Chapter 23: Homeless Populations & Public Health Care

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Welcome back to The Deep Dive.

I'm glad you're here with us today because we are about to tackle a subject that sits right at the intersection of healthcare, sociology,

law,

and frankly, human rights.

We are opening up the textbook again, specifically Community Public Health Nursing Seventh Edition, and we are turning to chapter 23.

That's right.

The title is short Homeless Populations, but the content.

It is massive.

It is complex.

And if you are training to be a nurse or just someone who wants to understand how our society functions or, you know, malfunctions, this is just essential reading.

It really is.

You know, often when we think about nursing textbooks, we think about diagrams of the heart or lists of medications But this chapter authored by Meredith Trautman Jordan is different.

It's essentially a field guide to a humanitarian crisis that is happening in our own backyards.

Yeah.

And for the students listening, this isn't just about memorizing a definition for the board exam.

This is about understanding a reality you will encounter in the emergency room, in the community clinic, and well, on the street.

That's the goal today.

We are going to walk through this chapter exactly as it's written.

We want to be your translators.

We're going to take those academic concepts, which can get a little dense and turn them into a conversation that actually makes sense.

Right.

We need to cover the mission of this chapter first.

What are we actually trying to achieve here?

Because it seems like more than just how to treat frostbite.

It is so much more than that.

Yeah.

The mission here is to provide a comprehensive framework.

The text outlines a specific roadmap.

We start with the foundational stuff,

definitions.

Okay.

And as we will see, defining homelessness is surprisingly controversial.

Then we move to prevalence.

How do we count people who are often trying to stay hidden?

Right.

We'll break down the demographics to see who is actually affected, which might shatter some stereotypes.

We'll look at the contributing factors, the structural drivers like housing and income.

Then we examine the health status of these populations across the lifespan.

A lot to cover.

And finally, we land on the nursing framework,

the specific tools and mindsets like upstream thinking that nurses use to help.

I love that roadmap.

It feels logical.

But you mentioned something that caught my ear immediately.

You said defining homelessness is controversial.

To the average person walking down the street, homelessness seems pretty self -explanatory.

You don't have a home.

You're on the street.

Why does the chapter start by saying this

It's what the text basically calls the battle of definitions.

And it matters so much because definitions in a policy context aren't just words in a dictionary.

They are gatekeepers.

Gatekeepers.

How so?

The text makes this point very clearly.

Definitions determine who gets counted in the census, who gets described in research, who gets planned for in city budgets, and most critically, who is eligible for help.

So it's about access to resources.

If you don't fit the specific legal wording, you might be struggling.

You might have nowhere to go.

But the system says, sorry, you aren't homeless enough.

Exactly.

That is precisely it.

You could be sleeping in a car or on a friend's floor.

And depending on which definition we use, you might be invisible to the system.

Wow.

To help us understand this, the text breaks it down into two main approaches.

The conceptual approach and the legal approach.

And to get a handle on the conceptual side, the text actually takes us on a little field I saw that.

It discusses the European perspective.

Let's unpack this.

What can we learn from how Europe defines this?

Well, the text highlights the work of Fianza.

That's the European Federation of National Associations working with the homeless.

They developed a model called ethos.

E -T -H -O -S.

Right.

And what is fascinating here is that they don't start by defining homelessness.

They start by defining home.

That feels like a very philosophical place to start.

You have to know what you are missing to understand the loss.

Precisely.

They argue that a home has three domains.

First, the physical domain.

Do you have a dwelling?

Is it adequate?

Do you have exclusive possession of it?

Okay.

So a roof over your head, basically.

Kind of, but it's more than that.

The second is the social domain.

Do you have privacy?

Can you maintain social relationships there?

Can you have family over?

And third, the legal domain.

Do you have a title?

Do you have a place?

Do you have security of occupation?

Right.

I really like that social domain aspect because you could be in a shelter.

So you technically have a roof,

the physical domain, but you are sleeping in a room with 50 strangers.

You have no privacy.

You can't invite your family over for dinner.

So in that sense, you don't have a home.

Exactly.

Under the ethos model, that counts as a form of exclusion.

It's not just about a roof.

They identify four types of exclusion.

Rooflessness, which is what we call sleeping rough.

On the street.

Yes.

Then houselessness, which means being in shelters or institutions.

Then insecure housing.

So you have no legal rights.

You could be evicted any second.

And finally, inadequate housing, where you might have tenure, but the conditions are unfit.

So it's a spectrum.

It's not just a binary on -off switch.

Exactly.

