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Understanding the Special Health Care Needs of Elderly Persons Who Are Homeless

Program Assistance Letter 2003-03

The faces of homelessness we see or hear about do not usually include images or stories of elderly persons who are homeless. Homeless elders, although increasing in numbers, continue to be a forgotten population. In an attempt to bring to the forefront the very real and growing existence of elder homelessness, this paper discusses the special health care and service needs of elderly homeless people and the barriers that they encounter when trying to access services. It also presents service-delivery models from communities that are addressing the multiple health care and social service needs of this frail and vulnerable population.

In addition to the elderly who are facing homelessness for the first time or are at risk of becoming homeless, there are also chronically homeless adults who are aging on the streets and are often multiply diagnosed, i.e. suffer from a range of complex health, mental health, and substance abuse issues. Both face unique health care and service needs that require a multidisciplinary-team approach with minimal barriers in order to achieve optimum health and housing stability.

Health Issues

Physical Health Problems
Elderly people who are homeless are more likely to experience multiple medical problems and chronic illnesses that may have gone untreated for years. In addition to illnesses common to aging such as diabetes, cardiac disease, circulatory problems, and hypertension, the health of an elderly person who is homeless is also compromised by the harsh environment of homelessness (e.g., exposure, hypothermia, frostbite). For an elderly person who is homeless in a “survival mode” and trying to find a safe place to sleep every night, addressing his or her health care quickly loses priority.

Elderly people who are homeless or recently homeless and lack social supports are especially prone to depression, dementia, and other mental health problems. An elderly demented person may present with significant memory problems, cognitive impairments, poor judgment and poor comprehension. Dementia, as well as depression, makes it very difficult to provide follow-up, which is necessary to secure housing. Both conditions may also threaten an elderly person’s stable housing (e.g., non-payment of rent because of cognitive difficulties and memory loss) or create a dangerous environment in the home, often leading to loss of housing (e.g., leaving water running or forgetting to turn off the stove).

Critical Service Needs

Case Management
For both those elderly persons experiencing homelessness for the first time, as well as those who have been living in the streets or shelters for many years, intensive case management services are an integral part of the transition into permanent housing. Along with this is a requirement to establish other much needed services such as health care and behavioral health services. Good case management allows for continuity of care, coordination of services, and follow-through, while maintaining the dignity of each individual and addressing his/her unique needs.

Once in a stable housing situation, previously homeless elderly persons may benefit from on-going case management services. The on-going involvement of social workers or case managers may help to ensure that the elderly person maintains his or her independence in the community for as long as possible. The case manager may coordinate supportive services such as in-home care, meal deliveries, transportation to medical appointments, medication monitoring, and visitors, which help to improve the quality of life for the elderly person. The case manager and support network may also monitor potentially dangerous situations such as risks for eviction (e.g. for non-payment of rent) or self-neglect.

Housing Assistance
A stable living environment is important for an elderly person in order to allow for the identification and resolution of their neglected health care and other needs. Due to the transitory nature of an emergency shelter, which often provides only a bed for the night, it is usually not an appropriate placement for an elderly homeless person. For example, it is rare that one is allowed to securely store belongings at the shelter and a bed is not always guaranteed every night. Thus stability and security are lacking.

Housing options for elderly homeless persons are limited. Complete medical, mental health and case management assessment are important in determining the appropriate housing needs of an elderly homeless individual. An elderly person found wandering on the streets and presenting with dementia, chronic medical conditions, poor hygiene and self-neglect may be deemed incapable of living independently in the community. However, after intensive medical and case management intervention, the same person may be able to thrive in a permanent housing situation with supportive services and social networks in place. Collaboration between case managers, health care providers, substance abuse counselors, and mental health providers are integral in developing a housing plan that takes into consideration the specific needs and wishes of the elderly person.

Board & Care homes or Residential Care Facilities (RCF) exist for older adults who need a minimum level of supervision. Housing and meals are provided in a communal living situation and medical supervision is available. Unfortunately, in some communities, some Board & Care homes or RCFs that will not accept a resident whose only income comes from Supplemental Security Income, making this option unavailable for seniors on a fixed, limited income.

