Ch.41: Care of Persons who are Experiencing Homelessness and Mental Illness

Community Services for Persons with Mental Illness who are Homeless

-Diverse services and integrated systems are essential to address all aspects of the life situations of people who are without a home and experiencing psychiatric disorders -Essential components include Safe Havens -The agencies that provide these services must develop a physical and emotional atmosphere that conveys a sense of caring and community -Often, community agencies are located at one site, much like a shopping mall, so that the person or family does not have to travel to numerous separately located agencies to get their needs met

Improving Quality of Life for Persons with Mental Illness who are Homeless

-Interventions that improve quality of life include providing food, clothing, and assistance with housing; addressing physical health problems; promoting safety and self-esteem; and educating the person to decrease the risk of victimization -A trusting relationship with the care provider and ongoing follow-up care is also necessary -People who have been homeless for several years have greater difficulty readjusting to stability and need more time for healing, depending on illness severity, comorbidity, and available support system -People who are experiencing homelessness, including those with psychiatric disorders, become creative at surviving on the streets -Explore resources with the individual or family

Recovery-Oriented Care for Persons with Mental Illness who are Homeless

-It is beyond the scope of most mental health services to meet many of the urgent needs for individuals with mental illness who are homeless -The mental health system is often the first contact for the person who is homeless or facing homelessness -The mental health team should have a working knowledge and relationships with community resources that provide housing, physical health care, financial support, and legal support

Employment Services for Persons with Mental Illness who are Homeless

-Job placement is most likely when an employment program teaches basic job-seeking skills (e.g., resume writing; interview skills; appropriate attire, hygiene, and behavior; and computer skills) and offers job training in settings that prepare the person for the real world and real jobs -Case management during employment training can increase self-confidence, teach budgeting skills and methods of coping with the stresses of regular employment, and link the person with community resources -It can also help to teach various skills for job retention and career development -The employment service should periodically follow up with both the employee and their employer to ensure a successful record and movement to independence

Risk Factors for Homelessness Among People with Serious Mental Illness (Societal and Family)

-Lack of affordable housing; affluent economic times have caused housing prices to soar out of reach, to reduce construction of low-cost housing, and to create a tight rental market -Insufficient disability benefits; Social Security income recipients are below the federal poverty level -Lack of coordination between mental health and substance abuse systems -Waiting lists to receive a subsidy that requires the person to pay only 30% of income for rent and utilities -Lack of job opportunities for disabled people -Stigma and discrimination; resistance to community housing for people with mental illnesses is widespread -Poor family relationships; willingness to help the ill person is exhausted as relatives cope with frightening or disturbing behavior and receive insufficient help from the community or medical profession

Spiritual Assessment for Persons with Mental Illness who are Homeless

-Listen for expressions that convey a spiritual faith, a connection to a transcendent being, or a belief system that helps the person endure -Questions about the spiritual dimension may convey an invitation to talk about an aspect of life that is often ignored but that may be very important to the beliefs, and preferred practices will help determine relevant therapy approaches

Nursing Implications for Recovery, Homeless, and Mental Illness

-Many of the predictors for recovery occur within the context of permanent housing -Finding housing facilitates mental health recovery

Risk Factors for Homelessness Among People with Serious Mental Illness (Environmental)

-Mental Health System Factors -Inadequate discharge planning with a lack of appropriate housing, treatment, and support services -Lack of funding for community-based services -Lack of integrated community-based treatment and support services for individual and group therapy, medication monitoring, and case management -Lack of community-based crisis alternatives for housing, health care, and respite care for families with risk for rehospitalization and loss of residence -Lack of attention to consumer preferences for autonomy, privacy, and integrated regular housing -Changing environment, such as loss of home caused by natural or human-made disaster

Advocacy for Persons with Mental Illness who are Homeless

-Nurses can share experiences and research findings with the local chapter or national headquarters of NAMI and with state legislators and members of Congress who are involved in developing legislation and policies related to people who are homeless, mentally ill, and substance abusing -Continued advocacy is essential to convey the perceptions and needs of this population, to influence allocations for needed programs and services, and to end the social injustice of chronic homelessness

Screening, Brief Interventions, and Referral to Treatment for Persons with Mental Illness who are Homeless

-Screening, brief interventions, and referral to treatment (SBIRT) integrates initial screening with brief interventions or referral to treatment for people who may have substance use disorders and co-occurring mental disorders -SBIRT is particularly useful for individuals who are homeless -The screening requires little time—5 minutes to screen and 10 minutes to provide the interventions

Meeting Spiritual Needs for Persons with Mental Illness who are Homeless

-Depending on the person's beliefs, the nurse may explore ways to meet spiritual needs -In one study, respondents listed the following as ways to meet spiritual needs: pray and put trust in God, hope that things will get better, obtain strength from religious beliefs and say these beliefs to self daily, seek a religious worker and attend religious services, talk about the meaning of the life situation with someone who is understanding and caring, and read devotional material (e.g., the Bible or the Koran) -Providing physical resources, social services, and social and legislative advocacy counter the negative social and emotional effects of homelessness for the person and family

