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Archives of Family Medicine and General Practice

ISSN: 2578-6539

PERSPECTIVE | VOLUME 4 | ISSUE 1 OPEN ACCESS

Historic and Current Health Care Struggles for the Homeless and Skills for Providers to Improve Care

Stephanie K Hardee, Gary Sanford and Donald Burnes

  • Stephanie K Hardee 1*
  • Gary Sanford 2
  • Donald Burnes 2
  • School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
  • Burnes Center on Poverty and Homelessness, Graduate School of Social Work, University of Denver, Denver, USA

Hardee SK, Sanford G, Burnes D (2019) Historic and Current Health Care Struggles for the Homeless and Skills for Providers to Improve Care. Arch Fam Med Gen Pract 4(1):76-81.

Accepted: March 23, 2019 | Published Online: March 25, 2019

The Patient Companion in the Consultation of Family Medical Practice is an Indicator of Hidden Family Problems

Abstract


This paper discusses improvements that health care providers can integrate into their practices to better serve individuals and families experiencing homelessness. To begin, the past and present methods of care for the homeless population are described, including the government's role in shaping the issue. Homeless individuals face immense barriers to receiving care, including fear of the health care establishment and the likelihood of judgement and disrespect. Next, methods to ease these fears and frustrations to create the optimal environment for building trust, demonstrating empathy, and providing clear communication are given. Methods to best educate and inspire patients to engage in healthy practices (e.g. peer support programs) are described. The homeless population has much higher rates of mental illness, substance abuse, and trauma given the inherent stress of existing without a permanent home. This paper outlines the challenges that each of these bring and describes how to best help the patient. Using a communication method known as trauma-informed care has proven effective for helping homeless patients with physical, emotional, sexual abuse, or other forms of trauma. Providing support for individuals and families experiencing homelessness is rewarding for all parties involved and can significantly improve lives and outcomes.

Background and Problem


History

Before the modern condition of homelessness can be fully assessed, it is important to review some of the major developments of the 20th century that impact the homeless of today. Homelessness has been a common thread throughout American history, from the colonial castoffs and frontier explorers in the earliest days of the country to the hobos and Skid Row inhabitants after the industrial revolution [1]. With each generation of homeless and impoverished people, new methods of rising out of poverty emerged, including moving West to seek new opportunities, enlisting in the Army during wartime, and institutionalizing themselves when they faced a mental illness. During the 1950s, the homeless had numerous options available to them. They could join a Skid Row community where they could be independent but live among others whose struggles were similar, commit themselves to a behavioral health facility and be treated for mental health problems, or stay in a government-funded shelter. However, throughout the 1960s and 1970s, existing policies that had previously benefitted the homeless were changed. President Lyndon B. Johnson's "War on Poverty" closed "flophouses" that had once provided inexpensive lodging for the homeless and gentrified Skid Row areas that had previously given the homeless both a refuge and a community [2].

A substantial portion of the homeless population suffers from mental illness; thus, many in the twentieth century chose to remain in residential behavioral health facilities. However, over the following decades, most of these facilities would be shut down through the process of deinstitutionalization, an idea which became popular during the 1950s. Several movies and novels, such as One Flew Over the Cuckoo's Nest by Ken Kesey, portrayed mental institutions in a negative light and argued that they were inhumane [2]. The movement continued to grow, and in 1963, President John F. Kennedy signed the Community Mental Health Center Act into law, beginning the process of deinstitutionalization [1]. By the mid 1970s, up to 85 percent of these patients were released back into the community [3].

With the passing of the Community Mental Health Center Act, funding for residential mental health facilities shifted from state to federal. While the federal government had initially promised to create 3,000 new facilities, only 800 were actually made. With so few residential psychiatric facilities, only the minority of mentally ill could be housed there. Instead of caring for the impoverished mentally ill, the community health facilities tended to treat the middle class "worried well" [2]. In 1955, prior to deinstitutionalization, there were 558,239 patients in residential psychiatric facilities, but by 1994, there were only 71,619 [4]. Thus, a substantial number of people who once would have been institutionalized, were forced to live elsewhere, many of whom could not work due to their illness and became homeless.

