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Primary Care: The Health Center Program

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Understanding the Health Care Needs of Homeless Youth

Program Assistance Letter 2001-10

It is estimated that 1.6 million youth are homeless each year in the United States. Some may stay away from home for only one or two nights while others have been living on the street for years. Approximately 200,000 youth each year live permanently on the street – a life that is extremely difficult, often dangerous, and associated with multiple health problems. Sadly, 5,000 teenagers are buried each year in unmarked graves either because they are unidentified or unclaimed.

Homeless youth have been identified by several different designations in the literature depending on the circumstances causing their homelessness. Runaway youth have been defined by the U. S. Department of Health and Human Services as “a person under 18 years old who absents himself or herself from home or place of legal residence…at least overnight…without the permission of parents or legal guardians. “Throwaways” are youth who have been thrown out of the house by parents or guardians. The reasons cited by adolescents for being thrown out of their homes include drug use, pregnancy, and gender identification conflicts. The term “street youth” is used to indicate youth who have been living on the street for some time and do not tend to use shelters or other traditional services. Unless otherwise specified, this paper will discuss homeless youth (ages 12-21), including runaways, throwaways and street youth, who do not live with parents or guardians. Youth who are homeless and living with their parents face some of the same issues as youth without parents or guardians, but are not the focus of this discussion.

Many of the health issues faced by homeless youth are similar to those faced by anyone experiencing homelessness. However, as adolescents, homeless youth are still developing psychologically, cognitively and physically and may make choices that are not in the best interest of their health. Before becoming homeless, these youth may have endured a chaotic and often violent home life and they may be distrustful of authority and adults. For these reasons, homeless youth can benefit from services that are specific to their needs rather than incorporated into services for the adult homeless population. This paper will discuss the health and social service needs of homeless youth and provide information about models of health care delivery.

SERVICE NEEDS

Health Care
Homeless adolescents often have a greater number of physical and mental health problems than their housed counterparts. They are more likely to engage in high-risk behaviors such as unprotected sex with multiple partners, drug use, and exposure to and participation in violence. In addition to health risks, homeless youth face a number of barriers in accessing health care. These include lack of insurance, a need for parental consent, difficulty navigating the health system, and the attitude of health staff.5 These issues will be explored in greater depth below.

Intensive Case Management
In order to provide a continuum of care from outreach efforts to the delivery of services, intensive case management is needed. These young people need extra help navigating a health care system that is often confusing even to homeless adults.6 Case management services must be comprehensive and address not only physical health needs, but also mental health and social service needs.6 For example, it may be beneficial for homeless youth to obtain early emancipation. (Emancipation may not be automatic just by living away from one’s family.) The benefits of early emancipation must be weighed against the loss of certain protections afforded a minor such as the parents’ responsibility to support their child. Because of the complexity of addressing the many issues with which homeless youth present, it is reasonable to limit the number of youth assigned to each case manager.

Housing
As with all homeless people, stable housing is an important component to improving the health status of homeless youth. Currently, communities provide varying levels of accommodations specifically for homeless youth, ranging from emergency shelters to transitional housing that prepares young adults to live on their own. Many communities have a shortage of shelter space available for homeless youth. Some communities attempt to reunite the youth with his or her family. If this is not possible, either because the youth is unwilling or the family situation is unsafe, foster care is an option. Unfortunately, foster care is also a source of homelessness for youth. Some teenagers will run away from foster homes while others “age out” of foster care without the skills needed to live on their own and they may subsequently become homeless.1 7 Transitional Living Programs (TLP) for homeless youth are useful for addressing the latter. The TLPs differ by community, but have the basic mission of assisting troubled youth through their transition to adulthood. Housing and related services are provided for up to 18 months for youth ages 16-21 who are unable to return to their homes.8 Often, the space available in such programs is limited. The Administration for Children and Families through the Family and Youth Services Bureau (FYSB) also funds youth shelters that provide emergency shelter, food, clothing, outreach services, and crisis intervention for runaway and homeless youth.8Additional FYSB programs include grants to organizations serving runaway, homeless, and street youth to provide street-based outreach and education to prevent the sexual abuse and exploitation of these young people.