Homelessness and Hope

-Deprivation of needs, the sense of isolation and stigma, and the lack of accessible resources may be of short- or long-term duration -In turn, self-confidence and sense of competence can be eroded -Persons who have been or are homeless and have mental illnesses have typically endured and coped with constraints or problems with extreme stressors or catastrophes and negative life events -Instilling a sense of hope and possibility of recovery from homelessness and mental illness is important -Many people who experience homelessness maintain hope and a positive attitude, which in turn helps them to reach out to help, take advantage of opportunities, and become part of the housed population

Evidence-Based Nursing Care for Persons with a Mental Illness who is Experiencing Homelessness

-A holistic perspective is essential for assessing any person or family unit who is experiencing homelessness -Assessing a person who has a mental disorder and does not have a home requires patience and skill -Generally, these individuals have not been following a recommended treatment regimen and are symptomatic

Housing First

-A homeless assistant approach that prioritizes permanent housing to people experiencing homelessness -This approach is adopted by communities in providing services to people who are homeless -It is guided by the belief that people need basic necessities like food and housing before they can attend to other issues such as recovery from a mental illness, secure a job, and develop meaningful relationships -Case management, living skills classes, and other services are provided as "wrap-around" interventions as needed -There is a direct relationship between the safety and security provided by the Housing First program and a decrease in psychiatric symptoms and chronic homelessness, with an increase in a sense of independence, choice, and mastery of living skills

Definition of Homelessness

-A lack of a fixed, regular, and adequate nighttime residence, which includes places not designed for or ordinarily used as a regular sleeping accommodation (i.e., car, park, abandoned building, bus/train station), as well as publicly or privately operated shelters or transitional housing, including a hotel or motel paid for by government or charitable organization

Chronic Homelessness

-A person is considered to be experiencing chronic homelessness when they spend more than a year in state of homelessness or have experienced a minimum of four episodes of homelessness over a 3-year period -The experience of being homeless for a long time results in a sense of depersonalization and fragmented identity; a loss of self-worth and self-efficacy and a stigma of being "nothing," "a bum," "lazy," and "stupid" -They may have lived in poverty for years -People who are homeless are often chronically ill, jobless, or have recently lost all financial resources -Educational level varies greatly, from less than an eighth-grade education to doctoral degrees -Some people wrongly associate all homelessness with mental illness, violence, and alcohol or drug addiction -A person who is homeless for the first time or for a few months is more likely to have a more positive outlook than a person who has been experiencing homelessness for a longer period of time because the chances of recovering economic and social status are greater -Biographies and research describe the tragedy and nightmare of being homeless

Clinical Judgment for Persons with Mental Illness who are Homeless

-A person who is experiencing homelessness has several immediate needs -The first priority is safety from immediate harm to self or others -The next priority will depend upon the current housing situation—do they have safe shelter at night -The nurse should consider whether the gender, mental status, and history of mental disorders -Physical health needs should be a priority before addressing mental health needs

Homelessness

-A word that evokes images and feelings in everyone -Without a stable dwelling place, meeting basic needs is difficult -Homelessness means carrying all of one's possessions in a car, suitcase, bag, or shopping cart or storing necessities in a bus station locker or under the bed of a night shelter -It means no chest for treasured objects, no closet for next season's clothing, no pantry with food to eat, no place to entertain friends or have solitude, and no place for a child to play -People who are experiencing homelessness tend to be ignored or not seen by the general population, who hurry on their own way -The homeless community is treated poorly by society and often suffers from acts of violence -Many attacks go unreported -Hate crimes against the homeless community are a vital issue in the United States -Perpetrators of these acts are generally males under age 30

Assessment Tips for the Social Assessment

-Ask about support systems, people who could be helpful, and what services have been or could be used -Determine whether the person is isolated from the family, and if so, if it is by personal choice rather than by family choice -Respect that the person who feels isolated may avoid talking about their biologic family -Explore if the patient views a homeless peer, local pastor, counselor, or another health care provider as "family" or as a support system -Convey genuine interest in the person and convey that others may also care -Questions may be the catalyst to reestablishing family ties

Integrated Services for Persons with Mental Illness who are Homeless

-Assertive Community Treatment (ACT) programs focus on service delivery to the homeless and mentally ill population by a transdisciplinary team of 10 to 12 specialists with a 1:10 staff-client ratio -A single, integrated, mobile staff team uses outreach, case management, practical assistance and support, and rehabilitation services to maximize the possibility that the most disabled consumers will live independently in the community and have a good quality of life -The team provides counseling and advocacy; monitors the person's management of housing, income, medication use, and leisure activities; and provides opportunities for employment if appropriate -Substance abuse management and physical health care are provided as needed -Ongoing social support groups; membership in day treatment programs; attendance at meetings of AA, Narcotics Anonymous, or Cocaine Anonymous; or the local National Alliance on Mental Illness (NAMI) or Mental Health Association can help the person remain in the community and live independently or with family -Support groups foster peer socialization and problem-solving, enhance self-esteem, and offer many activities (e.g., art and recreation therapy, legal assistance) -For a number of years, the SAMHSA and the Center for Substance Abuse Treatment have funded treatment programs for women and young children -Long-term stays have been found to predict positive treatment outcomes, including lower rates of drug use, criminal behavior, and unemployment -Improved parenting and mother-child relationships, less child abuse and neglect, improved developmental outcomes in children, and lowered costs for mother and infant health are other benefits