The lack of behavioral health facilities became even more evident as the mentally ill population multiplied. One such cause of increased need for mental health services was the ending of the Vietnam War. Many soldiers returned home with Post-Traumatic Stress Disorder (PTSD) but had few options for treatment as the majority of VA behavioral health facilities had been closed. Numerous Vietnam veterans who had more severe forms of PTSD became homeless [3]. Another factor increasing need for these facilities was the growing baby boomer generation. Typically, most people begin to suffer from substance abuse or mental health problems between the ages of 18 and 30, thus the baby boomers needed mental health facilities after the majority of them had been dismantled [2].

A second major piece of legislation during this time also had an unintended negative impact on the homeless. The Uniform Alcoholism and Intoxication Treatment Act, which decriminalized public drunkenness was passed in 1971. The act shifted the duty of handling the publicly inebriate from the criminal justice system to the health care system, as these individuals could no longer be jailed [1]. The jails provided an inexpensive place for them to sober up and detox. Additionally, beds in detox-specific facilities for the inebriate were closed with the legislation as new, improved facilities were planned to be created. However, once again the result was far short of what was promised. Few new facilities were actually created, leaving most of the homeless people struggling with alcohol abuse with no place to recover [2].

During the 1980s, homelessness became a major political topic. The systems of care that the homeless had come to know and use were dismantled, and few alternatives were created to replace them. Homelessness has since increased in visibility and become a nationally recognized public health concern. There have been many attempts to help people access more affordable housing and receive better health care. However, with over 550,000 people experiencing homelessness on any given night in the U.S., these attempts have not been as significant as needed [5].

A recent development in health care for the homeless and impoverished has been the expansion of Medicaid beginning in 2010. Originally, Medicaid and Children's Health Insurance Plan (CHIP) coverage was only available to low income families, children, pregnant women, elderly, and disabled people. To qualify for Medicaid, a combination of income, household size, disability status, age and other factors would be considered for eligibility. However, in expanded states, people can qualify based on income alone, now allowing single adults to also be eligible for coverage [6]. Any individual whose income is below 138% of the federal poverty level qualifies for Medicaid. Not only has the Medicaid Expansion allowed low income people to afford health insurance, but it has also decreased the amount of uncompensated care, as individuals may be less inclined to visit the emergency room for care and can instead see primary care providers [6]. 34 states including D.C. currently have accepted Medicaid Expansion, 3 states are still considering it, and 14 have chosen not to adopt it [7,8].

Struggles with health care

People experiencing homelessness have numerous barriers to obtaining health care that the general population does not. They often have multiple needs such as physical health, mental health, housing, and nutrition. Each of these play a role in the overall health of the individual and often multiple needs must be addressed simultaneously. Understanding these needs is made even more difficult as homeless patients tend to distrust the medical community, whether it is because of a negative experience or a fear of vulnerability or judgement. Meanwhile, others lack positive social networks that support them in their health goals. Providers should strive to address the specific needs of their homeless patients, while remaining flexible, given the inherent challenges of homelessness. Many providers have had limited training in working with homeless patients. Providing a safe and welcome environment is demonstrated through empathy and support. Homeless individuals deserve access to high quality medical care, especially as they have three to four times the mortality rate of the general population [9].

A combination of health care, housing, and other social services are needed to stem the tide of homelessness. Maintaining physical and mental health while living in a shelter, on the streets, or any other form of temporary housing can be incredibly difficult. Guiding an individual or family through the process of gaining housing and health care requires the efforts of a team of people, including case managers, social workers, physicians, nurses, public health staff, and more. Working with the homeless poses unique challenges, and thus adequate training is vital to successfully meeting their health care needs.

