Health and Service Utilization Patterns among Homeless Men in Transition: Exploring the Need for On-Site, Shelter-Based Nursing Care

Article excerpt

Between September 1999 and May 2000, as part of a larger faculty/student teaching project, data describing the demographic, health problem and service utilization patterns of 183 newly sheltered homeless men (mean age = 42) seeking on-site nursing clinic services were collected and analyzed. Upon arrival to the transitional shelter, 46% of the study participants were medically uninsured or received state subsidized health benefits (49%). Almost all (99%) were in recovery from substance addiction. Despite numerous self-reported health problems, 44% had no primary care provider and 35% were seen only sporadically in local hospital clinics or in emergency departments. During the study period, nurse practitioner students and faculty managed most of the residents' episodic illnesses on-site, while assisting them to secure insurance coverage and medical appointments as a prelude to independent living. This was an attempt to curtail residents' previous pattern of waiting until medical problems became serious before seeking treatment. These findings mirrored those in studies of similar populations equating on-site delivery of health care to cost reduction. Unfortunately, many nurse-managed clinics, like our study site, fail to generate data supporting nurses' clinical efficiency and cost effectiveness in caring for homeless individuals. As such, nurses' work remains invisible and underappreciated. This article argues that future studies examining nurses' work and worth in caring for homeless individuals are necessary in determining future health care service planning with this vulnerable population.

With estimates of the number of homeless persons in the United States ranging anywhere from 0.5 to 3 million (Hwang, Orav, O'Connell, Lebow, & Brennan, 1997), there is a pressing need to compile accurate national health statistics about the magnitude of homelessness and its impact on the health care system. Part of the problem in creating a comprehensive database of the homeless, however, relates to variations in the definition of homelessness (Burt, 1996), difficulty measuring the characteristics of homeless individuals among urban, rural, and suburban communities (First, Rife & Toomey, 1994; Phelan & Link, 1999), and the invisibility of many homeless persons in society (Piliavin, Westerfelt, Wong, & Afflerbach, 1994). In addition, health and social issues range widely among homeless individuals of varying ages (Bissonette & Hijjazi, 1994; Cohen, 1999; Crane, 1998; Ensign, 1998); gender (Burg, 1994), and racial/ethnic backgrounds (Rosenheck & Seibyl, 1998). Growing numbers of a more heterogeneous population of homeless individuals demand unique approaches to successfully manage their complex health care and social needs.

HOMELESSNESS, HEALTH, AND HEALTH CARE

While earlier studies of homelessness and health care showed evidence of poorer health among homeless compared with non-homeless individuals (Brickner, Scharer, Conanan, Savarese, & Scanlon, 1991; Winkleby, 1990), newer research focuses on the predictors of health status and health care utilization among homeless individuals as evidence for present and future health care service planning (Glied, Hoven, Moore, & Garrett, 1998-1999; O'Toole, Gibbon, Hanusa, & Fine, 1999; Rosenheck & Seibyl, 1998; Spanowicz, Millsap, McNamee, & Bartek, 1998). For example, Piliavin and colleagues. (1994) identified the health attributes of 336 homeless adults in Minneapolis, Minnesota. The inclusion criterion for homelessness was broadly defined on a continuum from 1-day temporary residence in a shelter, automobile, shanty, or public building to 1-week stays with friends or relatives. Demographic variables collected for study participants included age, gender, race, education, military service, and marital status. In addition, the presence or absence of two health problems deemed to be associated with length of homelessness was documented: mental health status and alcoholism. …