It treats homelessness as a continuum of exclusion, which is, I think, a much more humane way to look at it.

The text also mentions Canada has a similar conceptual model.

Yes.

The Canadian Homelessness Research Network.

Their model is also really insightful.

They have four categories.

Unsheltered, emergency sheltered, provisionally accommodated.

Okay.

That sounds like couch surfing, maybe.

It could be, yes.

It's temporary.

But here's the key one.

The fourth category is at risk of homelessness.

At risk.

That feels like a huge distinction to make in a definition.

It's proactive.

It is huge.

By explicitly including those at risk in the definition, the Canadian model acknowledges that the crisis starts before you hit the pavement.

So it's trying to catch people before they fall.

Yes.

It includes the person paying 70 % of their income on rent or the family one paycheck away from eviction.

It frames it as a precarious state of existence, not just a physical location.

Okay.

So that's the international conceptual side.

It's broad.

It's nuanced.

But we are reading a U .S.

textbook and we are looking at the U .S.

healthcare system.

The text suggests that when we cross the border back home, things get a lot more rigid.

They do.

In the United States, definitions aren't driven by these broad research concepts.

They are driven by federal legislative acts.

We are in the realm of the legal approach.

So less about philosophy, more about bureaucracy.

Exactly.

And the problem, and the text really highlights this, is that we don't have one single definition.

We have different federal departments that define homelessness differently based on their own goals.

This is where it gets really interesting and confusing for students.

You have HUD, the Department of Education, and HHS.

Let's start with the big one.

HUD.

The Department of Housing and Urban Development.

Right.

They control the housing vouchers, right?

What is their definition?

HUD's definition is the one most people are familiar with.

It's codified in the Hearth Act.

They break it down into four categories.

Category one is literally homeless.

Literally homeless.

That sounds very strictly interpreted.

It is.

This refers to individuals or families who lack a fixed, regular, and adequate night time residence.

Meaning what, exactly?

This includes people sleeping in a place not meant for human habitation.

A car, a park, an abandoned building, a bus station, or an airport.

It also includes people living in a publicly or privately operated shelter.

Okay, so that's the visible homelessness we see in city centers.

What is category two?

Category two is imminent risk of homelessness.

This includes individuals or families who will imminently lose their primary night time residence.

And how does HUD define imminently?

Usually as within 14 days.

But there is a catch.

To qualify, you must have no subsequent residents identified and no resources or support networks to obtain other permanent housing.

So you have the eviction notice in your hand, you have to be out in two weeks, and you have absolutely zero money and no family to help.

It's a crisis point.

A complete crisis point.

A very tight window.

Then you have category three,

homeless under other federal statutes.

That sounds complicated.

It is a bit of a catch all for unaccompanied youth or families with children who fit the definition of homeless under other federal laws, but don't quite fit HUD's strict,

literally homeless criteria.

However, there are very strict rules on how long they've been unstable to qualify here.

It's complicated to navigate.

I can imagine.

And category four.

Category four is fleeing or attempting to flee domestic violence.

This is critical.

If you are fleeing dangerous or life -threatening conditions, dating violence, sexual assault,

stalking, and you have no other residents and lack the resources to obtain one, HUD considers you homeless.

That is a crucial safety net because you might have a legal home, a lease with your name on it, but you can't be there.

It's not safe.

This recognizes that home isn't a home if it's dangerous.

That makes a lot of sense.

So that's HUD.

They focus on housing status, but then the text throws a curve ball.

It introduces the Department of Education, the ED, and they define it differently.

Why?

Because their mandate is different.

It's a totally different goal.

The ED administers the McKinney -Vento Act.

Their goal isn't just to house people.

It's to ensure that children and youth have equal access to public education.

So it's about school stability.

Exactly.

So they cast a much wider net to make sure kids don't fall behind.

How much wider?

What's the big difference?

The critical difference, and the text basically bolds this, is that the ED includes children and youth who are sharing the housing of other persons.

We call this being doubled up.

Doubled up.

Let's paint a picture of that.

Imagine a family loses their apartment.

They can't afford a new deposit, so they move in with an aunt and uncle.

You have four people sleeping in a living room, maybe on the floor or couches.

Right.

It's crowded.

It's stressful.

It's temporary.

Under HUD's strict, literally homeless definition, that family technically has a roof.

They aren't in a shelter.

So they might not qualify for certain housing vouchers.

But in the eyes of the school system, those kids are homeless.

That is a massive distinction.

So you could have a child who qualifies for free lunch,

transportation assistance, and tutoring because they're homeless at school, but the family can't get into a HUD -funded housing program.