Solution: Skills and Competencies


While changes in clinical practice will not address the complex social, political, and economic issues of homelessness, they can go a long way to provide better health care for these patients. Some of these adjustments include viewing the patient holistically, building a trusting relationship, demonstrating empathy and compassion, and ensuring clear communication and care coordination. A strong patient-provider relationship will allow the patient to feel more confident in their medical care and achieve the best outcomes possible.

Holistic view

Virtually all health care providers face a similar problem: How to provide the best care for the patient in a limited amount of time. Too often, clinicians become focused on the physical ailments of a patient, and in check-list fashion, work through each symptom, checking them off as they go. A holistic approach considers not only physical symptoms, but considers the intertwined psychological, social, finical, and even spiritual aspects of care.

Frequently, mental illness plays a significant role in the physical health of the patient. Once a connection is identified, the interaction must be explored. There is a strong linkage between the state of homelessness, intense stressors, and poor mental health, which lead to negative health outcomes. People experiencing homelessness have a higher need for behavioral health resources. Leane Vasquez understands the needs of the homeless more than most. Having faced and recovered from homelessness, she works as a peer support specialist at Mental Health Partners (MHP) in Boulder, Colorado. She provides an example of mental health playing a role in physical health:

"Imagine a 25-year-old patient complaining of seemingly unexplainable chest pains. Knowing that the individual is homeless, it is highly likely that they face extremely stressful situations every day. This individual may struggle with obtaining food, finding safe accommodations at night, or securing a job. These intense stressors put them at risk for additional mental health problems. The provider and patient should discuss mental health conditions such as depression and anxiety to identify if this may be the cause of the symptoms. While ensuring that the patient knows that their pain is valid, the provider can help connect the individual with a professional in behavioral health".

At MHP, the entire team of medical and behavioral health professionals meet every morning to discuss the needs of each individual patient. They review the patient's history in both the medical and behavioral health departments and discuss what the acute and chronic needs are. By piecing the various aspects of the patient together, the team is prepared to deliver the best care.

Establishing trust and rapport

Many people experiencing homelessness tend to distrust health care providers. Perhaps due to their mental or physical disease burden they face "unwelcomeness" in clinic settings [10]. Distrust of the health care system may stem from a number of causes. For example, they may have had previous negative experiences with health care providers, and thus, may be wary of further involvement. They are also more likely to fear the "establishment" and feel uncomfortable or nervous in clinical settings. This may minimize the sharing of personal information, which makes managing medical care more challenging [9]. However, trust in health care settings is crucial. Patients with higher trust levels seek primary providers more often, as opposed to utilizing Emergency Rooms for care, and are more likely to reveal information that could help with their treatment. Once the appointment is over, trust in their provider helps ensure that the patient adheres to their treatment plan [10]. A trusting relationship is built not only on the provider's clinical competence, but also excellent communication skills, openness, empathy, and reliability.

Establishing and maintaining trust requires consistent high-quality care and open communication. Building trust while managing a chronic disease can be challenging, because the treatment process is long, and progress may seem minimal. Leane Vasquez recommends using the word "we" when discussing care: "we should," "we can," or "we will". By using statements including the word "we" as opposed to statements like "I think" or "you should," the clinician demonstrates an investment in the relationship. Patients experiencing homelessness have significant daily struggles, thus the provider's sensitivity and understanding strengthens the therapeutic relationship [11].

Empathy

Empathy is the ability to appreciate and acknowledge another's experience from their perspective. Too many people experiencing homelessness face discrimination in health care settings; places where they should feel welcomed and cared for. A homeless participant interviewed in a study regarding his experience in health care facilities stated that he is treated as a castoff object, "it makes me subhuman, like that I don't really belong in society" [12]. When a patient perceives this degree of contempt, they may become withdrawn, rendering any hope of addressing their needs nearly impossible.

However, there are steps to ensure that these patients understand that their provider is there to support them and that the health care setting is a place for them to heal physically, mentally, emotionally, and spiritually. It is helpful to include front desk staff in homeless sensitivity training and encourage them to remain informed about the pressing issues of the homeless. Staff responsible for greeting are the front line for putting the patients at ease. Homeless patients may present wearing dirty clothes and having poor hygiene, but these people should not be mistreated or judged. People experiencing homelessness are among those most in need of both kindness and medical treatment.

