Survey report Health care crisis for Birmingham homeless

In May of 2009, members of this team published a scientific report that raised concern regarding access to health care for home-less persons in Birmingham.. Even though our survey in-

steps to escaping homeless-ness When seeking care at safety net health care pro-viders, many report it was not easy to get If Birming-ham is to reduce homeless-ness, we will need to ad-dress this most fundamental form of human suffering

Read on to learn about this survey, and what it shows

Introduction

No one would be surprised

to learn that life is tough for

the 2500 persons homeless

in Birmingham each night

Astonishingly this new

200-person survey shows that

when it comes to getting

health care, life is far

tougher than we ever

thought it was

Birming-ham’s homeless are in

poor health and at

higher risk of dying than

the population at large

They have enormous diffi-culty obtaining health care

of any kind They mostly

do not get the medica-tions they know they need Among homeless

parents, some had trouble

getting care for their children And many

re-port that the inability to get

health care stands in the way of obtaining a job

or housing, the two key

SURVEY REPORT

HIGH HEALTH NEEDS AND POOR ACCESS TO CARE

H EALTH C ARE C RISIS FOR B IRMINGHAM H OMELESS

S URVEY T EAM

S TEFAN G K ERTESZ , MD, MS C

W HITNEY M C N EIL

J ASON K ELLY

J ULIE J C ASH , RN, MSN

M AX M ICHAEL , MD

H ERMANN F OUSHEE , P H D

R ENEE D ESMOND , P H D

S TUDY UNDERTAKEN WITH SUP‐ PORT FROM UAB S CHOOL OF

M EDICINE ( PRINTING , SURVEY INCENTIVES ), AND UAB S CHOOL

OF P UBLIC H EALTH ( DATABASE )

FAST FACTS

Number of persons Surveyed

200

% chronically

% with no health

% with 2 or more medical conditions 43%

% who state they required medica‐

tion since becom‐

ing homeless

70%

Among this group, % who have report they have never

obtained the medi‐

cations they need

40%

*U.S Federal definition is homeless 4

or more times in 3 years or for more than 1 year continuously

In May of 2009, members of this

team published a scientific report

that raised concern regarding

access to health care for

home-less persons in Birmingham

Comparing survey data from

1995 and 2005, the report

de-tailed that the percentage of

homeless persons in Birmingham

with unmet health care needs

had risen to 54%, up from 32%

in 1995 (1) This new survey

was designed to answer the

ques-tions “what kind of health care is

difficult to obtain?” and “where

are homeless persons finding it

difficult to get care?”

Questions in this survey were

designed through an 18-month

consultation and review process

involving faculty and students

from the University of Alabama School of Medicine, the Jeffer-son County Department of Pub-lic Health and the UAB School of Public Health Many questions were modeled after standard items used in national surveys and in prior Birmingham home-less research A team from the University of Alabama at Bir-mingham surveyed 200 persons experiencing homelessness in Birmingham during a 2-month period The goal was to reflect the diversity of Birmingham’s homeless, including men and women, people who slept out-doors and people who did not

The team surveyed 50 persons at each of four shelters that serve very different subgroups among

Birmingham’s homeless: Church

of the Reconciler, the Old Fire-house Shelter, Salvation Army Shelter, and Pathways to Hous-ing In each place the team sought a random sample Partici-pants gave informed consent for the survey, and names were not recorded Of 250 eligible par-ticipants approached, 200 (80%) completed the survey This pro-ject had ethical approval by the Institutional Review Board at the University of Alabama at Bir-mingham Surveys were adminis-tered by 2 medical students and

a faculty member from the UAB School of Nursing Work was directed by Dr Stefan G

Kertesz (Birmingham VA Medi-cal Center, UAB)

slept outdoors in 2009 Per-sons who stay in shelters of-ten have an easier time seek-ing care from clinics and hos-pitals We therefore believe these data, as grim as they are, may actually offer a ros-ier picture of health care ac-cess than is actually the case

in Birmingham today

Compared to the city-wide

homeless Point-in-Time

sur-veys of 2009 and 2005, our

sample is similar in age,

gen-der and race to Birmingham's

overall homeless population

Even though our survey

in-cluded one shelter for people

who mostly sleep outdoors

(23% of our sample), we

know from other data that

53% of Birmingham homeless

S URVEY B ACKGROUND

P AGE 2

HEALTH CARE CRISIS FOR BIRMINGHAM HOMELESS

Describing Health as only “Fair” or “Poor” :