That is exactly the situation that happens every single day.

And the text points out that this is the core of the discrepancy we see in numbers later on.

I see.

The ED also includes children in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations.

They include children awaiting foster care placement.

They are trying to catch everyone who is unstable to keep them in school.

And there's one more agency you mentioned, right?

Health and Human Services or HHS?

Yes.

HHS runs the healthcare for the homeless programs, the HCH programs.

Their definition is vital for nurses to know.

It basically combines the two.

How so?

It includes people in transitional housing, supportive facilities, and crucially, it also includes the doubled up population.

But here is a key detail for discharge planning.

Okay.

This is important for our student listeners.

Very.

HHS considers people being released from an institution like a prison or a hospital without a stable home to be homeless.

That is so important.

If you are a nurse discharging a patient who says, I don't have anywhere to go, I might crash on a friend's floor.

HHS allows you to treat them as a homeless patient regarding resources and referrals.

Correct.

It gives you the framework to connect them to HCH services.

So the takeaway here for a nursing student is that a patient might be homeless in the eyes of the clinic or the school, but not qualify for HUD.

It's a bureaucratic maze and part of the nurse's job is helping patients navigate that.

Which leads us perfectly into the next nightmare.

Counting.

If we can't even agree on who is homeless, how on earth do we count them?

We call this section counting the invisible.

The text is very honest about the difficulty of enumeration.

It's an incredibly hard thing to do.

The primary method we use in the U .S.

is the point in time count or PIT count.

I've heard of this.

This is the one that happens in January.

Yes.

It's a requirement for HUD funding.

Local communities and providers have to go out on a single night, usually in the last 10 days of January, and count everyone they can find who meets that HUD definition.

Why January?

That seems like the hardest, most dangerous time to be outside.

The logic, according to the text, is that because it is cold, more people will seek shelter, making them easier to count in the shelter system.

Also, it provides a kind of worst case scenario snapshot.

Well, there are huge flaws, right?

Oh, massive flaws.

The rule is that they must count the sheltered homeless annually, so everyone in a shelter on that night.

But counting the unsheltered people under bridges, in cars, deep in the woods is only required every two years on odd -numbered years.

Wait, so on the even -numbered years, we might just be missing the street population entirely in the official data?

In some jurisdictions, yes, although many communities volunteer to do it annually.

But just think about the logistics.

You have volunteers walking around clipboards at 2.

am in January.

If someone is sleeping in a locked car with fogged windows, or if someone is hiding for safety, they are not going to be counted.

It's just impassable.

So the count is inherently an undercount?

Almost certainly.

It's the best tool we have for this specific purpose, but everyone acknowledges its limitations.

And the text mentions some acronyms here that students need to know.

HMIS and AHR.

Let's decode those.

HMIS is the Homeless Management Information System.

It's the local database where providers input data about the people they serve.

It's the raw data feed.

And AHA.

That data is rolled up into the annual Homeless Assessment Report, which is what gets sent to Congress.

So Congress gets the AHR, looks at the numbers, and decides funding.

What did the numbers look like in the source text?

I think we are looking at 2015 -2016 data here.

Right.

And this is where the definition battle comes back to haunt the data.

According to the 2016 AHR, based on that HUD data from the PIT count, the total homeless population was around 550 ,000 people on that single night.

Okay.

Half a million.

That number represented a slight decrease of 2 .6 % from the previous year.

It also showed decreases in families with children and veterans.

So if you just looked at that report, you'd think, great, policy is working.

The numbers are going down.

Exactly.

You'd feel like progress is being made.

But then you look at the Department of Education numbers for roughly the same period.

In the 2014 -2015 school year, they enrolled over 1 .2 million homeless students.

1 .2 million students.

Just children.

Just children in school.

But the HUD count for the entire population, adults, veterans, everyone, was only 550 ,000.

That's a massive, massive discrepancy.

It is staggering.

And the text gives us the key detail that explains it.

The vast majority of those students, over 950 ,000 of them, were doubled up.

They fit the ED definition, but they don't show up in the HUD point -in -time count because they aren't in a shelter or on the sidewalk.

They're invisible to that counting method.

That really illustrates why definitions matter.

You literally have two federal agencies telling two completely different stories about the scale of the problem.

And that leads to the numbers game caveat.

The

Rachel and her children.

It's a powerful quote.

What does he say?

He says,

I like that.

Whether it's 500 ,000 or 4 million, the point is there are people without homes.

The problem exists.

Precisely.

The issue remains critical regardless of the exact statistic.