The daily survival needs of the homeless require more effort and time than the housed. Many must find a place to sleep each night where they can be protected from the dangers of the streets and must find enough food each day to survive. Leane Vasquez works closely with homeless individuals who have mental illness or substance abuse problems. She shared that during her discussions with patients, it is vital to meet them where they are physically and emotionally. Some may be just beginning their healing process, while others may be at a low point in their recovery. Empathy is a critical communication skill. Questions, clarifications, and responses facilitate the demonstration of empathic care. Phrases such as "what has this been like for you," "tell me more about...," and "I can imagine..." serve as portals into the empathic space where care and concern are experienced [11].

Empathic communication improves patient-provider relationships. Receiving negative medical news or learning about a new treatment or procedure can be very frightening. Time should be given for the patient to express their fears and concerns. Provide honest reassurance for the patient about the diagnosis and treatments given. A little positivity can carry the individual far, especially when they live with constant fear and doubt. Without giving false hope, remind them that their problem can be managed, and their providers will help them every step of the way [13].

Communication

Communication skills are weighed most heavily when patients are asked to rate their providers and overall quality of medical care [13]. Providers who can clearly and efficiently articulate medical concepts and ideas are typically considered the most intelligent. These providers better educate their patients on diagnoses and treatments, and thus improve adherence to medication and therapy schedules, leading to better outcomes [13]. Simple changes in behavior and manner of speaking enhance patients' feeling of "welcomeness" in the clinic.

As Donald Burnes stated in an interview, the clinical mindset is often "we are professionals and we know what you need". However, the true experts are the patient themselves. Only the patient can know what treatment options will be achievable with their resources and schedule. Asking the patient questions about their daily life can give insight into treatment options. What resources do they have access to and when? What potential side effects are acceptable, and which are not? Who can support them with their medication schedule, physical therapy, or diet? With collaboration between the patient and the provider, the best possible solution can be found.

Patients respond best when they feel like their provider is speaking to them as a peer, as opposed to a parent [13]. As they are often mistreated by those around them, it is vital that they are treated with kindness and respect in clinic settings. Though the provider may have advanced training, homeless patients can still learn enough about diagnoses to make informed medical decisions for themselves [13]. Patients should be equipped with the knowledge and tools that they need to better themselves. As Burnes said, "give a man a fish, and he'll eat for a day, teach a man to fish and you feed him for a lifetime, but some people need a fishing pole".

People experiencing homelessness can have long periods of hopelessness. From waiting on paperwork for housing and applying for jobs and benefits, to dealing with chronic health concerns, they may need reminding that their progress is beneficial. Celebrate even the small things with the patient, whether health related or not. As Leane Vasquez says, "small is big!" If the person is progressing well in physical therapy or their blood pressure is improving, they should feel proud of their progress. Each small improvement of their health or step closer to receiving housing serves as proof of their progress [11].

Support

People with similar life experiences and interests can support each other through difficult times. Donald Burnes interviewed eight formerly homeless individuals who are now successfully housed and recovering. These individuals came from a variety of backgrounds, some having experienced homelessness during their childhood and others who were survivors of traumatic events but all managed to rise above their poverty. The key characteristic each of these individuals shared in their recovery from homelessness was a person or group that supported and cared for them (or as Burnes identifies these groups, "who do you call at two in the morning?"). Loneliness is an epidemic sweeping through the nation, and the homeless are at the highest risk. Support networks are essential to overcoming homelessness and health problems [2].

Homeless persons lacking meaningful relationships should be provided resources to find social support, including peers, groups, or day programs. This network will give them people to contact, whether in emergencies or situations requiring guidance. The caring community also allows them to overcome their social isolation [2]. Leane Vasquez shared her progress in creating a group program where patients can share their stories, successes, or struggles, and gain ideas from others. The group will discuss important health-related topics including healthy eating, stress management, physical health, and spirituality. In this type of program, the patients can learn valuable skills from one another, while also sharing in each other's goals and successes [11].