Case Management for Persons with Mental Illness who are Homeless

-Case management is essential in addressing an individual's needs and preventing the person from becoming lost in the complexity of community services -Case management involves systematic assessment, planning, goal setting, counseling and other interventions, coordination of services, referral as necessary, and monitoring of the person's or family's needs and progress -It enhances self-care capability and quality of care, decreases fragmentation, provides for cost containment, and reduces unnecessary duplication of services or hospitalization -The case manager is the gatekeeper and facilitator who may at first network with services on the person's or family's behalf and then encourage them to deal directly with other service providers to obtain bus passes and transportation, children's services and supplies, medical or obstetric care, or housing -The nurse is the ideal team member or case manager because of knowledge about both psychiatric and physical diseases and the ability to develop therapeutic relationships and stay connected with persons or families who are homeless and with the health care system

Homelessness and Mental Illness

-Children, adults, and families can become homeless from encountering a natural disaster, home fire, some situational crisis or unexpected overwhelming life situation, or economic hardship -Others find themselves homeless because of problems related to substance use or mental illness -Homelessness can be either sheltered or Sheltered homeless individuals obtain temporary or transitional housing operated by public and private agencies for individuals and families who do not have stable housing -Unsheltered homeless individuals live in places that are not used for housing, such as cars, parks, abandoned building, tents, or bus/train stations -As the United States is emerging from the COVID-19 pandemic, homelessness will continue to be a national crisis -Homelessness has been increasing since 2016 as likely consequences of the national recession, economic disparities, and the pandemic

Overcoming Barriers to Care for Persons with Mental Illness who are Homeless

-Cost and lack of insurance are the biggest barriers to health and hospital care for people who are homeless -Another barrier is the inability of this population to carry out treatment recommendations; survival is their first priority -Compliance with medication and treatment regimens is difficult because successful treatment requires collaboration, monitoring, time for medication and other measures to be effective, and a secure place to keep medication -People with mental disorders who are experiencing homelessness often cannot routinely get prescriptions filled -Medicine may be stolen -It is necessary for the person or family unit to have a place to keep medications that can be reached at the necessary times and to have access to primary care services for regular check-ups, assessment for adverse drug responses, and necessary blood monitoring -The priority for people who are experiencing homelessness is meeting the basic needs—food, shelter, and so on -Care for the response to the mental illness is secondary -Use Maslow hierarchy of needs as the guiding framework when you are planning interventions

Cultural Assessment for Persons with Mental Illness who are Homeless

-Cultural value differences exist between people who are experiencing homelessness and people in the dominant American culture, to which most providers of health care subscribe -Thus, providers and the person who is homeless and needs health care may experience cultural conflict in their norms of health and illness, basic value systems and priorities, and perceptions about health care -Health care providers expect patients, including those who are homeless and mentally ill or chemically dependent, to problem solve, become more independent, and be future oriented -These values affect assessment, treatment, and interactions with the person and can interfere with the nursing process and patient response to the health care system -Consider how the person perceives their everyday life and vary the assessment and therapy approach accordingly

Day Treatment Programs for Persons with Mental Illness who are Homeless

-Day treatment provides a bridge between institutional and community care for people with mental illness or substance abuse problems -Participation in structured day treatment programs can provide emotional and practical support and strengthen ties to community services and potentially to family and friends -A day treatment program can provide legal assistance, help with finding employment and independent housing, and a mailing address for people who are homeless -It can provide case management, assistance with goal setting and problem-solving, and psychiatric or medical care -The day treatment program may incorporate adult basic education classes to increase literacy and survival skills, and general education development (GED) classes for those who want a high school diploma, and computer skills to improve employment options -A Living Skills Program typically includes content in nutrition, budgeting, parenting, household and family management, tenant responsibilities and rights, and employment readiness -Such classes are especially useful to women who will no longer be receiving welfare benefits -The person can receive assistance applying for government benefits, if qualified, and obtaining identification, such as a birth certificate, if needed -The informal environment of day treatment programs promotes a feeling of camaraderie, self-confidence, trust in staff, and aspirations for independent living

Family Response to Homelessness

-Family homelessness, whatever its cause, has an especially adverse effect on children -Underprivileged children move two or three times within 1 year before becoming homeless and moving into a shelter -Children experiencing homelessness are generally school-aged or younger -These children have high rates of both acute and chronic health problems and are more likely than children who are not homeless to be hospitalized, have delayed immunizations, and have elevated lead blood levels -In addition, they are at risk for developmental delays and emotional and behavioral difficulties -School attendance is disrupted frequently, and they are vulnerable to violence, either as victims or witnesses -Children who experience family homelessness, even for brief periods of time, are significantly more likely to be a victim aggressor or aggressor compared with those who have never experienced homelessness -Living in shelters is stressful for families for several reasons -Many shelters exclude men and adolescent boys older than 12 years; thus, family members are separated -Overcrowding prevents privacy and promotes loss of personal control -Stressors of poverty and reduced social support compound the trauma of these experiences -A history of abuse and assault is common among homeless -Women have greater mental health concerns, higher rates of diagnosed mental health issues, suicidal thoughts and attempts, and adverse childhood trauma -Mothers who are experiencing homelessness have often left abusive relationships and have difficulty accessing shelter and health care