Assisted living facilities provide housing and personalized care for elderly persons who need help with activities of daily living such as bathing, eating, dressing, and housekeeping. Assisted living facilities allow a senior to remain in his/her community while providing necessary supportive services on-site. In Boston, the Committee to End Elder Homelessness (CEEH) is currently developing an assisted living facility specifically for elderly homeless persons. The new CEEH program will provide affordable housing and services such as laundry, health care, medication monitoring, and meals.

Finally, there are subsidized senior housing programs that usually have long waiting lists. Residential hotels or single room occupancies (SROs) often become the housing of choice for many low-income seniors faced with homelessness and waiting to get into subsidized senior housing programs. Unfortunately, there has been a steady trend of diminishing SRO housing stock in many urban areas due to conversion into more high-rent condominiums, apartments, or tourist hotels (Minkler and Ovrebo, 1985).

Many elderly persons face evictions because of ever-increasing rents in many communities, which also have tight housing markets, thereby creating a need for eviction prevention assistance. Elderly persons need to be aware of their rights as tenants and of legal eviction procedures. In conjunction with general case management, eviction assistance, availability of emergency rental funds, and advocacy may prevent many elderly persons from losing their homes. An additional obstacle to finding other housing can be the inclusion of an eviction history on one’s housing/rental record, making eviction prevention assistance critical.

Financial Management
Determining an elderly person’s eligibility for financial benefits and securing a stable income is necessary to obtain permanent housing. The elderly person may be unaware of benefits such as Social Security, Supplemental Security Income, VA pensions, and private retirement pensions. In some States, very low-income older adults may be eligible for food stamps and/or State-funded public assistance. In addition, many seniors are unaware of their eligibility for Medicare upon reaching 65 years of age. Lastly, very low-income and/or disabled seniors may be eligible for the State-supported Medicaid program and therefore be dually eligible for Medicare/Medicaid. Following through with the application process necessary to secure such benefits requires paperwork and long waits for filing this paperwork that an elderly person (or anyone else for that matter) may find discouraging. Elderly persons with cognitive disabilities or elderly immigrants faced with changing immigration policies and language and cultural barriers may require even more assistance.

In addition to assistance with securing a stable income, elderly persons, especially those with significant mental health problems, cognitive impairments, or substance abuse problems, may need assistance with money management or benefit from participation in representative payee services. Such services ensure that the participant’s rent is paid or that the limited income lasts through the month to support the senior’s need for food, prescription co-payments, and transportation.

Nutritious Meals
A well-balanced, nutritious meal is crucial for an elderly person with ailing health, chronic medical conditions, and living in a harsh environment on the streets and in shelters. Elderly persons may utilize community soup kitchens and senior nutrition sites available in many cities to provide meals exclusively for persons age 60 and older. Senior meal sites provide what may often be the only hot, nutritious meal an elderly person will have for the day. In addition, mealtime may also serve as a significant place for socialization and interpersonal contact.

BARRIERS TO ACCESSING SERVICES

Elderly persons who are homeless encounter barriers to services similar to those that younger homeless persons experience (e.g. lack of transportation, long application processes to obtain services, lack of awareness of resources). However, they often find these barriers more difficult to overcome because they are frequently burdened by poor health and chronic medical conditions, frailty, poor mobility, and physical limitations common to aging such as loss of hearing or sight. In addition, for some seniors, aging may come with cognitive impairments and changes in mental status such as dementia. The barriers homeless seniors face can be grouped into external or real barriers and internal or perceived barriers. External barriers are those obstacles encountered in the physical world, while perceived or internal barriers refer to an individual’s perceptions or beliefs regarding his or her environment which may prevent him/her from seeking much needed services. In order to make an already overwhelming social service system more accessible and to provide services that effectively address the needs of elderly persons who are homeless, one must look at both external and internal barriers.

