Damian Sendler: Homelessness is a major public health problem that disproportionately impacts people with mental illness. There were 552,830 persons suffering homelessness on a particular night in 2018 based on a point-in-time count [3]. However, in 2000, it was estimated that between 2.3 and 3.5 million individuals [4] were homeless at any given time [5.] While the overall rate of homelessness in the United States has decreased over the last ten years, it has climbed in 12 states and certain areas [5]. Homelessness has climbed by 17% in San Francisco, 42% in Alameda, and 43% in Orange County during the previous two years in California [6]. Officials in Los Angeles have declared a public health crisis due to the rise in the number of homeless people and fatalities among them [7]. Issues like housing instability, economic shock-induced homelessness, or living in two places at once may be important even in areas where homelessness is on the decline [9].
Damian Jacob Sendler: Even in places where homelessness is not on the rise, psychiatry residents are likely to treat homeless patients because of the high incidence of mental illness among those who are homeless [10, 11]. Psychiatrists trained in broad public psychiatry do not have the therapeutic skills and expertise essential to treat patients who are homeless. However, approximately 60 percent of psychiatric residency programs include instruction and clinical rotations that concentrate on homelessness, and only 11 percent of these programs are accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Sendler: When it comes to psychiatry residency, there’s a typical situation that’s been documented by Braslow and Messac [14]. The authors describe a patient with a history of prolonged homelessness who shows up in an ED with psychotic symptoms and begs for treatment. There are several instances when the patient’s psychiatry resident sees that he has comparable concerns, thus she chooses to release him from the ED. The patient’s result was described as “dismal,” and he is presently in prison awaiting trial on felony charges, according to the authors.
Resident training may help improve outcomes in these situations by teaching specific clinical skills and strategies. Research on mental illness in those who are homeless is reviewed here. Following this, we examine the present situation of psychiatry residency training in the area of homelessness in the United States today. For psychiatry resident training programs, we suggest a set of educational objectives and didactics focusing on homelessness. We have also offered ways for programs to include education on homelessness into current didactics for those lacking the ability to construct a new set of didactics. As a result, we hope that this paper will serve as a wake-up call for residency directors to guarantee that the next generation of psychiatrists are prepared to care for the homeless.
Damian Sendler
The area of mental health has played a significant role in addressing homelessness for a long time. 28 percent of the homeless population has a persistent mental disease. Between 4.4 to 16 percent of the homeless population is thought to have schizophrenia, while 11.4 percent of the homeless population has serious depression [16,17]. 37.5 percent of people with major mental illness who are homeless expressed suicidal thoughts in the preceding month, and more than half had attempted suicide in their lives, according to a survey of people with homelessness.
30 percent to 49 percent of homeless persons in the United States suffer from a substance use disorder (SUD), which has catastrophic consequences: drug overdose is the primary cause of mortality for homeless people [19]. In a study of emergency department patients, those who were homeless had greater rates of alcohol abuse, binge drinking, and illicit substance use than those who were housed [20]. Drugs and alcohol may be used as a technique of coping with physical pain or emotional discomfort in older persons who are suffering homelessness. Despite provisions in the Affordable Care Act defining substance use treatment as an essential health benefit [23] and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) [24], many studies have found barriers to access to mental and behavioral health services for people experiencing homelessness [22].
Because the stresses of homelessness are distinct from the stresses of living in poverty when housed, it is crucial to recognize them. Food insecurity, bad health, and criminality may all be a problem for a patient who lives in poverty but has a safe place to reside. Loss of home, on the other hand, puts patients at risk for a worsening of all of these conditions. As a result, they may be cut off from their friends and family, as well as their jobs and their sense of purpose (Ijadi-Maghsoodi et al., manuscript in progress). Some destitute patients may be compelled to participate in “survival sex,” which is exchanging sex for necessities like food and shelter. [25] (Ijadi-Maghsoodi et al., manuscript in progress). Without a place to call home, patients may neglect their medical and mental health needs owing to competing demands, or they may be reluctant to take sedatives at night for fear of becoming sleep deprived in an unsafe environment. Mental and physical health might be harmed as a result of these pressures.
The most effective doctors, researchers, and advocates for these patients may be developed with specific training, but any psychiatrist can interact with persons who are suffering homelessness. Psychiatry residency programs might include homelessness into their curriculum in a variety of ways. Public psychiatry focuses on populations and services that are underfunded and understaffed. Residents who participate in public psychiatry training are exposed to specialized interdisciplinary services for underprivileged groups at an early stage of their training. Exemplifying this concept include the street psychiatric rotations at UNC-CH and Brown University-Boston, as well as an elective at the West Los Angeles Veterans Administration’s Interprofessional Academic Homeless Patient Aligned Care Team (HPACT).