Education
Homeless youth often have troubled schooling histories including having to repeat grades. In addition, homeless, unaccompanied youth face several barriers to obtaining an education. They are often prevented from enrolling in school because of liability concerns, legal guardianship requirements and curfew laws.9 In 1987, the Stewart B. McKinney Act established the Education of Homeless Children and Youth Program. Unfortunately, the program has not yet received the full funding authorized in 1987. Only 3 percent of local education agencies receive funding.10 The link between a lack of education, unemployment and poverty is obvious. In addition to needing to complete high school successfully, homeless youth need job training skills to be successful in the job market. In some communities, the lack of appropriate employment opportunities is seen as contributing to the incidence of street crime by at risk and homeless youth.

HEALTH ISSUES

The health issues discussed below were developed from a review of several studies available in the literature and may not necessarily reflect homeless youth in a specific geographic area. Since the demographics and services offered to homeless youth vary by region, State, city and neighborhood, these differences need to be considered when developing or offering services.

Barriers to Care
The barriers homeless youth face in accessing health care services are similar to those faced by homeless adults. Examples include lack of transportation, address requirements and lengthy bureaucratic processing, lack of financial resources or health insurance, and lack of awareness of services. However, because of their age and lack of experience, homeless youth are less able than their adult counterparts to overcome these barriers. The barriers to care for homeless youth include confidentiality issues, need for parental consent, distrust of adults and professional agencies, denial on the part of the youth of a need for care, and lack of coordinated services and outreach for homeless youth. In addition, for many of these young people, health care may not be a priority over day-to-day survival issues. A study in Minneapolis of runaway youth looked at barriers perceived by street youth being served by community-based agencies. The most common

When designing a health system for homeless youth, both real and perceived barriers to care should be addressed. Having services that are convenient, low or no cost and specific to meet the needs of homeless youth may help to overcome these barriers.

Substance Abuse
It is not clear to what extent substance use by adolescents leads to homelessness. Many homeless youth report using alcohol and other drugs prior to and since becoming homeless. In one study, street youth reported the highest rate of substance use, followed by sheltered youth, runaways and housed youth.1 In another study, 48 percent of homeless youth report significant alcohol use, compared to 19 percent of housed youth. 26 percent of homeless youth report using injection drugs. Most (74 percent) used illicit drugs before leaving home and about one-fifth reported that drug use contributed to their leaving home.

Parental substance use is common among homeless youth. In one study, one quarter of homeless youth report that they ran away from home because of arguments or physical violence brought on by parental alcohol use. In another study, 44 percent of homeless youth reported that at least one parent had received treatment for alcohol, drug or psychological problems.

Mental Health
Rates of serious mental illness among homeless adolescents, as reported in the literature, range from 19 to 50 percent. This figure contrasts with 4 to 9 percent of community and school samples of adolescents. The most common serious mental illness is major depression. As with the adult homeless population, co-occurrence of substance abuse disorders and serious mental illness is not uncommon.

Rates of suicide attempts are much higher among homeless adolescents than their housed counterparts. One study of street youth in Hollywood reported that up to 48 percent of homeless youth have attempted suicide with many making repeated attempts.

Many homeless youth have been exposed to both domestic and street violence. A recent study of youth in a shelter in north central Florida revealed that 66 percent of the youth had experienced some type of abuse.4 The most common form of abuse reported was physical abuse (46.5 percent), but these youth also reported sexual abuse (23.3 percent), emotional abuse (2.3 percent) and a combination of the above (27.9 percent).4Running-away behavior by youth has been identified as a method of coping with such abuse.

Either as witnesses or victims, youth are also exposed to violence on the street. In a study of homeless youth in Baltimore, 75 percent of the homeless youth reported that they had witnessed a shooting or stabbing. A study of homeless and runaway youth in Hollywood found high rates of witnessing violence and being a victim of violence. These episodes occurred prior to and since living on the street: 85 percent had seen someone being physically attacked, 44 percent had seen a dead person somewhere in the community, 31 percent had seen someone being killed and 24 percent had seen someone being sexually assaulted.14 As victims, 70 percent reported having been punched, hit, burned, or beaten up; 14 percent reported having been shot at and hit by gunfire; and 32 percent reported having been sexually assaulted, with females being more likely than males.

Because of the high rate of exposure to violence as spectators and victims, homeless youth are at an increased risk of post-traumatic stress disorder (PTSD).1 According to one study of homeless youth in Hollywood, 46 percent of homeless youth had symptoms consistent with PTSD. They are at increased risk of learning to use violence as a means of resolving conflicts, although the Hollywood study found that few youth resort to lethal forms of violence.