A. External Barriers

Difficulty Utilizing Shelter System
The emergency shelter system, which generally lacks sensitivity to sub-groups among homeless persons, can be an especially harsh environment for an elderly person. Most shelters, when developing shelter rules and regulations, do not take into consideration the physical limitations and multiple medical conditions many elderly persons face. For instance, in addition to having to stand in long lines in order to “sign-up” for a bed, elderly persons often have a particularly hard time using a general shelter system that requires a late entry (sometimes as late as 9:00 p.m.) and very early morning exit. Normally, shelters do not allow for adequate hygiene and self-care. Not only is it difficult to maintain one’s personal hygiene, but elderly persons also undoubtedly have a difficult time maintaining their health and following up on medications while staying in a shelter. Medications are at risk of being lost or stolen in a crowded shelter where there is usually a lack of private, personal space. In addition, shelters located up or down stairs may not be accessible to those with limited mobility.

Elderly persons who are homeless, especially those who are homeless for the first time and may lack “street smarts”, are easy targets for assault and robbery by the younger residents staying at the shelter, particularly if the elderly person is under the influence of alcohol, drugs, or medications. Many seniors may feel unsafe in shelters and avoid staying in them altogether, only to expose themselves to equally dangerous elements on the streets.

Lack of Respite Services and Transitional Housing Programs
Elderly persons who are homeless often have compromised immune systems related to aging, poor nutrition, and chronic medical illnesses. They are often hospitalized and may be prematurely discharged from hospitals or discharged without a housing placement, making it difficult, if not impossible, to adequately recuperate and regain their health. This only exacerbates existing medical conditions and likely leads to repeat hospitalizations. Elderly persons who are homeless need recuperative care or respite services that allow for the time necessary to heal.

Sometimes persons in substance abuse treatment programs, hospitals, or jails are thrust into homelessness after being prematurely discharged into the streets or shelters. It is not unheard of for an elderly person, for instance, to lose his/her housing after an extended hospital stay especially in cities where there is a tight housing market. In urban areas where high rental market rates persist and affordable housing has long waiting lists, transitional housing programs may be necessary to immediately stabilize an individual’s situation. Elderly persons who are faced with homelessness need a stable place to stay while receiving case management services and awaiting permanent housing. Especially for persons who are being discharged from substance abuse treatment programs or jails, timely follow-up with supportive services and stability is necessary to decrease risks for relapse or return to incarceration.

Conflicting Service Hours
During a consumer focus group conducted for the preparation of this paper, a 67 year old senior who had been homeless for about a year summarized one of the access barriers that many homeless people encounter: “Do I line up so that I can get a bed for the night, or do I get my foot taken care of?” Homeless persons find that the business hours when essential medical care, shelters, or meals are available can overlap and interfere with one another, forcing the homeless person to neglect some of the assistance that they require.

Lack of Transportation
There are two factors that, when combined, compound people’s difficulty in access services: conflicting service hours (discussed above) and a lack of available transportation. Lack of transportation may especially be difficult for elderly persons who, due to poor mobility, cannot get around as easily or as fast as their younger counterparts. Even in areas where sufficient public transportation may exist, an elderly person with poor cognitive capacity will have a difficult time following directions and utilizing available public transportation.

Lack of Awareness of Resources and Benefits
As with other age groups experiencing homelessness, lack of information about resources and eligibility requirements is a significant barrier to accessing services. Many seniors may not be aware of what benefits they are eligible for or they may not know how to begin applying for benefits (e.g. SSI, food stamps). The daunting paperwork procedures, and extensive follow-up needed may be intimidating and prevent some persons from applying for benefits or assistance altogether.

Elderly persons, especially those with physical limitations and/or changes in their mental status, require extensive assistance when applying for benefits or housing, a process that often requires supplementary documents and personal interviews. Not only is it important to make persons aware of their eligibility, but it is essential to make certain that there is follow-through with appointments and completing paperwork.

Inadequate Substance Abuse and Mental Health Services
Annie is the shelter director of the Lazarus Day Center, a daytime drop-in center for seniors 50 and older located in Seattle, WA. In working with chronically homeless elderly persons, many of who have a history of substance abuse or are often dually diagnosed, she states, “We need to get them [homeless seniors] into a program as soon as they say they’re ready.”

Lack of access to adequate mental health and substance abuse services poses a challenge to providing comprehensive behavioral health evaluations and treatment. Elderly persons who are homeless or are in jeopardy of homelessness are at great risk for depression. Chronic mental illness and/or substance abuse that remain undiagnosed and untreated can be a factor leading to homelessness or prolonged homelessness. Proper mental health evaluation is an important component in long-term case management planning toward stabilizing an elderly person’s homeless situation.