Peer support specialists are a growing resource, especially for those who are struggling with mental illness or substance abuse. Peers are people have recovered from homelessness, addiction, or mental illness and can advise those who are still struggling. Peer support systems provide a means of communication with a caring individual. Not only can they provide empathy from their own personal experience with homelessness, but they can assist with guidance and resources [14]. The Behavioral Health and Wellness Program at the University of Colorado Anschutz School of Medicine, the Metro Denver Homeless Initiative, the Metro Community Provider Network (MCPN), and several other organizations worked together to create the Peer Navigator Program in Denver [15]. The program was funded by a grant from the Colorado Department of Public Health and Environment for three years, from 2015 until 2018. Peers were initially placed in the community for outreach, including libraries and other public spaces, and soon after were expanded to health care facilities, including the MCPN and Homeless Outreach Providing Encouragement [16].

Overall, 1,071 people were engaged by the peer navigators during the three-year grant, with 823 screened for chronic diseases and 429 patients successfully connected to health care resources [15]. Peer Navigator Leane Vasquez stated in the program's Project Playbook, "Having experienced homelessness, addiction, poverty, and trauma helps me to relate to the courage of those who are simply surviving. I offer no judgement, only compassion".

Trauma-informed care

Sadly, many struggling with homelessness have lived through traumatic events that have shaped their outlook on their own life. Providers trained in trauma-informed care (TIC) can more effectively communicate by respecting their patient's needs, knowing the symptoms and effects of trauma, and guiding the patient towards recovery. Trauma is both a cause and consequence of homelessness. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as "an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being" [17]. Experiencing homelessness certainly falls under this definition.

Even just the process of becoming homeless causes intense stress and produces symptoms of psychological trauma. Remaining homeless for extended periods of time can be traumatic due to a lack of control, predictability, and safety. During these stressful times, those who have a history of trauma can have their symptoms exacerbated [18]. Additionally, the homeless lack access to many basic survival needs including shelter, food, water, clothing, transportation, and other things many take for granted. They also face higher rates of theft, violence, and sexual assault, all of which can be extremely traumatic [19]. Hardy and Midgley shared in an interview, "their value and worth as a person, their experiences of respect and dignity, and their basic human rights are consistently violated". While many show remarkable resiliency and strength in regards to these traumatic events, the toxic stress their body and mind endures can negatively impact their health. They can manifest signs related to their coping mechanisms, including hopelessness, helplessness, anger, isolation, numbing, hypervigilance, anxiety and depression [20].

Many people experiencing homelessness were victims of Adverse Childhood Experiences (ACEs) including child abuse or neglect, household dysfunction, poverty, violence, or other events [21]. Around 10 million children currently endure trauma and one in fifteen children will experience intimate partner violence. Traumatic stress can trigger changes in the brain, including long term effects on behavior, memory impairments, and planning and impulse control deficiencies [20]. The original ACE study in 1998 included 17,000 participants, of whom 64% reported at least one ACE, and 12.5% reported at least four ACEs. ACEs were directly correlated to other health hazards including substance abuse, tobacco use, risky sexual behaviors, and obesity [21]. Those with four or more ACEs had an increased rate of smoking by 2.2 times, alcoholism by 7.4 times, substance abuse by 4.2 times, intravenous illicit substance abuse by 11.3 rimes, severe obesity by 1.6 times, and sexual intercourse with fifty or more partners by 3.2 times. People suffering from this "trauma organized lifestyle" are also at increased risk for diseases ranging from stroke and heart disease to anxiety, depression, and suicide. People with four or more ACEs were 4.5 times more likely to have clinical depression, and their suicide attempts are 12.2 to 15.3 times the general population. Having six or more ACEs reduces the individual's life expectancy by twenty years [20].