Pregnancy
44 Gary F, Moorhead J, and
In recent studies, the lifetime pregnancy rate for homeless adolescent girls ranged from 27 to 44 percent.1 This compares to 8.5 percent in a national survey of the adolescent female general population in 1997. From 6 to 22 percent of ever pregnant homeless girls reported having given birth.1 Because homeless teenage girls are less likely to get prenatal care and may have an inadequate diet, they may be at risk for low-birthweight babies and high infant mortality.

Sexually Transmitted Diseases
The lifestyle of a homeless adolescent places him or her at a great risk of acquiring a sexually transmitted disease (STD). This is especially true if the youth is well entrenched into the street culture, where they may trade sex for money, drugs, food, or a warm place to stay. A study of street youth in Hollywood found that 29 percent of males and 33.5 percent of females had a history of STDs. Risk factors for STDs include beginning sexual activity at an earlier age, having multiple partners, having sex with high-risk partners, and sexual abuse. Studies show that 62 to 93 percent of homeless youth are sexually active compared to 48 percent of all United States adolescents. 15 Homeless adolescents initiate sexual activity up to 2 years earlier than housed adolescents. Often, youth do not practice safe sex techniques. Only one-third to one-half report using condoms regularly.1 The low rate of condom use places the youth at high risk for STDs. Attempts to practice safe sex may be hampered by engaging in sexual activity while under the influence of drugs or alcohol. Being forced to have sex also may make it less likely that an adolescent will be able to use safe sex techniques. In one study comparing homeless youth to youth seen in a school-based clinic in Baltimore, 26 percent of homeless youth had been forced to have sex compared with 8.5 percent in the school-based clinic.

HIV/AIDS
Homeless youth are at high risk for HIV infection. The national estimate of seropositivity among homeless youth is 5 percent, but one study reported a rate as high as 17 percent among street youth in San Francisco.18 By comparison, studies on more general adolescent populations such as military recruits or Job Corps entrants report seropositivity rates of 0.2 to 0.4 percent.18 Several factors place homeless youth at risk for HIV, especially those well-entrenched in the street culture. These risk factors include survival sex (trading sex for basic needs), having multiple sexual partners, boys engaging in homosexual/bisexual activity, low frequency of condom use, and injection drug use.1 18 The frequency of survival sex has been reported as high as 43 percent in one study of street youth in Los Angeles.18 The early start of sexual activity and the large number of sexual partners also place some homeless youth at risk for HIV infection. In one study of New York City street youth, 21 percent of males and 24 percent of females reported having had more than 100 lifetime partners.18 As mentioned above, 26 percent of homeless youth report injection drug use placing them at high risk for HIV infection.

Oral Health
As with homeless adults, oral health is an often-neglected area of health by homeless youth.6 19 Very little formal research exists looking at oral health and access to dental care among homeless youth. Poor oral health affects not only the health of the individual, but also can hinder a youth’s attempts to improve his or her life circumstances. Decayed or missing teeth can lower an individual’s self-esteem and have an impact on social interactions including attempts to find employment.

There are many factors that lead to poor oral health among homeless youth. These include poor nutrition, difficulties in maintaining regular habits and an inability to clean their mouths.19 Dental services, including preventive and restorative services, must be a part of a comprehensive primary health care system.

Legal Issues/Consent to Care
The ability to consent to health care is an important issue for homeless youth under age 18. Because they may no longer have a relationship with a parent, their ability to receive even basic health care can be hindered by statutes requiring parental approval for care. Very few States have laws specifically dealing with the ability of homeless and runaway youth to consent to medical care. In most States, only laws dealing with minors in general (homeless or housed) are found, and they are scattered throughout the State’s legal code.20While there are some general issues related to consent to care, it is important that providers of health care to homeless youth understand the laws governing a minor’s consent to care for individual States.

As a general rule, minors cannot consent to their own health care. However, over the past two-to-three decades, all States have enacted laws that allow minors to consent to some health care, without parental consent or notification.20 These laws are usually related to specific disease States or medical conditions. For example, all 50 States and the District of Columbia allow minors to consent to care for sexually transmitted diseases including HIV (three States limit HIV care to testing only).21 Twenty-five States and the District of Columbia allow minors to consent to contraceptive services and 27 States and the District of Columbia allow minors to consent to prenatal care.21 The ability to consent to care for these conditions does not necessarily mean that a minor can consent to all health care services. Only 22 States allow minors to consent to general medical and surgical care. Some States allow this only under certain circumstances such as being pregnant, having a child or having reached a certain age.