45% of Birmingham’s Homeless in 2010

10% of Americans in 2006

Compared to persons reporting “Excellent”…persons with “Fair” health have

a 44% greater chance of dying

Persons with “Poor” health have a 92% greater chance of dying (2)

Characteristics of the Survey Sample (200 persons) Basic characteristics    Age  (standard deviation)  45 (10) 

African­American  74%  White/Other  26% 

Health Insurance Present  31%  Cooper Green Card but 

No insurance, no Cooper 

Homeless characteristics    Chronically homeless  44%  Homeless with children  10%  Military service history  20%  Where person slept most in the past  week 

Street/Outdoors  23%  Emergency Shelter  47%  Friend/Relative’s  12%  Treatment Program/other  18% 

Health characteristics    Average number of medical 

High blood pressure, %  46%  Mental illness, %  46%  Chronic lung disease, %  21% 

Substance abuse in last 

References: 1 Kertesz et al Journal of General Internal Medicine 2009; 24(7): 841-847 2 DeSalvo et al Journal of General Internal Medicine 2006; 21(3): 267-275

This survey identifies serious

health vulnerabilities among

homeless persons in

Birming-ham We asked about 10

common health conditions,

ranging from diabetes and

congestive heart failure to

mental illness The average

respondent had 2 of the 10

conditions (21% had 3 or

more) As shown in the

Ta-ble on page 2, proTa-blems such

as high blood pressure,

men-tal illness, chronic lung

dis-ease, and diabetes were

espe-cially common Additionally,

6% had a prior heart attack

and 4% had a prior stroke All

of these conditions typically

require follow-up treatment

Fully 66% of the sample

stated that they were

“supposed to be taking medi-cation right now”

A separate indicator of the

vulnerability is the percent-age reporting that they are in “fair” (31%) or

“poor” (14%) general health, when compared to

Americans at large (7.4%

report “fair”, 2.4% “poor”)

In research literature, this single question has consis-tently been shown to predict greater likelihood of death and hospital utilization (1) In fact, research has consistently shown that homeless persons are 3-4 times more likely to die than the general popula-tion (2)

————*————

Homeless person’s need for each type of health care was assessed with the

following question: “Since

becoming homeless have you needed to ….” Six categories

of health service need were presented to all 200 survey participants The categories, and the number endorsing each need are shown in the

Table at right

References: (1) O’Connell JJ

Prema-ture Mortality in Homeless Populations: A Review of the Literature (http://

www.nhchc.org/PrematureMortalityFinal.pdf)

(2) DeSalvo et al Journal of General Internal Medicine 2006; 21(3): 267-275

P AGE 3

The City of Birmingham

en-dorsed a 10-year Plan to

Pre-vent and End Chronic

Home-lessness in 2007 Unaddressed

health needs can limit a

homeless person’s capacity to

pursue jobs and housing

op-portunities For example, a

person who is too sick to

work cannot easily obtain a

job For many forms of

em-ployment, particularly day

labor, needing to go to a

doc-tor’s appointment will

inter-fere with being hired An

unstable mental condition can

interfere with participation in

rehabilitation programs

Per-sons in our survey commonly

endorsed this view (see

Chart, above) Among the 77

persons who reported

need-ing mental health care, 57%

felt the problem affected their chance to get a job

Among the 83 who reported needing to see a specialty medical care provider, 24%

felt it affected their chance to

gain employment The Chart

below details the percentage endorsing this view for each problem

What type of health care did Birmingham home-less persons say they needed? (n=200)

Health care

General health care provider 153 (77%) Specialist doctor 83 (42%)

Mental health

Health care pro-vider for your

Medications 140 (70%)

For each need category, several exam-ples of providers in that category were named For example, “Specialist doctor” was “who focuses on a particular medi-cal problem, surgimedi-cal care, or OB/GYN care for women’s problems”

HEALTH CARE CRISIS FOR BIRMINGHAM HOMELESS

All 200 participants in this survey were asked if

they had ever tried to obtain care at each of 16

major health care providers The percentages

who sought care at each site are shown in the

Chart at right Homeless persons were more

likely to have sought care at major clinics and

emergency departments that are sometimes seen

as being part of Birmingham’s “safety net”,

in-cluding a federally qualified health center

(Birmingham Health Care), two major

emer-gency departments (Cooper Green and UAB),

and a faith-based clinic that receives homeless

persons from shelters at certain hours (M*Power

Ministries)