Trauma-informed care is a specific method of interacting with those who have experienced severe trauma in their lives. The approach encourages health care providers to realize the prevalence of trauma and its impact, recognize its signs and symptoms, respond by integrating knowledge of trauma, and revisit the recovery of each person [20]. TIC seeks to shift the mindset of providers from "what is wrong with you" to "what has happened to you?" Elissa Hardy and Alix Midgley are Social Workers who reach out to people experiencing homelessness in the Denver Public Library system. They shared that they treat all people, from their homeless clients to their colleagues, as though they have experienced trauma that has changed the way they see the world. Thus, they remain flexible in the support that they give to their clients and ensure a sense of safety and trustworthiness in their meetings. Empowering the patient is key in TIC as often the individual can feel powerless in their own life. Hardy and Midgley suggest that to practice social work ethically, the client should direct the discussions and make decisions that they feel are beneficial and achievable. The homeless understand their needs better than anyone; thus, the provider should provide necessary support for the specific needs.

Conclusion


Improving care for homeless patients is an important step in the long process of lifting these individuals out of homelessness. They need help in finding affordable housing, gaining a steady income, and addressing their physical and mental health needs. By making strategic changes in communication and care, providers can make a difference in the individual's health, which is a critical step in their path to recovery. People struggling with homelessness face extreme adversity but should feel both welcome and safe in health care settings. Though the homeless may be among the more difficult to treat, they are perhaps the most rewarding. They require compassionate care to improve their lives. The current health care system does not adequately address the unique challenges that the homeless face. Thus, health care providers must begin by understanding the patient's lifestyle, abilities, and health needs. This can be made easier by learning about the current issues faced by the homeless. Through establishing trust, showing empathy, and having clear communication, the clinician can build a strong relationship with the patient. The partnership between the patient and the provider will certainly take effort to build and maintain, but only through both parties working together to address the patient's unique needs will they receive the health care they deserve.

References


  1. Baum Alice S, Donald W Burnes (1993) A Nation in Denial: The truth about homelessness. Westview Press.
  2. Burnes Donald (2018) Personal interview.
  3. Burnes Donald W, David L DiLeo (2016) Ending homelessness: Why we haven't, how we can. Lynne Rienner Publishers.
  4. Torrey E Fuller (1998) Out of the shadows: Confronting America's mental illness crisis. Wiley.
  5. Henry Meghan, Rian Watt, Lily Rosenthal, et al. (2017) The 2017 Annual Homeless Assessment Report (AHAR) to Congress. The U.S. Department of Housing and Urban Development Office of Community Planning and Development.
  6. U.S. Centers for Medicare and Medicaid Services (2018) How medicaid health care expansion affects you.
  7. (2018) Medicaid expansion enrollment. KFF: Henry J Kaiser Family Foundation.
  8. (2018) Current status of state medicaid expansion decisions. KFF: Henry J Kaiser Family Foundation.
  9. Institute of Medicine (US) Committee on health care for homeless people (1988) Homelessness, health and human needs: Health care services for homeless people. National Academies Press, Washington (DC).
  10. Berk-Clark Carissa van den, James McGuire (2014) Trust in health care providers: Factors predicting trust among homeless veterans over time. J Health Care Poor Underserved 25: 1278-1290.
  11. Vasquez Leane (2018) Personal interview.
  12. Wen CK, Hudak PL, Hwang SW (2007) Homeless people's perceptions of welcomeness and unwelcomeness in healthcare encounters. J Gen Intern Med 22: 1011-1017.
  13. Barnard Stephanie (2001) The business aspects of health care. In: Deborah St. James, Writing, speaking, and communication skills for health professionals. Yale University Press.
  14. Noland Derek (2018) Personal interview.
  15. Behavioral Health and Wellness Program (2018) The collective impact for high public service utilizers project. University of Colorado Anschutz Medical Campus School of Medicine.
  16. Mayer Rebecca (2018) Personal interview.
  17. (2018) Trauma and violence. SAMHSA: Substance Abuse and Mental Health Services Administration.
  18. Goodman L, Saxe L, Harvey M (1991) Homelessness as psychological trauma: Broadening perspectives. Am Psychol 46: 1219-1225.
  19. Hardy Elissa, Alix Midgley (2018) Email interview.
  20. Kelloff Jennifer (2018) Trauma-informed care. Continuing Medical Education, Kaiser Permanente, 25.
  21. Felitti VJ, Anda RF, Nordenberg D, et al. (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14: 245-258.