Most States allow health care providers to proceed with emergency services if delaying treatment awaiting parental consent would endanger the minor’s health or well being.20Most States give minors the authority to consent to drug and alcohol counseling and treatment. Only 20 States and the District of Columbia give minors the authority to consent to outpatient mental health services. However, if a State permits a minor to consent to general medical care, these laws may be broad enough to cover mental health and substance abuse treatment as well.

Needs Assessment
Each community will have its own needs regarding health care for homeless youth. In order to understand the needs of a community, a needs assessment should be performed. This assessment should estimate the size of the target population, identify the geographic area with the greatest need, identify the health care needs of the target community and identify the existing health care resources. The best understanding of the needs of the homeless youth within a community comes from the youth themselves. The needs assessment should include a survey, formal or otherwise, in which youth can help identify the barriers in accessing care and the gaps in services. Health care, social services, mental health, dental care, substance abuse, housing, and educational needs should be identified. A firm understanding of the local legal considerations, especially in the area of a minor’s ability to consent to care, is essential.

Financial Support
The needs assessment will help a program determine the resources needed to address the gaps identified. The program should identify potential funding sources such as Federal, State and local grants, charitable community organizations, and foundations. There may be available services in the community to which a program can link, and collaborations with other organizations may provide “in-kind” support and services. Identifying these potential partners can prevent a duplication of services, thus ensuring that resources are used wisely.

Choosing a Model of Health Care Delivery
The needs assessment and projected funding available will help to determine the model of care delivery to be used. Below are examples of models current programs are using. Possible models range from having a separate comprehensive site (with primary care, mental health, substance abuse, dental, social services and housing) to linking youth with existing community services and facilitating their movement through the system. Depending on the level of need and available resources, a separate clinic setting geared exclusively toward youth may be more acceptable to homeless youth. Many homeless youth are distrustful of authority and adult systems because adults have failed them in the past. Having a youth-oriented center and staff who are sensitive to the unique needs of homeless youth can increase their acceptance of assistance and care. If it is not feasible to set up a separate clinic, setting aside services within an existing clinic is a reasonable alternative. This can be accomplished within a fixed site, at a shelter or in a mobile van. If little financial support is available or the targeted population is small, an alternative is to provide a linkage to existing services. In this case, a program may want to target most of its resources toward case management in order to help the youth navigate through an adult or general adolescent system of care.

EXAMPLES OF PROGRAM MODELS

Comprehensive Model

Covenant House-Under 21, New York, New York
Covenant House-Under 21 provides comprehensive primary health care services to homeless youth up to the age of 21 and their children. The program operates a 12-hour clinic, Monday through Friday, which includes on-site laboratory and X-ray facilities. The clinic is housed within a 24-hour crisis shelter called Crisis Center. In addition to comprehensive primary health care services, Covenant House also provides mental health services and social services such as eligibility assistance, substance abuse services, legal services and outreach services. More recently, Covenant House has expanded its services to include street outreach and satellite sites providing social services. The street outreach program operates a nightly van to offer services to youth who are in need, but are not ready to come into Covenant House. Covenant House also operates a transitional living program called Rights of Passage where, in addition to housing, youth are provided with job training and interviewing skills as well as help with job placement. All youth staying in Covenant House are given a thorough health assessment upon arrival.

Other supportive services offered by Covenant House include a Mother/Child Program addressing the needs of young homeless mothers. The program provides short-term housing along with classes in parenting skills, child development and health care. Covenant House has a school-based program that is designed to help needy high school students stay in school. The program includes counseling, educational training such as tutoring and SAT preparation and vocational training in their Regional Training Center. Each school-based program runs a youth group that allows participants to explore issues of self-esteem, conflict resolution and violence prevention.

For more information contact Diana Holmes at 212- 613-0300 or visit the Covenant House New York web site .

Fixed-Location Clinic Model

Family Health Centers of San Diego, San Diego, California
Family Health Centers of San Diego uses a model that emphasizes intensive case management. In addition to health care, case managers in this setting help with basic services such as linking youth with social services, housing services including transitional living programs, substance abuse detox, emergency shelters, and transportation for follow-up appointments. Family Health Centers of San Diego has a free-standing clinic exclusively for teens. While the clinic is not just for homeless youth, it does serve as an important source for on-going health care for this population. Teens help clinic staff and serve as peer educators. Family Health Centers of San Diego also has maintained a clinic in a homeless alternative school for 6 years.

