SURVEY REPORT H EALTH C ARE C RISIS FOR B IRMINGHAM H OMELESS H EALTH C ARE C RISIS FOR B IRMINGHAM H OMELESS H IGH HEALTH NEEDS AND POOR ACCESS TO CARE F AST F ACTS Number of persons Surveyed Introduction No one would be surprised to learn that life is tough for the 2500 persons homeless in Birmingham each night Astonishingly this new 200person survey shows that when it comes to getting health care, life is far tougher than we ever thought it was Birmingham’s homeless are in poor health and at higher risk of dying than the population at large They have enormous difficulty obtaining health care of any kind They mostly not get the medications they know they need Among homeless parents, some had trouble getting care for their children And many report that the inability to get health care stands in the way of obtaining a job or housing, the two key steps to escaping homelessness When seeking care at safety net health care providers, many report it was not easy to get If Birmingham is to reduce homelessness, we will need to address this most fundamental form of human suffering Read on to learn about this survey, and what it shows 200 % chronically homeless* 55% % with no health insurance 69% % with 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 or more times in years or for more than year continuously 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 R ESOURCES 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 ) Publication Date: August 26, 2010 H EALTH C ARE C RISIS FOR B IRMINGHAM H OMELESS P AGE S URVEY B ACKGROUND In May of 2009, members of this team published a scientific report that raised concern regarding access to health care for homeless persons in Birmingham Comparing survey data from 1995 and 2005, the report detailed 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 questions “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 Jefferson County Department of Public Health and the UAB School of Public Health Many questions were modeled after standard items used in national surveys and in prior Birmingham homeless research A team from the University of Alabama at Birmingham 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 outdoors 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 Firehouse Shelter, Salvation Army Shelter, and Pathways to Housing In each place the team sought a random sample Participants gave informed consent for the survey, and names were not recorded Of 250 eligible participants approached, 200 (80%) completed the survey This project had ethical approval by the Institutional Review Board at the University of Alabama at Birmingham Surveys were administered by medical students and a faculty member from the UAB School of Nursing Work was directed by Dr Stefan G Kertesz (Birmingham VA Medical Center, UAB) Characteristics of the Survey Sample (200 persons) Basic characteristics Age (standard deviation) 45 (10) Age range 2173 Males, % 60% Females, % 40% Race AfricanAmerican 74% 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) Health Insurance Present Cooper Green Card but Uninsured No insurance, no Cooper Green Card 31% 25% 44% Homeless characteristics Chronically homeless 44% Homeless with children 10% Military service history 20% Where person slept most in the past week W HO DID WE SURVEY ? Compared to the city-wide homeless Point-in-Time surveys of 2009 and 2005, our sample is similar in age, gender and race to Birmingham's overall homeless population Even though our survey included one shelter for people who mostly sleep outdoors (23% of our sample), we know from other data that 53% of Birmingham homeless White/Other 26% Street/Outdoors 23% slept outdoors in 2009 Persons who stay in shelters often have an easier time seeking care from clinics and hospitals We therefore believe these data, as grim as they are, may actually offer a rosier picture of health care access than is actually the case in Birmingham today Emergency Shelter 47% Friend/Relative’s 12% Treatment Program/other 18% Health characteristics Average number of medical conditions 2 High blood pressure, % 46% Mental illness, % 46% Chronic lung disease, % 21% Diabetes, % Substance abuse in last year, % 11% References: Kertesz et al Journal of General Internal Medicine 2009; 24(7): 841-847 DeSalvo et al Journal of General Internal Medicine 2006; 21(3): 267-275 54% H EALTH C ARE C RISIS FOR T HE B IRMINGHAM HOMELESS IN This survey identifies serious health vulnerabilities among homeless persons in Birmingham We asked about 10 common health conditions, ranging from diabetes and congestive heart failure to mental illness The average respondent had of the 10 conditions (21% had or more) As shown in the Table on page 2, problems such as high blood pressure, mental illness, chronic lung disease, and diabetes were especially 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 U NMET B IRMINGHAM H OMELESS P AGE HAVE SERIOUS HEALTH NEEDS stated that they were “supposed to be taking medication right now” ————*———— 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 A separate indicator of the vulnerability is the percentage 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 consistently 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 population (2) References: (1) O’Connell JJ Premature 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 What type of health care did Birmingham homeless persons say they needed? (n=200) Health care need Number (%) General health care provider 153 (77%) Specialist doctor 83 (42%) Mental health provider 77 (39%) Dentist 124 (62%) Health care provider for your children 13 (6.8%) Medications 140 (70%) For each need category, several examples of providers in that category were named For example, “Specialist doctor” was “who focuses on a particular medical problem, surgical care, or OB/GYN care for women’s problems” HEALTH NEEDS STAND IN THE WAY OF ENDING HOMELESSNESS The City of Birmingham endorsed a 10-year Plan to Prevent and End Chronic Homelessness in 2007 Unaddressed health needs can limit a homeless person’s capacity to pursue jobs and housing opportunities For example, a person who is too sick to work cannot easily obtain a job For many forms of employment, particularly day labor, needing to go to a doctor’s appointment will interfere with being hired An unstable mental condition can interfere with participation in rehabilitation programs Persons 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 D IFFICULTY OBTAINING CARE WAS COMMON 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 general 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 S EEKING unmet need for care was counted if the person said “yes” to the following statement: “At least once, you could not get this type of care at all” This is comparable to methods 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 calculate the percentage who had a time when they could not get care, relative to the number who said they HEALTH CARE : W HERE needed the care This approach reflects the community planning question: “where need exists, is it being met?” However, to compare to national reports on unmet need, we can provide figures with the denominator for all persons asked (n=200) The most commonly endorsed barriers to obtaining care are listed in the Box at right DO THEY GO ? 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”, including a federally qualified health center (Birmingham Health Care), two major emergency 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 hospitals and clinics operate under different legal mandates and expectations, with different sources of financial support, and they not all offer the same services The heavy use of emergency departments for care is particularly concerning 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 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 U NDERSTANDING WHERE GET TING CARE CAN BE DIFFICULT 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 W HAT CAN YOU DO TO HELP ? Addressing the problems shown in this survey requires committed action by multiple parties No single step will resolve the full challenge, but here are things you can do: 1) Contribute to philanthropic 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 be appointing an oversight Board very soon vices that ought to be provided outside of emergency rooms Homeless medical respite programs operate across the country and permit medical recovery for persons too sick to be on the streets, but not sick enough to require a hospital bed 3) Since transportation barriers were commonly cited, we should encourage and reward those health agencies that engage in systematic health care outreach to homeless persons, especially if those programs receive targeted funds for homeless or indigent health care 5) Support programs that promote access to health benefits where homeless individuals already have a legitimate entitlement These include, for some, federal Social Security Disability benefits, Medicare/ Medicaid or benefits for veterans Lastly: 4) Support programs that reduce homeless persons’ dependence on emergency departments and hospitals for care Birmingham has an ongoing need for psychiatric ser- 6) Do not accept the 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 advancing each of these priorities 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) Opinions expressed in this document are those of the authors and not reflect positions of the US Department of Veterans Affairs Publication Date: August 26, 2010 ... What type of health care did Birmingham homeless persons say they needed? (n=200) Health care need Number (%) General health care provider 153 (77%) Specialist doctor 83 (42%) Mental health provider... reward those health agencies that engage in systematic health care outreach to homeless persons, especially if those programs receive targeted funds for homeless or indigent health care 5) Support... for homeless persons in Birmingham Comparing survey data from 1995 and 2005, the report detailed that the percentage of homeless persons in Birmingham with unmet health care needs had risen to