Research Psychiatric Center
October 17, 2013

Carmen Kynard

By Carmen Kynard, RN, MSN, FNP-BC, MBA, MEd, CPHRM, at Research Psychiatric Center | Reprinted courtesy of KC Nursing News

The homeless are defined as persons who “…lack a fixed… nighttime residence; [whose] primary nighttime residence is a public or private place not designed …as a regular sleeping accommodation for human beings… [or who as] individuals or family [units are] living in a supervised publicly or privately operated shelter” (Steward B. McKinney Homeless Assistance Act of 1987, Title I, 42 U.S.C., 112-90).

How many people are homeless? Approximately one out of 200 Americans experience homelessness in a given year (Bauer, 2013). The precise number of persons who are homeless is difficult to determine for a number of reasons. First, there are different methods for counting the homeless that yield different results.

The “point-in-time” method counts persons who identify themselves as homeless on a given day. It does not include those who are “doubled up” and sleeping on a friend’s couch or living in a motel. The “period prevalence count” categorizes a person as homeless only after a given period of time (How Many People Experience Homelessness, 2009). Other factors that impact determination of the precise number include the weather, season, day of the week, the “trust level” of the homeless with those accomplishing the counts, and whether or not the homeless that “sleep rough” and reside in their vehicles, under bridges and; makeshift dwellings are identified and counted.

Adding in the unsheltered homeless that “sleep in the rough” can increase the count by 30 percent. According to the United States Interagency Council on Homelessness (USICH), in 2009 there were 643,067 homeless Americans (2010). Of this number, 404,957 were individuals, and 238,110 were those who were members of homeless family groups. Two-thirds were sheltered, and one-third were unsheltered (USICH). The National Law Center on Homelessness and Poverty reports a substantially higher count of the homeless and estimates that approximately 3.5 million people, of which, 1.35 million are children, are likely to experience homelessness in a given year (2009).

Is the number of homeless increasing? The rate of homelessness is reported to be increasing due to unemployment, unpaid bills, lack of affordable housing, catastrophic medical illnesses, substance abuse and the chronically mentally ill (Bauer et al., 2013). Homelessness has increased in 24 states and the District of Columbia (National Law Center on Homelessness and Poverty, 2012). The rate of homelessness is increasing in the transiently homeless, military veterans, and families (Bauer et al.). Missouri is reported as one of five states that have experienced the largest increases in homelessness. In 2007 there was an increase of 3,990 (63 percent increase), and in 2011 a further increase of 1,248 (13.9 percent increase) (Cortes, Henry, de la Cruz, & Brown, 2012). The complete findings from 2013 are pending.

Why should nurses be concerned? Regardless of their precise number, of concern is the homeless experience increased rates of morbidity and mortality as compared to the general population and at any given time have on average eight to nine illnesses (Levy & O’Connell, 2004, O’Connell et al., 2005). When they seek care, many utilize emergency departments inappropriately for non-emergent needs and, in doing so cause the diversion of emergent patients. The most common chronic illnesses of homeless persons include chronic obstructive pulmonary disease, seizure disorders, hypertension, diabetes, musculoskeletal disorders, depression, schizophrenia, dementia and substance abuse (Hwang, Ueng, et al., 2010, Levy & O’Connell). Because of their greater morbidity, when homeless persons are admitted to hospitals, they are sicker and experience longer and more complicated lengths of stay. The average age of death of the average American male is 78, but the age is between 42 and 52 in the homeless male (O’Connell, et al., 2005, The Hard, Cold Facts About the Deaths of Homeless People, 2006). Sadly, the condition of homelessness, in itself, is an independent risk factor for death (Morrison, 2009).

Homelessness remains a significant public health issue. Much is being done to help the homeless to regain a foothold in our society. As nurses, we enter the field with the expectation of caring for those who are unable to do so for themselves. It is incumbent on us to help address this group of marginalized persons that are in need of assistance.

Stay tuned for approaches to the care of the homeless and how you can help.