As part of the ACGME educational competence for systems-based practice, residents may learn about homelessness. Teaching residents how to use system-level resources for the benefit of patients has been adopted by educators. Examples of systems-based practice educational interventions, such as a patient screening for housing status, include a resident quality improvement initiative [20, 23].
It is possible to learn about the importance of understanding the institutions that affect health in residency programs, such as housing and zoning rules [29]. Patients facing homelessness may benefit from increased financing for evidence-based supportive housing or community-academic collaborations if they have a structural competence approach to homelessness. Yale, UCLA, NYU, Columbia, and the University of California-Davis are among the institutions offering psychiatric training programs that include systems-based practice and structural competence curriculum.
Damian Jacob Markiewicz Sendler: As an initial step in resident training, it is important to assess patients, especially those with special needs, for their housing situation and pertinent socioeconomic determinants of their health. Health care providers that are sensitive, collaborative, and competent in caring for homeless patients would benefit from an understanding of the socioeconomic determinants of health. As a major social factor of health, homelessness has a significant impact. Estimated life expectancy for persons who are homeless is between 43 and 47 years of age [36]. A primary care doctor may not be able to treat people who are homeless because they may not be able to attend appointments or prove their insurance status, or they may have had unpleasant experiences with health care [38]. There are times when persons experiencing homelessness sacrifice health care services in favor of basic requirements like food and shelter, which may lead to delays in receiving preventative treatment and an overuse of emergency rooms. Prior to beginning psychiatric therapy, residents may need to build trust and rapport with their patients by helping them find accommodation or a job.
Damian Jacob Sendler
Residents should be aware of the particular socioeconomic characteristics of certain patient groupings. Housing instability, parental drug abuse and mental health issues, poverty, and exposure to violence have a substantial influence on children. Adverse childhood experiences (ACEs) are a term used to describe a wide range of negative life events that occurred during a child’s formative years. Academic difficulties, mental health issues, developmental delays, cognitive outcomes as well as homelessness are all possible in the future for these children [41, 42].
Additionally, residents should be aware of the socioeconomic determinants of health among homeless women. For women, domestic violence is the greatest cause of homelessness [43], and a study of moms who were homeless revealed that 93 percent had been traumatized. Their sexual abuse may persist because they may engage in “survival sex” to meet basic necessities; they are also at risk for sexually transmitted illnesses.
As a final point, veterans who are homeless have distinct social factors and resources. Veterans are more likely to be homeless than the general population for a variety of reasons, including, but not limited to, military service-related trauma, traumatic brain injury, and difficulties transitioning to civilian life [48]. Veterans who suffer from PTSD or sexual trauma in the military may be more likely to become homeless [49, 50]. Women who have been in the military are four times more likely to become homeless than women who have not served in the military [49, 51].
Re-traumatization in health care settings may occur because of the high occurrence of trauma during times of homelessness, particularly for vulnerable groups including women, children, and veterans. This group of patients may benefit from a trauma-informed approach to treatment when people assess their living situation, enquire about socioeconomic determinants of health, and address mental health problems One of the guiding concepts of trauma-informed care (TIC) is that therapy should prevent discomfort and re-traumatization by adhering to values such as trust, empowerment, and safety. Residents may help patients regain control of their health and well-being by providing chances for them to do so during clinical encounters, as well as by ensuring the safety of both the physical environment and their own emotions.
Patients who are homeless need to be referred to evidence-based health care models, and this is where resident education comes in. Patients with a history of homelessness benefit from specialized medical attention. By learning about these models, community members will get a better understanding of the fundamental components and advantages of these programs, allowing them to make more effective recommendations to other services in their area. If evidence-based services are not accessible in their areas, residents may be inspired to advocate for such programs via education on these models. HCHP (Health Care for the Homeless Program in the United States) is one example of a delivery model that offers primary care, drug abuse treatment, and other supporting services all under one umbrella. More than two-thirds of the country’s 285 HCHPs are situated outside of California. Thousands of Boston’s homeless population are served through the Boston Health Care for Homeless Program (BHCHP). Its outreach workers visit patients in shelters and on the streets in an effort to overcome stigma, transportation, and property hurdles in the clinic [54]. I
Patient-centered medical homes (PCMH), which are physician-directed care settings that offer coordinated and continuous care for patients who are homeless, are another delivery paradigm that is well-suited for this population [55]. With the Homeless Patient-Aligned Care Team (HPACT), the VA provides social assistance, primary care, and mental health treatment to homeless veterans. Using an empathetic approach to patients who are aware of their obstacles to treatment is a key component of the HPACT model. Among other things, HPACT aims to accommodate walk-ins wherever feasible, for example. HPACT reduced emergency department visits by 19% and hospitalizations by 34% in the first six months [28].
