A Primary Care Approach to Treating Women Without Homes

Roseanna H. Means, MD, MSc

Disclosures
In This Article

Etiology of Homelessness in Women

Homelessness occurs when income falls short of expenses for shelter. In 1993, 39.3 million persons had incomes below the federal poverty level. This group included 1 in 4 American children.[1] (The US Census Bureau reports that in 1999, 32.3 million persons had incomes below the poverty level.) Although 15% to

20% of homeless persons maintain full or part-time jobs,[10] the gap between earnings and the expenses for housing has grown wider.[1,4,11,12,13] ( According to the year 2000 report of the National Low Income Housing Coalition, 40% or more renters in the United States could not afford the Fair Market Rent, and a record 5.4 million households paid more than 50% of their income for housing.[9] Although men and women arrive at the state of homelessness via different routes (Table 2),[14] (also ref 12) insufficient and affordable housing is the single largest contribution to the epidemic of homelessness in the United States today.

The majority of homeless women report experiencing physical or sexual violence before becoming homeless or as precipitating their homelessness.[15,16,17,18,19] Further exacerbating the situation is the inadequate number of safe shelters that exist for battered women. This fact compels many women to have to choose between the uncertain trauma of the streets and the certain violence in their homes. For women, more so than for men, the poverty that propels them into homelessness is accompanied by physical and sexual trauma, which can challenge their coping skills.[20]

Route to Losing One's Home. One becomes homeless either suddenly or gradually. Generally, women who suddenly lose their homes through fire, flood, or natural disaster are quickly channeled into relief efforts, given emergency assistance and emotional support, and often regain their homes within months. Women who lose their homes through poverty tend to lose their homes slowly.

A woman with children who is unable to make ends meet may qualify for Transitional Aid to Needy Families (TANF). But over the past 25 years, Aid to Families with Dependent Children (AFDC) and now TANF benefits have not kept up with cost of living expenses.[3,27] Impoverished women make difficult choices: they may need to cut back on food, utilities, and medicine in order to pay the rent. They may need to use food pantries, sit in dim rooms, sell all their valuables, and get their clothes second hand. When they can't pay the rent, they are evicted. This process of decline can take months or years.

An exception to this pattern is women who impulsively flee abusive relationships. The loss of home and all connections is sudden, fearful, and desperate. Women who become homeless in this manner face a myriad of government agencies and demands for "proof" of their poverty in order to receive services.

Circumstances that exacerbate the trauma of losing a home are lack of social support, psychological instability, chemical dependency, catastrophic illness in the absence of any or adequate medical insurance, imprisonment, divorce, abandonment, and abrupt eviction.

Medical Benefits Available to Women Without Homes. Medicaid is the shared state and federal entitlement program of medical benefits to individuals who qualify. Studies have shown that Medicaid enrollment improves health outcomes.[28] But there are several barriers that prevent many homeless persons from getting this entitlement. A licensed clinician must complete a form and provide objective substantiation of the diagnoses. However, medical training does not include any teaching about the application or the determination process for Medicaid.

Further, one only qualifies for Medicaid by having accepted and proven medical conditions. Poverty is not always sufficient to qualify. This means having the psychological stamina to initiate and follow through on the necessary visits to undergo the requisite questions, exams, and tests and to adhere to the administrative requirements. Many times the client is asked to give details of her personal and medical histories to clerks at the Welfare Office who may lack clinical or psychological training. It is difficult to follow through with this process when one has no steady address or telephone and when one's energies are directed toward basic needs. The multistep process can also be intimidating, requiring literacy and a minimal level of executive cognitive function.

In addition, the "rules" seem to change every few years. For instance, the 1996 Welfare Reform removed substance abuse as a covered disability and imposed time limits and stringent work requirements on female heads of households. Medical and financial benefits for women were split, leaving many women confused about their entitlements. Finally, medical care is only one entitlement that requires proof and process. Different entitlements are administered from different offices. Welfare, medical care, food, and shelter are not always handled in the same venue. One then may be required to go to several agencies and to fill out numerous forms. In Massachusetts, the application for food stamps is 8 pages long.

Shelters. Shelters were intended to be a temporary response to the need for food, beds, and protection but have become permanent fixtures in the United States.[29] The first shelters for women were not established until the 1970s. "Single women" -- that is, those traveling alone or whose children have been taken from them -- are admitted to single adult shelters. Mixed single adult shelters have separate dormitories for men and women. Pregnant women or women with small children are admitted to family shelters. In many places, teenage male children are not allowed to stay in family shelters. Moving into a shelter often means separating from one's familiar places: the neighborhood, church or synagogue, one's children's schools and friends, and medical facilities. Nationally, there are more homeless women than there are beds -- which means that women without homes have no predictable guarantees of safety or protection.

Shelters may offer a variety of services: food, clothing, beds, showers, outreach services, referrals, counseling, job assistance, mailboxes, health clinics. Day shelters offer services only during the day. Overnight shelters offer many of the drop-in services mentioned as well as cots or beds. The beds can be closely spaced in dormitories. Overnight shelters often release the guests to the streets at dawn. In some cities, such as Boston, street life means lining up outside shelters and soup kitchens for admission to use the services. Arriving late can result in missing the meal or the bed for the night. Even in the North, most shelters don't permit entry during the day in the winter except under the most extreme weather conditions.

A small percentage of homeless individuals refuse to use the shelters. These are people with severe mental illness or those who see the shelters as punitive, overly confining, or dangerous. Persons who exhibit aggressive behavior can be "barred" from a shelter, regardless of their medical conditions.

Challenges to Providing Medical Care. Homeless persons receive medical care in all settings, public and private. Because urban homeless individuals move frequently within the shelter system, many receive their care at hospital emergency rooms, public clinics, walk-in clinics, and shelter clinics. The inherent mobility of this population hampers long-term therapeutic relationships in a single setting.

Some of the traditional expectations of medical caregivers do not work well with this population. Homeless persons are required to keep all their medicines with them. To expect them to take their medicines as directed while living under chaotic conditions and having unpredictable meal times may be expecting too much. Homeless persons cannot easily get bed rest, elevate a limb, apply ice, or watch their diet. Survival needs take precedence.[30]

The homeless are a transient population, not held by the boundaries of the homeless clinics or traditional medical facilities or even those of the shelters and outreach teams. Continuity of care is one of the greatest challenges in caring for the homeless. Thousands of clinical visits are performed in shelters and drop-in centers. Medical care in these settings may be unhurried, feel safe, and be less confusing or overwhelming, but because such visits are not recorded in the client's "official" medical record, important continuity of care can be lost. Because so many homeless individuals have serious medical conditions that warrant close observation and follow-up, it is vital that the lines of communication be opened between the shelters and clinics where the homeless receive their medical care. At the same time, privacy and confidentiality need to be maintained for women whose safety and privacy have repeatedly been threatened.

In some cities, public and private grant-funded Health Care for the Homeless clinics have been established through the 1987 McKinney Act to meet the medical needs of homeless persons.[31] The Health Care for the Homeless clinics have the advantage of being staffed by clinicians especially trained in the care of this population. Through their network of services, homeless patients have been able to develop long-term primary-care relationships.

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