Section 8 Housing

-Federally subsidized housing units are supervised or operated by the state or city, for which tenants are responsible for paying one-third of the monthly income (e.g., Supplemental Security Income or Social Security Disability Insurance) toward rent -The difference between the tenant payment and the maximum fair market rental price is calculated as the federal Section 8 housing contribution to the housing provider

Etiology of Homelessness

-Homelessness has no single cause -People want to have a home and be part of a family or social group -People do not choose or purposefully maintain homelessness and living on the streets -Many factors—unemployment, lack of skills, mental illness, substance abuse, domestic violence—typically combine, with time, to cause the person or family to lose permanent housing -The series of events that results in having no home is the culmination of individual and environmental factors, including factors in the mental health system, society, and family or community -The reduction of psychiatric beds has had a huge impact on the increase in the number of persons with mental illness who are homeless -In 1955, there were 337 beds per 100,000 persons -The deinstitutionalization movement decreased the number of state hospital beds to 11.7 per 100,000 by 2016 -Even though there has been an increase in community and private hospital expansions to provide mental health services, their beds are primarily occupied by insured patients who have voluntarily sought care -State hospitals that do exist dedicate most of their beds to those who have committed crimes and have court-ordered treatment -Even under these circumstances, there is often a 30-day to 6-month wait for a bed -Many "nonforensic" individuals are detained in emergency departments (EDs) until beds are available -Gentrification is increasingly a factor in creating homelessness among urban residents -Middle-class and upper-middle-class professionals, mostly White individuals, are relocating to the inner city -Thus, abandoned or substandard buildings are demolished to build modern condominiums or "lofts" -People who reside in poverty-stricken urban areas cannot afford the new housing in their regenerated neighborhood -They are often displaced and are at risk of becoming homeless

Support Network and Support System Assessment for Persons with Mental Illness who are Homeless

-Homelessness is an expression of and response to certain family, societal, or environmental conditions, as well as to individual factors -It is also important to consider that childhood abuse and prior trauma may be continuing to affect the person as a stressor or contribute to interpersonal crises

Stress and Coping Skills for Persons with Mental Illness who are Homeless

-Homelessness is stressful -It is important that the nurse understands how the person who is experiencing homelessness copes on a day-to-day basis -The nurse should ask the person how basic needs are met: How the client eats and sleeps? How does the person cope with experiencing homelessness?

Criteria that Defines Homelessness in the United States

-Individual or family who lacks a fixed, regular, and adequate nighttime residence -Individual or family who will imminently lose their primary nighttime residence with no subsequent residence identified, and they lack resources or support networks to remain in housing -Unaccompanied youth under 25 years of age, or families with children and youth who do not have permanent housing -Any individual who is fleeing or attempting to flee domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening situations related to violence and lack resources or support networks to remain in housing

Common Physical Health Problems Experienced by Homeless People

-Injuries, fractures, epistaxis, or edema from trauma, falls, burns, assault, gunshot wounds -Influenza, colds, bronchitis, asthma, shortness of breath -Hypothermia, hyperthermia -Arthritis, musculoskeletal disorders, headaches, fatigue -Diabetes mellitus -Hypertension -Cardiovascular and peripheral vascular diseases -Malnutrition -Pulmonary tuberculosis -Infestations, such as lice or scabies -Dermatitis, sunburn or frostbite, bruises -Foot injury, blisters, calluses -Sexually transmitted diseases -Hypothyroidism or hyperthyroidism -Kidney or liver disease -Cancer -Epilepsy -Impaired vision, glaucoma, cataracts -Impaired hearing -Dental caries, periodontal disease

Integration with Primary Care for Persons with Mental Illness who are Homeless

-Integrating crisis intervention with physical and medical care is essential for individuals with psychosis who are seeking service in a hospital ED -The ED is likely to emphasize triage and rapid disposition while administering essential care -The physical orientation supersedes care for the emotional status of the person -Medication should be supplemented by crisis intervention techniques -The developmental level of the person, regardless of age, should also be considered -Emergency shelters typically provide refuge at night, along with an evening meal and morning coffee -Shelters for homeless women and children usually allow them to remain during daytime hours as well -The child leaves the shelter for school; the mother may attend educational classes, counseling, day treatment, rehabilitation, or employment programs

Mental Health Nursing Interventions for Persons with Mental Illness who are Homeless

-Interventions are to be directed at the social system, as well as at the individual or family level -Interventions should take advantage of community resources and the inner resources and support systems of the individual or family

Assessment Tips for the Psychological Assessment

-Observe for behavior that indicates hallucination and try to validate -Listen for delusions or denial over time; try to sense what purpose these serve -Observe and listen to what the person defines as a problem and potential solution and what they consider to be a strength or coping strategy; validate and reinforce when applicable -View the person and their situation from the individual's perspective; be a patient, nonthreatening listener -Such an approach encourages the person to return regularly; the nurse can then observe the patterns of behavior -Determine the extent of stability or integration of the person's sense of self, cognitive appraisals, and overt behavior -Lack of integration or stability indicates the need for continued monitoring and therapy