Damien Sendler: People with severe mental illness may also benefit from ACT programs, which have been shown to improve symptoms and housing status in the homeless population [56]. In addition to mental health care, these programs offer extensive case management and social work assistance to those who are homeless. ACT has been extensively researched and has been linked to decreased rates of mental hospitalization and improved housing stability [56].
For the third and final purpose of resident education, it is to examine the mechanisms that influence housing and advocate for the health of individuals who are homeless Psychologists would benefit from learning more about the various factors that contribute to homelessness, such as racial bias and the criminal justice system. This knowledge can be found in economic policy and historical practices like redlining as well as current issues such as the lack of rent stabilization or other tenant protections. Advocate on behalf of patients suffering homelessness: Psychiatrists When it comes to preventing homelessness, psychiatrists may play a key role as gatekeepers who can help patients get access to resources such as financial assistance (such as disability payments) and alternatives to jail. New York City’s NY/NY III Housing system requires that psychiatric examinations be conducted as part of a patient’s application for permanent supportive housing (HRA 2010e). It has been established as part of the core curriculum for UCLA’s residency in psychiatry to teach residents about local legislation on homelessness and the role of a psychiatrist [58]. The instructor is a member of the local government.
Cities are experimenting with new ways to combat homelessness. As part of Measure H in Los Angeles County, $40 million has been designated for such help; monies may be used to pay rent or relocation fees for those who would otherwise be homeless. There are a number of programs that can help low-income families in their area, including Housing First, Housing Opportunities for People with AIDS (HOPWA), Public Housing, the Low-Income Housing Tax Credit program, and other housing options for special populations like the elderly or those with disabilities. Those who are interested in learning more about these programs can visit the Housing First website.
This relationship between HUD and VA Supportive Housing (HUD-VASH) is critical to ending veteran homelessness for those who have served in the military [62]. Housing Choice Vouchers (HCV) for civilians are part of this initiative. In the same way that all other HCV vouchers are, HUD-VASH vouchers are also exchanged for private rents and distributed exclusively to veterans [62]. In 2018, the government allocated $40 million particularly for new HUD-VASH vouchers, in addition to renewing current housing vouchers [65]. In most cases, homeless veterans may be screened by the VA and then directed to local housing organizations for assistance.
In combination with local medical-legal partnerships, where legal specialists and health care professionals work together to help patients who are homeless, or local legal aid groups that specialize in housing and eviction defense, residents may learn to recommend and advocate for their patients [66]. Residents may learn to advise patients who are being evicted to seek legal aid via this cross-sector partnership.
Humanism is the fourth aim of resident education while working with homeless patients. A research by Braslow and Messac [14] shows that patients suffering homelessness might be stigmatized by locals, which can lead to hurdles to treatment. As a result of rude or dismissive personnel, patients who are homeless may not be able to establish treatment in outpatient clinics [67]. A few of training facilities have implemented instructional programs aimed at raising provider awareness of the plight of patients who are homeless. Storywork and reflective techniques in an interprofessional healthcare curriculum improved trainee empathy and helper behavior towards homeless patients [68].
We designed and use “Humanism Pocket Tool (HPT)” to promote humanism and minimize stigma in Veterans Affairs Greater Los Angeles Healthcare System’s Homeless Aligned Patient Care Team (HPACT). Patients’ objectives and obstacles to reaching them may be conveyed via the use of “vivid vignettes” in this tool. [69] When residents and other team members talk about their patients, they are encouraged to utilize humanistic language. Research is required to better understand the attitudes of residents and the reasons for their reluctance to treat those who are homeless, including probable worries about available resources, lack of knowledge, or lack of support. As a starting point, we propose a didactic on humanistic clinical encounters with patients facing homelessness, which would involve instruction on obtaining a narrative history and how to evaluate personal subjective responses to patients, such as prejudice or cynicism.