Abstract


This paper discusses improvements that health care providers can integrate into their practices to better serve individuals and families experiencing homelessness. To begin, the past and present methods of care for the homeless population are described, including the government's role in shaping the issue. Homeless individuals face immense barriers to receiving care, including fear of the health care establishment and the likelihood of judgement and disrespect. Next, methods to ease these fears and frustrations to create the optimal environment for building trust, demonstrating empathy, and providing clear communication are given. Methods to best educate and inspire patients to engage in healthy practices (e.g. peer support programs) are described. The homeless population has much higher rates of mental illness, substance abuse, and trauma given the inherent stress of existing without a permanent home. This paper outlines the challenges that each of these bring and describes how to best help the patient. Using a communication method known as trauma-informed care has proven effective for helping homeless patients with physical, emotional, sexual abuse, or other forms of trauma. Providing support for individuals and families experiencing homelessness is rewarding for all parties involved and can significantly improve lives and outcomes.

References

  1. Baum Alice S, Donald W Burnes (1993) A Nation in Denial: The truth about homelessness. Westview Press.
  2. Burnes Donald (2018) Personal interview.
  3. Burnes Donald W, David L DiLeo (2016) Ending homelessness: Why we haven't, how we can. Lynne Rienner Publishers.
  4. Torrey E Fuller (1998) Out of the shadows: Confronting America's mental illness crisis. Wiley.
  5. Henry Meghan, Rian Watt, Lily Rosenthal, et al. (2017) The 2017 Annual Homeless Assessment Report (AHAR) to Congress. The U.S. Department of Housing and Urban Development Office of Community Planning and Development.
  6. U.S. Centers for Medicare and Medicaid Services (2018) How medicaid health care expansion affects you.
  7. (2018) Medicaid expansion enrollment. KFF: Henry J Kaiser Family Foundation.
  8. (2018) Current status of state medicaid expansion decisions. KFF: Henry J Kaiser Family Foundation.
  9. Institute of Medicine (US) Committee on health care for homeless people (1988) Homelessness, health and human needs: Health care services for homeless people. National Academies Press, Washington (DC).
  10. Berk-Clark Carissa van den, James McGuire (2014) Trust in health care providers: Factors predicting trust among homeless veterans over time. J Health Care Poor Underserved 25: 1278-1290.
  11. Vasquez Leane (2018) Personal interview.
  12. Wen CK, Hudak PL, Hwang SW (2007) Homeless people's perceptions of welcomeness and unwelcomeness in healthcare encounters. J Gen Intern Med 22: 1011-1017.
  13. Barnard Stephanie (2001) The business aspects of health care. In: Deborah St. James, Writing, speaking, and communication skills for health professionals. Yale University Press.
  14. Noland Derek (2018) Personal interview.
  15. Behavioral Health and Wellness Program (2018) The collective impact for high public service utilizers project. University of Colorado Anschutz Medical Campus School of Medicine.
  16. Mayer Rebecca (2018) Personal interview.
  17. (2018) Trauma and violence. SAMHSA: Substance Abuse and Mental Health Services Administration.
  18. Goodman L, Saxe L, Harvey M (1991) Homelessness as psychological trauma: Broadening perspectives. Am Psychol 46: 1219-1225.
  19. Hardy Elissa, Alix Midgley (2018) Email interview.
  20. Kelloff Jennifer (2018) Trauma-informed care. Continuing Medical Education, Kaiser Permanente, 25.
  21. Felitti VJ, Anda RF, Nordenberg D, et al. (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14: 245-258.