Homelessness and COVID-19

-People experiencing homelessness are at high risk for contracting coronavirus -Many people who are homeless live in congregate living settings and might not have access to basic hygiene supplies or shower facilities -Their exposure may negatively affect their ability to find safe housing and the mental health -COVID-19 infection increases the mortality disparity between those who are homeless and those who are not

Characteristics of People who are Mentally Ill and Homeless

-People with mental disorders are at greater risk for homelessness than the general population -Mental health problems increase with the duration of time the person is homeless -They have at least one psychiatric service encounter annually, usually in an ED rather than inpatient or outpatient units -They are homeless for longer periods, often years, than are those who are homeless and not mentally ill or substance abusing -They are more likely to be in poor physical health compared to other homeless people -They have more contacts with the legal system than other homeless or housed people -They are more likely to encounter employment barriers and less likely to benefit from societal economic growth -They are less likely to have contact with family or friends, especially if they come from higher-income households -Most are eligible for, but have difficulty obtaining, income maintenance such as Social Security Disability Insurance, Veterans Affairs disability benefits, or other benefits -Most are willing to accept treatment after basic survival needs are met and a therapeutic relationship has been established

Causes of Homelessness

-Poverty; history of childhood family instability -Lack of affordable housing; doubling up with relatives or friends until the situation is intolerable -Mental illness or substance abuse and lack of needed services -Low-paying jobs; unemployment -Domestic violence; flight from a violent home or abandonment; youth aging out of services -Eviction for not paying rent; multiple movers -Limited life coping skills; disturbing behavior -Changes or reductions in public assistance programs Veteran status -Prison release; having no money, job, or place to go

Establishing Recovery and Wellness Goals for Persons with Mental Illness who are Homeless

-Prioritizing the patient's goals will guide the nursing care -The individual may only want to get a warm coat and a bus pass -The nurse should encourage the patient to identify meaningful goals, but it is important that their primary needs are met -Hospitalization may be needed to treat illness symptoms and providing immediate shelter -The nurse should advocate for finding permanent housing, which is associated with mental health recovery

Physical Health Assessment for Persons with Mental Illness who are Homeless

-Provide privacy for any assessment -Be gentle -Avoid hurry -Explain the need for any physical examination -The person may feel very embarrassed about their physical appearance or body odor if there has been no opportunity for physical hygiene or clothing change -Observation of mucous membrane and skin integrity, including the face, torso, limbs, and feet, is essential -Explain your concern about the person's health status and the need to remove clothing, including shoes and socks, and to pull down underwear -Realize that many people who are experiencing homelessness consider themselves well as long as they can get where they need to go -The individual may believe that refusing to admit illness is adaptive behavior -Be aware of the many health problems that may be present -Children and adolescents who are experiencing homeless may experience any of those listed, plus diseases that are specific to their age group -If a woman is pregnant and experiencing homelessness, assess indications that she is at high risk for maternal or fetal complications

Teamwork and Collaboration: Working Toward Recovery for Persons with Mental Illness who are Homeless

-SAMHSA recommends a five-stage process in homeless rehabilitation for persons who are homeless with a mental illness -Outreach and engagement is the first step in the process and involves facilitation of the individual into behavior changes -Outreach and engagement involves recognizing the needs of people who are homeless for preventive and basic service and developing a trusting and supportive relationship with these individuals -Transition to intensive care occurs when individuals agree to accept health and/or financial benefits, substance abuse/mental health treatment -During this phase, the clinician maintains a relationship with the individual and works with any resistance or concerns the person has -Intensive care phase emphasizes the person's participation in defining and managing their own goals -The primary focus of this phase is mental health treatment, accessing benefits, attending to medical problems, accessing housing, and seeking preventive services, such as skills training -Transition from intensive care to ongoing rehabilitation is preparation for sustaining the process of recovery -Depending on the individual, some may move quickly into affordable housing and maintain an independent lifestyle -Others may need 1 or 2 more years of supportive recovery and housing -Ongoing rehabilitation is an open-ended phase in which people gradually establish an identity as no longer homeless -This stage includes an active and continuing supportive counseling relationship, participation in mental health treatment as needed, and continued participation in prevention programs as appropriate

Safety Issues for Persons with Mental Illness who are Homeless

-Safety needs are always a priority -If an individual is threat to others or self, safety interventions should be implemented -The person may be involuntarily hospitalized for stabilization of symptoms -Overdose of opioids or alcohol intoxication is also a priority care issue -Persons should be referred to emergency services -The nurse may be required to take immediate action to reverse the drug effects by administering naloxone -Other priority issues involve basic needs, including housing and food -Many persons who are homeless are fearful of being incarcerated and resist any attempts to provide shelter

Therapeutic Relationship for Persons with Mental Illness who are Homeless

-Self-awareness on the part of the nurse is important -Often people do not know how to respond to a person who is homeless and who asks for food, money, or interpersonal communication because they hold common stereotypical beliefs about homelessness -Nurses and teachers, for example, who are accustomed to caring for others and giving attention to people who ask for it may find themselves considering various myths when approached by a person who is homeless -To respond appropriately, one must first examine these myths and one's own feelings about people who are homeless and mentally ill -Relating to people who are homeless requires a gentle and compassionate approach