Three years ago, starting with a planning grant from many contributors, the center began a mobile medical unit. The Teen Outreach Mobile Clinic is the result of collaboration between the health center and several partners including private and non-profit foundations, academic centers, and city, county and State health departments. The program has incorporated youth into its advisory group that assists in the design, implementation and evaluation of the mobile clinic. The mobile medical unit is set up to provide a clinic session on the street in those areas frequented by homeless youth. Youth accessing the mobile medical unit receive direct care, follow up services, and referrals for medical and supportive services throughout the community.

One of the primary goals of the Teen Outreach Mobile Clinic is to work with the youth to establish a permanent medical home. The free-standing Teen Clinic often serves in this capacity. Initially, the mobile medical unit operated only one night per week, but because of an increase in resources, it soon increased its operation to three nights per week. The Mobile Clinic is now able to provide services in three different locations around the city on a weekly basis. The locations were chosen because each has a high prevalence of homeless and runaway youth. The unit operates for 4 hours each evening and provides services to 15 to 35 youths during each clinic session. By meeting the youths’ health needs on the street, the goal is to establish a relationship with the young people, and ultimately help them integrate into more traditional health care service sites.

For more information contact David Vincent, MSW at 619-515-2371.

Collaboration Model

City of Manchester Public Health Department, Manchester, New Hampshire
The City of Manchester Public Health Department has been able to provide services to homeless youth through The Mobile Community Health Team Project/Health Care for the Homeless (HCH) program and its collaboration within the community. The HCH team provides its primary health care at a large adult shelter in Manchester. Manchester is an urban center where youth tend to congregate however, the homeless youth population in Manchester is small relative to other large cities in New Hampshire. Agencies that perform street outreach bring homeless youth to the HCH team for basic evaluations and medical attention. The HCH team cares for the youth directly and/or provides linkages to existing services as indicated. Teens who are 17 or older and who frequent the adult shelter receive care from the HCH team at the shelter. Primary health care includes physical exams, health maintenance, immunizations, Tuberculosis and HIV screening, PAP smears, substance abuse counseling, health education, dental services and eye care. Because of the rules of the shelter, teens under 17 cannot receive care on a continuing basis. After their initial visit the younger teens may be referred to Child Health Service’s High Risk Pediatric Clinic or their Teen Health Clinic at the Young Women’s Christian Association. Both offer settings sensitive to the needs of homeless youth. Future plans by the HCH team for youth programs include fitness activities and recreation sessions conducted by the Fitness Specialist and health education regarding addictions, relationships and communication skills. These interventions have proven successful with other homeless subgroups in Manchester and it is agreed that they will be beneficial to youth as well.

The HCH team recognizes the importance of providing culturally competent care, so they advocate for homeless patients and teach non-HCH providers about issues specific to homeless youth. The HCH team collaborates with other service providers on a regular basis. They include the Academy Parole Program, Our Place Program for Pregnant Teens, Child and Family Services Transitional Living Program, The Merrimack Valley AIDS Project, The After School Program for Homeless Youth conducted by the city’s Board of Education, the Homeless Liaison counselor at each public school, the Salvation Army’s Kid’s Café, The Mental Health Center and the Serenity Place Sobriety Maintenance/Crisis Shelter. In addition the HCH substance abuse counselor serves as a New Futures Community Leader, in a Statewide effort to prevent youth substance abuse. Plans are under way to set up a shelter for homeless youth that may include Alcoholics Anonymous meeting opportunities for teens. As the HCH team collaborates with other service providers, a comprehensive network is created to meet the needs of homeless youth. For many young people who are homeless, the HCH team is the point of entry toward recovery.

For more information contact Marianne S. Feliciano, BSN, Homeless Care Coordinator at 603-663-8716 or Frederick Rusczek, MPH, Executive Director at 603-624-6466.

Summary
Homeless youth are a unique subset among the larger group of people experiencing homelessness. Many of their health concerns are similar to homeless adults, however, due to their young age, high-risk behaviors and legal concerns, homeless youth require specialized services. Health care and social services geared exclusively to homeless youth can provide a place for youth to obtain needed services without the help of parents, to ensure successful transitions from childhood to adulthood, and from homelessness to being housed.

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