Lack of Affordable Housing
One of the dilemmas faced by homeless persons who are elderly is the long waiting list for affordable senior housing. In most urban areas, the waiting list for subsidized housing can be as long as 3 to 5 years. This is especially true in areas where the rental market tends to be most expensive and elderly persons with limited incomes who becomes homeless are unable to find alternate housing that is within his or her economic means. Compounding this lack of affordable housing are the stringent and often extensive criteria for acceptance into many existing affordable housing programs. Most housing programs seek applicants who have clean housing histories with no prior evictions. In addition, they are often hesitant to accept applicants who have a history of mental health, substance abuse problems, or past criminal records.

Lack of Economic Resources
The amount of financial assistance an elderly person receives from Social Security is dependent on the number of years or quarters they have worked and contributed to the Social Security system. Currently, if one retires at the age of 65, the individual will receive the maximum benefit each month. However, if one retires before reaching the age of 65 years, the amount they are entitled to receive every month is decreased. In some States, Social Security can be supplemented with Supplemental Security Income (SSI) for seniors who are 65 years or older and whose monthly income is below the SSI limit. For many elderly persons 65 years or older who do not have a work history with Social Security, SSI becomes the primary source of income. The cost of living, including housing and other expenses, is often not sufficiently covered by SSI.

One of the barriers which Twyla Smith, Health Care for the Homeless nurse practitioner in Seattle, WA, observes is the reluctance and hesitance of many elderly homeless persons to accept any housing that will significantly deplete their Social Security or SSI check. She states, “The [homeless] seniors are aware of their need to accept certain services such as housing, but when it comes down to parting with the very little money they have, they are adamant about not wanting to.”

Some elderly persons find it necessary to obtain employment in order to supplement their limited monthly income to meet the costs of basic housing and living. However, elderly persons may have medical and physical conditions that may make it difficult to work. Many others encounter difficulty in obtaining employment, not because of any physical limitations, but because of their age. While some seniors may access employment training and placement in part-time work through National Council on Aging programs, others may face the discriminatory practice of ageism in the job market, which may defeat their attempts to establish or improve their income.

B. Internal Barriers

Lily Cabeza, nurse case manager for the San Diego Health Care for the Homeless Program in San Diego, CA, has found that elderly people who are homeless tend to be more difficult to work with than her younger patients because of the greater distrust that elderly people experiencing homelessness have toward service providers. She shares that many of her elderly patients who are homeless have a “fear of the system” and a fear of “being put in a home”. An elderly person, afraid of losing his or her independence, may think that seeking help from a social service agency will lead to institutionalization. Unfortunately, the lack of trust in providers and fear of social service agencies prevents elderly persons, either homeless or at risk of becoming homeless, from receiving the services they need.

The pride and self-perception an elderly person carries may also be a barrier that prevents him or her from seeking much-needed services. Case managers at St. Anthony Foundation in San Francisco, CA, observed among many of their elderly homeless clients, a resistance to accept services because “they [homeless seniors] do not want to rely on anybody.” To some of the elderly people who are homeless, accepting services may equate to admitting that they are aging and are no longer as independent as they had been previously.

Risk of Victimization

Elderly persons who are homeless are at greater risk for victimization and injury than their younger counterparts. Because most seniors receive a regular monthly income (e.g. VA pension, Social Security, and SSI checks), and are less likely to be able to defend themselves, they are perceived as easy targets for robbery (Hudson, et al, 1990). Because of their limited physical mobility, frailty, and often, cognitive impairments, elderly persons are extremely vulnerable both on the streets and in the shelters. They may also be less likely to report an incident and more likely to be ignored by law enforcement. In addition, an elderly person with poor mental status and impaired judgment may be at risk for being abused financially. Because they are particularly vulnerable to victimization and abuse, special awareness and attention should be given to the protection and safety of elderly persons who are homeless.