Emergency Services for Persons with Mental Illness who are Homeless

-Some agencies provide a street or mobile outreach program -As part of this program, a van travels the streets to areas where homeless people are found outdoors -Food, warm coffee, hygiene kits, and blankets are the first steps in building trust between staff and homeless persons -The person who is homeless may accept an offer to be driven to a local shelter for the night -Following up the next day by van or bicycle provides a way to recontact the individual and invite them to the agency programs or take them to other social service or health care services -Luncheon sites for homeless people are a basic step in emergency services -Some agencies have a health clinic on site for treatment of minor problems

Interventions for People who are Experiencing Homelessness

-Stabilize physical health status -Provide a list with addresses and telephone numbers of shelters and luncheon sites that provide food; discourage rooting through dumpsters and panhandling -Provide a list of facilities that are safe, including shelters that provide clothing, a safe place to sleep, and opportunity for basic hygiene and laundry -Give information on city ordinances that forbid sleeping on park benches, in building doorways, on sidewalk grates, at bus or train stations, in vacant buildings, or in viaducts -Explore sources of income, such as gathering and selling aluminum cans or engaging in temporary day labor -Discourage selling blood or plasma -Assist the person directly or by referral to pursue entitlements, such as Social Security, veterans, or other benefits -Explore how to stay safe -Even in a night shelter, the person who is homeless may not be safe from assault -It is difficult for the person who is homeless to know who is trustworthy; carrying a bag or case is usually considered a marker for being robbed on the streets -Explore how to secure privacy, which is difficult to achieve, and how to cope with loneliness, which can be overwhelming -Give a list of names, addresses, and telephone numbers of agencies that offer services and socialization, such as the local mental health agency, the local chapter of NAMI, or the local Emotions Anonymous group -Give information about meetings of Alcoholics Anonymous, Narcotics Anonymous, or Cocaine Anonymous if the person is using substances

Risk Factors for Homelessness Among People with Serious Mental Illness (Individual)

-Symptoms of mental illness, including unpredictable behavior; an inability to manage everyday affairs; and an inability to communicate needs, which results in conflicts with family, employers, landlords, and neighbors -Youth and adults with a concurrent mental disorder and substance use are at high risk for eviction, arrest, and incarceration in jails or repeated admissions and short stays in mental hospitals -Coexisting HIV or AIDS with mental illness, chemical use, or both -Coexisting demographic and societal factors of poverty; single-parent family (usually female headed); dependent child; child in foster home; underrepresented groups; veteran status; single men and women; ex-offender released from jail or prison -Coexisting physical illness or developmental disability -Exposure to traumatic events repeatedly, resulting in posttraumatic stress disorder and deficits in independent living skills -Exposure to victimization (physical and sexual abuse), especially if a family member was the perpetrator -Inability to cope with or manage the requirements of family, community, or group living home -Lack of high school education or equivalence -History of war veteran

U.S. Military Veterans Services for Persons with Mental Illness who are Homeless

-The Veterans Administration has a national service dedicated to the care of homeless veterans with mental health problems -The Health Care for Homeless Veterans (HCHV) Program provides community-based residential treatment for homeless veterans -The HCHV serves as a hub for housing and other services that provide the Veterans Health Administration with a way to reach and assist homeless Veterans

Mental Health Nursing Assessment for Persons with Mental Illness who are Homeless

-The assessment begins at the point of the person's need; often, it is a physical need or health problem -The person may be malnourished and most concerned about food and shelter -Because of negative past experiences with the health care system or providers or because of mental illness or substance use, the person may not allow a thorough physical examination or may refuse to answer questions about history at the first visit

Epidemiology for Homelessness and Mental Illness

-The homeless population includes people of all ages, economic levels, racial and cultural backgrounds, and geographic areas -In January 2019, more than 560,000 people were homeless on a single night in the United States -Seventy percent of people experiencing homelessness are living on their own or in the company of other adults -The remainder are people in families with children -Sixty percent of all people experiencing homelessness are male -Most underrepresented groups are considerable in the homeless population, with African American individuals making up the largest group -Among individuals experiencing homelessness, one in two are unsheltered -Approximately, one-third of the total homeless population are persons with untreated serious mental illnesses -Many of these individuals suffer from schizophrenia, bipolar disorder, or major depression -Substance use is common, which further impairs these individuals -Many of these individuals were discharged from state and federal facilities with limited opportunities for housing and follow-up treatment -Studies show that persons with psychosis are more likely to be assaulted or threatened while homeless -Stigma and discrimination toward individuals remain pervasive across societies -Homelessness was a major problem for veterans since the early 2000s -Since 2011, the number of veterans experiencing homelessness had dropped by 43.3%, and since 2018, the number dropped another 2.1% -However, in 2019, still more than 37,000 veterans were homeless on a single night

