies that could form a solid foundation upon which to build in experimenting with these types of adaptations. Many of these programs, including those operated by Plymouth Housing Group and Compass Housing Alliance as well as Downtown Emergency Services Center and Catholic Housing Services, have partnered with HCHN to bring limited levels of nursing, behavioral health, primary care, palliative care, and other services into some of their PSH buildings. HCHN-sponsored discussions surfaced the following potential adaptations for older PSH residents:
- On site patient assessment, nursing/care coordination services, primary care, mental health and chemical dependency services tailored to the specific needs of people with common geriatric conditions
- Improved access to chore workers and home health aides who assist with ADLs, possibly through negotiations with the Washington Department of Social and Health Services (DSHS) to improve coordination of COPES services with PSH case management and pilot a streamlined system for clustered COPES assessments and services
- Individualized treatment plans for older residents with special needs for intensive support, to be developed by health care providers working in coordination with PSH case managers
- Multi-disciplinary teams that include housing case managers, health care providers, chore workers or other staff assigned to help with ADLs that are provided the time required to enhance coordination and communication among the key individuals supporting older residents with intensive support needs
- Expansion of Harborview Medical Center’s Homeless Palliative Care Program, created in partnership with HCHN, to serve additional PSH buildings and increase its PSH service level and intensity for residents with end-of-life care needs
- Training for all staff at selected PSH buildings on working with cognitively impaired clients on life skills, end-of-life planning and issues, and creating safe living spaces
- Adaptations of existing training on motivational interviewing and trauma-informed care to better equip health care and housing providers to meet the needs of cognitively impaired clients
- Adoption of PSH program policies and procedures that accommodate stays in hospitals and convalescent care facilities, avoid tenants’ loss of housing, and provide clearly established referral routes to smooth the transfer of the tenant to the most appropriate setting
- Training and consultation to PSH program staff provided by Harborview Medical Center’s Comprehensive Outpatient Rehabilitation Program (CORP) and/or other geriatric health and housing experts related to strategies for conducting assessments and modifying interactions, environments, and expectations related for residents with cognitive impairment and other geriatric conditions impacting ADLs
Resources
- Ending Homelessness among Older Adults and Elders through Permanent Supportive Housing, a paper published by The Corporation for Supportive Housing and Hearth Inc. Retrieved from https://www.csh.org/wp-content/uploads/2012/01/Report_EndingHomelessnessAmongOlderAdultsandSeniorsThroughSupportiveHousing_112.pdf
- Rebecca T. Brown, Kaveh Hemati, Elise D. Riley, Christopher T. Lee, Claudia Ponath, Lina Tieu, David Guzman, and Margot B. Kushel.
- A Lifetime of Independence: Recommendations to the New York City Supportive Housing Task Force. Prepared by the Corporation for Supportive Housing. Retrieved from https://gallery.mailchimp.com/d477f3e2e075003c9d2f335a3/files/A_Lifetime_of_Independence.pdf
- Rebecca T. Brown, Kaveh Hemati, Elise D. Riley, Christopher T. Lee, Claudia Ponath, Lina Tieu, David Guzman, and Margot B. Kushel.
- Garibaldi, B., Conde-Martel, A. & O’Toole, T. P. (2005). Self-reported co-morbidities, perceived needs, and sources for usual
- A Lifetime of Independence: Recommendations to the New York City Supportive Housing Task Force. Prepared by the Corporation for Supportive Housing. Retrieved from https://gallery.mailchimp.com/d477f3e2e075003c9d2f335a3/files/A_Lifetime_of_Independence.pdf
- I am grateful to Trudi Fajans, former Health Care for the Homeless Network Community Partnerships Manager at Public Health-Seattle and King County, for her research, analysis, and other significant contributions to this paper.
- CSH, Housing is the Best Medicine, July 2014. Retrieved from https://www.csh.org/resources/housing-is-the-best-medicine-supportive-housingand-the-social-determinant
- Freedman, Vicki A., and Brenda C. Spillman (2014) Disability and care needs among older Americans. Milbank Quarterly. Vol. 92, No.3
Retrieved from https://aspe.hhs.gov/sites/default/files/pdf/77136/NHATS-DCN.pdf - A Lifetime of Independence: Recommendations to the New York City Supportive Housing Task Force. Prepared by the Corporation for Supportive Housing. Retrieved from https://gallery.mailchimp.com/d477f3e2e075003c9d2f335a3/files/A_Lifetime_of_Independence.pdf
- Ending Homelessness among Older Adults and Elders through Permanent Supportive Housing, a paper published by The Corporation for Supportive Housing and Hearth Inc. Retrieved from https://www.csh.org/wp-content/uploads/2012/01/Report_EndingHomelessnessAmongOlderAdultsandSeniorsThroughSupportiveHousing_112.pdf\
- TBI among Homeless persons.2008 – Jennifer Highly
- National Health Care for the Homeless Council. (2008). Healing hands newsletter: Aging on the streets. Retrieved from www.nhchc.org/healinghands.html
- U.S. Department of Health and Human Services, Health Resources and Services Administration. (2003). Homeless and elderly: Understanding the special health care needs of elderly persons who are homeless. Retrieved from https://bphc.hrsa.gov/policy/pal0303.htm
- McKenzie, J. F., Pinger, R. R., & Kotecki, J. E. (2008). An Introduction to Community Health (6th ed.). Sudbury, MA: Jones and Bartlett Publishers, Inc.
- Hearth, Inc. (2009). Ending elder homelessness: The importance of service-enriched housing. Retrieved from https://www.hearth-home.org/media/hearth_research09.pdf
- Brown, R.T., Kiely, D.K., Bharel, M., & Mitchell, S.L. (2011). Geriatric syndromes in older homeless adults. Journal of GeneralInternal Medicine, Published Online in Advance of Publication
- Hahn, J.A, Kushel, M.B., Bangsberg, D.R, Riley, E., & Moss, A.R. (2006). The aging of the homeless population: Fourteenyear trends in San Francisco. Journal of General Internal Medicine, 21(7), 775–778
- Best Practices for Serving Aging Tenants in Supportive Housing. July 2014 retrieved from https://www.csh.org/resources/best-practices-forserving-aging-tenants-in-supportive-housing/