Recommendations from Providers Who Serve Elderly People Who Are Homeless

  • Provide comprehensive centers where elderly persons experiencing homelessness can access multiple services under one roof.
  • Utilize a multi-disciplinary team model bringing together the skills of different providers (e.g. primary health care providers, social workers, mental health providers, substance abuse counselors), which allows for comprehensive assessment and evaluation.
  • In areas where there is a long waiting list for subsidized housing and a high-cost rental market, provide transitional housing programs to quickly move elderly persons out of shelters and off the streets. This allows seniors a period of time to “reconnect” and establish interpersonal contacts and social support.
  • Homeless persons 55-64 years old and not eligible for benefits such as Medicare do not have access to an affordable health insurance alternative, although many may have chronic medical conditions similar to those who are older. Development of health care resources for this age group is essential.
  • Provide outreach to elderly persons in shelters and on the streets, as well as those in the community who may be isolated and at risk of homelessness due to depression and other health problems.
  • Recognize that the “face of homelessness is changing”. In most discussions around homelessness, the needs of elderly people who are homeless and their special circumstances are often not included.

Community Models (What is working?)

Multidisciplinary Team Service-Delivery Model
Elderly persons who are homeless often present with multiple, chronic medical and social service needs that may be most effectively addressed using a multidisciplinary team approach. A multidisciplinary team service delivery model brings together services and providers under one roof. At North of Market Senior Services (NOMSS) in San Francisco, CA, homeless seniors age 55 and older who walk in immediately have access to primary health care, case management, substance abuse counseling, social programs, referrals to emergency shelters, assistance with permanent housing, and a hot, nutritious meal. The homeless case manager collaborates with substance abuse counselors and primary health care providers on-site in objectively assessing the needs of the client and assuring quality care.

For an elderly person who has been homeless for many years, transitioning into permanent housing may be difficult. NOMSS continues to provide support to previously homeless seniors and assists in their transition into permanent housing through long-term case management. Case managers work with seniors by coordinating support services which allow the senior to continue to live independently in the community and remain in stable housing for as long as possible.

For more information on NOMSS, contact Gay Kaplan, Executive Director, at 415- 885-2274.

Emergency and Transitional Shelters for Elderly People Who are Homeless
St. Martin de Porres in Seattle, WA was founded in 1984 as an emergency shelter for homeless men age 50 and older. The shelter accommodates 212 persons every night. Forty-five percent of shelter users are in their 50s while fifty-three percent are in their 60s. A large segment of the population served are veterans who are elderly and homeless. Twyla Smith is a Health Care for the Homeless nurse practitioner who provides clinic services on-site five times a week and establishes primary care for the clients at the shelter. She states that the shelter provides an especially safe and secure place for the older homeless men who increasingly are becoming targets for assault and robbery. In addition to health care, the shelter provides an evening meal, shower and laundry facilities, a library, and a respite program for participants with medical recovery needs.

For more information about St. Martin de Porres in Seattle, WA, contact Twyla Smith, Health Care for the Homeless nurse practitioner, at (206) 323-6341.

Shelter of the Cross, Inc. located in Danbury, CT is a transitional housing program for elderly people who are homeless ages 58 and older. The founder, Karen Messina, observed in her community a growing number of seniors living on the streets and an emergency shelter system, which was difficult for the seniors to access. Receiving referrals from churches, nursing homes, relatives, and emergency shelters, Shelter of the Cross works with up to 12 homeless seniors at a time, providing supportive services and housing for up to 2 years. During this period, the participants have a stable place to live while being placed on the waiting list for more permanent and affordable housing. They also have the opportunity to address neglected medical conditions, receive podiatry care, attend AA meetings, and, with the support and assistance of a case manager and staff, to consider reunification with their family.

For more information about Shelter of the Cross, Inc. in Danbury, CT, contact Karen Messina, Director, at 203-791-1050 or visit the Web site, www.shelter-cross.org.

Day Shelters and Drop-in Centers
Most emergency shelters open their doors after 6:00 p.m. to a long line of people seeking a bed for the night and then require everyone to leave as early as 6:00 a.m. the next morning. For a frail, elderly, homeless person, finding a place to stay during the hours when the emergency shelters are closed may be an extreme challenge. Lazarus Day Center in Seattle, WA serves homeless adults 50 years old and older by providing a safe place for them to stay during the day. The center, which is open 365 days a year, also offers a hot meal at lunchtime, showers, a clothing bank, computer and Internet access, restrooms, laundry facilities, telephones and a mailing address for their clients to use. For some, the center serves as a starting point for connecting with community resources and social services.