Mental Status and Appearance for Persons with Mental Illness who are Homeless

-The mental status examination may have to be done over several sessions -Symptoms of schizophrenia may be difficult to differentiate from emotional responses to the stressors of experiencing a homeless lifestyle -Required hypervigilance may augment suspicion or paranoid beliefs -The need for constant awareness of possibilities for meeting basic needs can augment self-preoccupation -Blunted affect, lack of communication, loose associations, ambivalence, isolation, and uncertainty may be the result of life on the streets and living in various places -Such symptoms or behaviors may be part of the homelessness experience and reflect healthy coping mechanisms and creative survival techniques rather than pathology -Substance abuse should be considered because it is common among people who are homeless, including people with mental illnesses -Because people who are experiencing homelessness, especially those with psychiatric disorders, are often victims of crime and violence, the incidence of posttraumatic stress disorder among them may be higher than in the general population -Homeless women are especially in danger of being assaulted, abused, and raped -When a child or adolescent is homeless, ask about the educational history, if the youth is enrolled in school, and about perceived progress -Homeless children often have difficulty with school; the school district may change every time the parent changes shelters or moves from a temporary residence -Determine whether the child has behavioral or emotional problems and whether they need special education services

Behavioral Responses for Persons with Mental Illness who are Homeless

-The nurse should recognize that the person who is homeless has their own way of being in the world -They may not have insight into their illness and deny that they have a mental health problem -Much of the behavioral assessment will be conducted through observation and listening to the person's explanation of events

The Experience of Being Homeless

-The person who is experiencing homelessness spends time hunting for shelter, food, and clothing and lacks consistent ways to meet basic needs -They are at higher risk for disease, infection, and exposure to the coronavirus -This lifestyle, plus grinding poverty and victimization, especially if the person is mentally ill, leaves little energy for change or reentrance into mainstream society -Panhandling, hustling, doing odd jobs, and selling plasma or aluminum cans are common sources of income, although some people who are homeless receive Social Security or veterans' pension benefits -The longer a person is homeless, the more likely the person is to experience mental illness or engage in substance use -The healthiest survivors seek support from others, maintain hope for the future, and strive to have valued lives and selves -They believe they are resourceful, can handle uncertainty, and can maintain health -Women with children who are experiencing homelessness have described the need to keep going for the sake of, and to avoid, losing their children -However, women living in temporary or transitional shelters are confronted with insecurity, lack of privacy, isolation, stigma, and disempowerment -Some women have preexisting mental health problems that lead to homelessness, while others develop mental illness because of their homelessness -Domestic abuse is often an antecedent to homelessness

Alcohol and Substance Use Treatment for Persons with Mental Illness who are Homeless

-The structure of some day treatment programs included alcohol and substance abuse treatment -Sobriety or harm reduction is the goal; the person attends daily meetings, receives necessary psychiatric and medical treatment, and participates in all of the other activities and services available at the day treatment program -No one is terminated for relapse; the person is referred to more intensive services, including hospitalization, if necessary

Risk Factors for Homelessness and Mental Illness

-There are a variety of factors that place individuals and families at risk for homelessness -Adolescents and runaway youths can become homeless because of strained family relationships, family dissolution, foster care struggles, economic instabilities, and instability of residential placements -The consequences of COVID-19-related restrictions, such as remote learning, stay-at-home orders, increase the risk of homelessness for vulnerable youth -Young people experiencing homelessness may resort to drug trafficking and prostitution to support themselves -They are at risk for physical and mental health problems, including substance abuse, HIV infection or AIDS, pregnancy, and suicidal behaviors -New immigrants and refugees can lose housing when they experience economic problems or conflicts with the sponsoring family or organization -Language barriers and citizenship/documentation status impede Latinx individuals' success in the rental market, increasing the risk of homelessness -Mental health problems arise because of torture experiences, losses suffered in the country of origin, culture shock, and discrimination experienced in the United States -Posttraumatic stress is common in this group; their physical health problems are often complex -Migrant workers and their families lack residential stability as they move from one geographic region to another for 6 to 9 months of the growing and harvest season -These laborers and their families may be U.S. citizens or foreign born -They are poor and typically lack adequate living quarters and health care -Physical health problems and depression are common in these families -After farm labor is completed, family members may be homeless until they can return to their place of origin or to a relative's home -Mental illness is significant risk factor for becoming homeless -Symptoms of mental illnesses often interfere with family relationships and impair judgments -Mental illness increases a person's vulnerability to be victimized

Federal Assistance

-There are several federal programs that provide assistance to people who are homeless -The McKinney-Vento Homeless Assistance Act (Public Law 100-77, first passed in 1987 as the McKinney Act), signed by President Ronald Reagan and confirmed by President Bill Clinton, provides federal money for homeless shelter programs -This law established the U.S. Interagency Council on the Homeless that provided for the use of funds in a coordinated manner, and for programs to assist the homeless, with special emphasis on older adults, persons with disabilities, families with children, Native American individuals, and veterans -This program is funded through grants to the states -Substance Abuse and Mental Health Services Administration (SAMHSA) recognizes that housing is critical to recovery from mental and substance abuse disorders and promotes safe, affordable, and permanent support housing in the community with access to benefits and services for individuals, families, and communities -SAMHSA has several initiatives to create safe places for people with mental illness and substance abuse -SAMHSA works closely with the U.S. Interagency Council on Homelessness to support and implement Opening Doors, the federal strategy to prevent and end homelessness -SAMHSA's programs emphasize the importance of employment and education as outcomes and core components of recovery

Evaluation and Treatment Outcomes for Persons with Mental Illness who are Homeless