It is important to note that each site of care is not

entirely comparable to the other The listed

hos-pitals and clinics operate under different legal

mandates and expectations, with different

sources of financial support, and they do not all

offer the same services The heavy use of

emer-gency departments for care is particularly

con-cerning While hospital emergency departments

are open 24 hours daily and are required by law

to evaluate all who enter, research has suggested

that where homeless persons have ready access to

regular primary care programs, they make much

less use of emergency departments

This survey identified serious

difficulty obtaining each typ

of health care, as shown in the

Chart on the first page of this

newsletter For example,

among the 153 persons who

stated that they needed

gen-eral health care, 46% said

there was a time they could

not get it at all

The primary measure of an

unmet health care need was

computed as follows:

For each category of service

where an individual reported

need for care (see the Table

on the right of page 3), an

unmet need for care was counted if the person said

“yes” to the following

state-ment: “At least once, you could

not get this type of care at all”

This is comparable to meth-ods of measuring “unmet need” in national surveys where people are asked if

they have ever had “a time”

when they could not get a needed health care service

The figures computed on the front of this newsletter calcu-late the percentage who had a time when they could not get

care, relative to the num-ber who said they

needed the care This

ap-proach reflects the commu-nity planning question:

“where need exists, is it being met?”

However, to compare to na-tional reports on unmet need,

we can provide figures with the denominator for all per-sons asked (n=200)

The most commonly en-dorsed barriers to ob-taining care are listed in the Box at right

Barriers to care most frequently endorsed

in this survey

Could not pay Did not have access card for the facility Transportation prob‐

lems Had to wait too long

to be seen Did not know where to

go

be appointing an oversight Board very soon

3) Since transportation barri-ers were commonly cited,

we should encourage and reward those health agencies

that engage in systematic health care outreach to homeless persons,

espe-cially if those programs re-ceive targeted funds for homeless or indigent health care

4) Support programs that reduce homeless per-sons’ dependence on emergency departments and hospitals for care

Birmingham has an ongoing

need for psychiatric

ser-Addressing the problems

shown in this survey requires

committed action by

multi-ple parties No single step

will resolve the full

chal-lenge, but here are things

you can do:

1) Contribute to

philan-thropic funds providing

homeless medications and

providing free care for

homeless individuals

2) Commit to financial

and political support for

the implementation of

Birmingham’s 10-year

plan to end chronic

homelessness The Mayor,

the County and our primary

philanthropic agencies will

vices that ought to be

pro-vided outside of emergency

rooms Homeless medical respite programs operate

across the country and per-mit medical recovery for persons too sick to be on the streets, but not sick enough

to require a hospital bed

5) Support programs that promote access to health benefits where homeless individuals already have a legitimate entitlement

These include, for some, federal Social Security Dis-ability benefits, Medicare/

Medicaid or benefits for vet-erans Lastly:

6) Do not accept the

W HAT CAN YOU DO TO HELP ?

common but incorrect assertion that existing needs are being met by existing programs It’s

wrong, and these data make that clear

There are programs that can benefit from your financial and political support in ad-vancing each of these priori-ties

If you would like to know more, contact Stefan Kertesz (Chairman) and Michelle Farley (Executive Director)

of One Roof/Metropolitan Birmingham Services for the Homeless

(skertesz@uab.edu, mbsh@bellsouth.net)

One purpose of this survey was to learn where homeless persons find it easier or more difficult to obtain health care For each site

where participants said they tried to get care, we asked “How easy was it for you to get care?” Response options were Easy, Not easy or hard, and Hard The two Charts below show the responses for the four health care facilities that served 50 or more

persons in our 200-person sample These charts are offered separately for emergency departments and for clinics

The charts show that homeless persons have difficulty across a variety of settings However, we recommend against

comparing percentages across different types of organizations For example, emergency departments and clinics are

expected to serve fundamentally different purposes in the health care system Emergency departments are legally required to provide care to all who enter, and must deliver rapid care for emergencies such as heart attacks and trauma While emergency departments sometimes serve as the “provider of last resort” for persons lacking access to a regular clinic, wait times and crowding may be experienced as making the care “hard to get” Published research suggests that use of funded homeless primary care clinics reduces the inappropriate use of emergency departments For that reason, one important area for future discussion is how to enhance the availability of such services for homeless persons in Birmingham

U NDERSTANDING WHERE GET TING CARE CAN BE DIFFICULT

Opinions expressed in this document are those of the authors and do not reflect positions of the US Department of Veterans Affairs