For more information on Lazarus Day Center, contact the Shelter Director at 206-623-7219.

Housing Development
The Committee to End Elder Homelessness (CEEH) was founded in Boston, MA in 1991 by a group of seven professional women who, in their work as public health nurses, social workers, and activists, became aware of high-risk homeless elders in their city. CEEH conducts outreach to homeless seniors 55 years and older and provides permanent housing and supportive services through facilities it develops, owns, and operates. To date, CEEH has developed four residences, with a total of 70 units, specifically for Boston’s elderly people who are homeless.

CEEH collaborates extensively with city agencies and other community-based organizations to bring such supportive services as primary health care to the residents of its buildings. CEEH also collaborates with Elders Living at Home Program that places homeless seniors in transitional shelters while awaiting permanent housing in one of the residences operated by CEEH.

CEEH conducts vigorous outreach to those at risk of becoming homeless and to chronically homeless elders. They seek to house the frailest seniors with the worst histories of homelessness. Elizabeth Babcock, executive director of CEEH, emphasizes that while most housing programs have very stringent rules for acceptance, CEEH seeks out homeless seniors who may otherwise be considered “difficult to house”, such as those often having a history of evictions, and those with substance abuse and/or mental health problems.

CEEH not only recognizes the dire need for development of affordable housing for elderly people who are homeless, but also the importance of providing comprehensive supportive services necessary for maintaining stable housing as well as a person’s independence in the community.

For more information on CEEH, contact Elizabeth Babcock, Executive Director, at (617) 369-1550

Community Education, Outreach, and Advocacy
One of the major barriers elderly people who are homeless face in accessing services is the lack of knowledge about resources in their community. Navigating through a social service system may be overwhelming, especially for seniors who are experiencing homelessness for the first time. Planning for Elders in the Central City (PECC), based in San Francisco, CA recognized the need to provide educational outreach to homeless elderly people in the community and increase their awareness of potential resources. Every year, PECC organizes a week-long "Homeless Senior Survival School" during which service providers give presentations to diverse groups of seniors, all experiencing homelessness. While learning about such general information as establishing primary health care and obtaining benefits such as Medicare, Medicaid, SSA, SSI, and VA pensions, the seniors also learn about resources specific to their own needs, such as shelters, housing assistance, and case management. The seniors are provided with practical information: Which shelter is the best one for an elderly person? Where can I store my belongings during the day? Where can I go to eat? How do I get on the waiting list for housing? After participation in the week-long program, the seniors "graduate" and have the opportunity to continue involvement with PECC as members of an advocacy group. The advocacy group meets with the San Francisco Mayor's Office on Homelessness every month with the goal of increasing the city's awareness of elder homelessness.

For more information on PECC, contact Jeanette Ilagan, Senior Survival School Director, at (415) 703-0188.

CONCLUSION

The programs highlighted in this paper are making significant contributions in their communities to address the needs of older adults facing homelessness, and yet the problems associated with elder homelessness will continue to grow as the Baby Boomer generation ages. Someone who has been homeless for most of his or her adult life may “age into elder homelessness”; or perhaps one unexpectedly becomes homeless for the first time during his or her “Golden Years”. Either way, the needs of the elderly homeless require special attention. Measures to address these needs will require multidisciplinary approaches that offer age-sensitive services, have minimal barriers to access, and are accommodating for the frail and multiply diagnosed senior. While this paper discusses the general health care and service needs of elderly homeless persons, individual communities will also have to consider the specific needs that may be encountered by seniors living in different geographic regions or in rural environments, and by seniors belonging to special demographic populations, including homelessness among the elderly in different racial and ethnic groups.

This paper can be used as a tool for increasing awareness about elder homelessness in local communities and among homeless service providers. As we continue to recognize the existence of elder homelessness, we are poised to ask questions about their special health care and service needs. Subsequently, we hope to implement recommendations to create resources and housing, develop prevention programs, and eliminate barriers to accessing services for seniors facing homelessness.

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