-There are two outcomes for people who are homeless with a mental illness -Recovery from a mental disorder and living in a housing of choice are primary -In some instances, after the mental disorder is treated and in remission, housing, a job, and positive interpersonal relationships follow -In other instances, finding housing sets the stage for strengthening coping skills to address the mental disorder

Housing Resources for Persons with Mental Illness who are Homeless

-Transitional housing may consist of a halfway house, a short-stay residence or group home, or a room at a hotel designated for people who are homeless -Some agencies have a transitional home and stabilization center where the atmosphere and staff are a model for residents, who work on specific goals and a treatment plan -Sharing housekeeping tasks; obtaining psychiatric stabilization; and attending residence group meetings, social skills and budgeting classes, day treatment programs, and vocational training are steps to independent housing and employment -A holistic program reduces readmission to the hospital and reentry to street dwelling skills -The HEARTH Act of 2009 consolidated the McKinney-Vento homeless assistance program, Shelter Plus Care Program, and Section 8 Moderate Rehabilitation single room occupancy (SRO) Program into one program known as the Continuum of Care -Section 8 housing has been helpful to this population for many years -Safe Haven programs are found throughout the United States and provide 24-hour residence for an unspecified duration -Safe Havens serve hard to reach people with severe mental illness who are on the streets and have been unwilling or unable to participate in traditional supportive services, meet the following criteria -A Safe Haven provides private or semiprivate accommodations and limits overnight occupancy to 25 persons -Supportive housing was previously considered too expensive -Today, communities are realizing that such programs for people who are mentally ill and homeless are a good investment -The person who is safely housed is less likely to use other acute care and publicly funded services, such as shelters, although case management services are needed -Use of acute psychiatric and medical services is reduced, and the person is less likely to be arrested or incarcerated

Assessment Tips for the Physical Assessment

-Use unobtrusive observation as a part of physical assessment -Some conditions will be immediately obvious -Other conditions may become apparent during the interview -Examine—look, touch, palpate, auscultate—the person to the extent that they allow -The person may resist anything more than a superficial conversation and observation -The nurse may need to perform initial palpation of the abdomen or auscultation of the lung through several layers of clothes -If the patient perceives the health care provider as too intrusive, the patient may leave the setting even though they are desperate for care -Listen carefully to what the patient does not say and pay attention to nonverbal as well as verbal expressions -Avoid unnecessary directness and probing. Give the person time to answer questions -The blood test or urine screen may have to wait; a patient, nonintrusive manner may ensure that the person returns for needed tests or screening -Determine whether the person has been prescribed medications in the past -Often, the person who is homeless is not taking medications, even if they are prescribed and essential -The person may have difficulty keeping pills dry and easily retrievable or paying for medications -A daily insulin injection, for example, may not seem practical -Or the person may have been mugged by another homeless person seeking to quiet addictive urges or to sell drugs for cash

Shelter Plus Care Program

Provides long-term housing and supportive services for people who are homeless with disabilities, primarily those with serious mental illness, chronic problems with alcohol or drug use, or AIDS or related diseases

Myths and Facts about People Experiencing Homelessness with Psychiatric Disorders

Myth #1. People choose to be homeless Fact: Most people who are homeless want what most people want: to support themselves, have jobs, have attractive and safe housing, be healthy, and help their children do well in school Myth #2. Housing is a reward for abstinence and medication compliance, and society shouldn't house people who have active substance use or mental disorders Fact: Housing may be the first step to becoming abstinent and/or entering treatment to address a variety of problems. From a public health perspective, adequate housing reduces victimization, hypothermia or hyperthermia, infectious diseases, and other risks to the population as a whole Myth #3. People who are homeless are unemployed Fact: Many people who are homeless are employed full or part time Myth #4. There are few homeless families Fact: Families become homeless for a variety of reasons Myth #5. People who are homeless aren't smart enough to make it Fact: Keeping things together while homeless takes ingenuity and experience. People who are homeless often have well-developed street skills, resourcefulness, and knowledge of the service system Myth #6. Those with substance use or mental disorders need to "bottom out," so homelessness is okay and provides a motivator to make behavioral changes Fact: People who have substance use and mental disorders are more responsive to interventions before they become homeless or when placed in housing Myth #7. Everyone stands an equal risk of homelessness Fact: Although any of us could find ourselves homeless in our lifetime, some people are at higher risk than others. If we can identify people at special risk of homelessness, we may be able to intervene earlier and prevent the devastating effects experienced by people who are homeless and have accompanying mental and/or substance use disorders Myth #8. All clients with substance use and mental disorders who are homeless require extensive, long-term care Fact: The process of recovery from substance abuse and mental illness is an ongoing and sometimes lifelong process, yet healing often begins with short-term, strategic interventions. Screening, brief intervention, and referral to treatment is a proven method for early intervention with substance use and mental disorders, and it can significantly reduce the impact and progression of illness

Supportive Housing

Permanently subsidized housing with attendant social services

Safe Havens

Stable shelters or residences, accessible outreach, integrated case management, accessible and affordable housing options, treatment and rehabilitation services, general health care services, vocational training and assistance with employment, income support, and legal protection

Gentrification

Upgrading of inner-city property so that it is affordable only to people who have the resources of upper-middle or upper economic levels