Arguing over the number can sometimes be a distraction from solving the problem.

Okay, so we've defined it and we've tried and struggled to count it.

Now let's look at who these people are.

Segment three.

Demographics.

I feel like everyone has a mental image of a homeless person, usually an older man maybe with a beard on a park bench.

Does the data back that up?

Well, let's look at the sheltered homeless adults from the 2015 data in the text.

The majority are men, about 62 .1%.

So that part of the stereotype has some basis in fact.

Okay.

But here's something that might surprise people.

The population is younger than the general public.

Really?

I would have thought it skewed older.

Nope.

Over one fifth of the sheltered population, 22 .3 % are children under 18.

If you walk into a shelter, you aren't just seeing old men.

You are seeing toddlers.

You're seeing infants.

That breaks the stereotype right there.

A fifth of the population are kids.

And we have to talk about race.

This is really stark.

Minorities are significantly overrepresented.

African Americans make up about 41 % of the sheltered population.

41%.

Despite being only about 13 % of the total US population.

That is a massive disparity.

It really points to structural issues rather than just individual bad luck.

Absolutely.

The numbers don't lie.

It points to systemic factors.

Yeah.

And regarding disability, adults with disabilities are three times more likely to be homeless than adults without disabilities.

This is a crucial intersection.

Disability and housing instability.

The text also breaks this down by subpopulation.

Individuals, families, and veterans.

Do these groups look different?

Very different.

And this is important for nurses because you can't treat them all as a monolith.

Individuals, meaning single adults, are mostly men, about 70%, and commonly between the ages of 31 and 50.

This group looks most like the traditional image.

Okay.

So that's the single adult population.

What about families?

Families usually consist of at least one adult and one child.

The adults in these families tend to be younger, often between 18 and 30.

A lot of young mothers.

And the racial breakdown there.

The racial overrepresentation is even more stark here.

Minorities make up nearly 78 % of sheltered homeless families.

Wow.

78%.

And veterans?

Veterans are a distinct group.

They're overwhelmingly men, 90%.

But the age curve is different.

They tend to be older, many in the 51 to 61 age range.

And again, minority veterans are overrepresented compared to the general veteran population.

So if you're a nurse, the profile of a veteran patient who is homeless is completely different from a young mother with two kids who is homeless.

Exactly.

Their health needs, their life experiences, the traumas they may have faced, and the resources available to them are all different.

You have to tailor your approach.

Which brings us to the big question, why?

Segment four covers the factors contributing to homelessness.

The text identifies three major drivers.

What are they?

The text is very clear that these three structural factors interact to create homelessness.

It's not one thing.

They are.

One, shortage of affordable housing.

Two, income insufficiency.

And three, inadequacy of support services.

Let's take them one by one.

Shortage of affordable housing.

What counts as affordable?

The standard rule, which the text cites, is that housing should cost no more than 30 % of your income.

If you're paying more than that, you are considered housing burdened.

And I'm guessing for most people in these situations, it's way more than 30%.

Oh, absolutely.

The text mentions that demand for assisted housing, like Section 8 vouchers, far exceeds the supply.

The waiting list can be years, sometimes decades, long.

Plus, market forces like the foreclosure crisis we saw and just generally rising rents have created what HUD calls worst -case housing needs, where people are severely burdened.

So housing is too expensive.

That leads to factor number two, income insufficiency.

It's the hard math.

It's the other side of the same coin.

Even if housing exists, if your income's too low, you can't access it.

In 2015, the poverty rate was 11 .3%.

But for children, it was almost double that, at 21 .7%.

A fifth of all children living in poverty.

Yes.

And the result is that people end up paying 50%, 60%, or even 70 % of their income on rent.

And when you pay 70 % of your income on rent, what gets cut?

Everything else.

Food, medicine, car repairs, school supplies, emergency savings.

You are one flat tire or one illness away from eviction.

There's no margin for error.

And that ties into the third factor, inadequacy of support services.

This affects specific groups heavily.

People with mental illness or substance abuse disorders often need support to maintain housing.

They might need case management, therapy, or just help navigating the system to pay their rent on time.

And the services are scarce.

Extremely scarce.

The text notes that the working poor need valid wages, but the chronically ill need comprehensive behavioral health care.

And often it just isn't there.

The safety net has holes.

Now I want to touch on something the expert in the text brings up, causation versus contribution.

This feels like a philosophical point, but it's important for a nurse's mindset.

It is.

It's critical.

The text explicitly states that these are contributing factors, not simple causes.

And it addresses the choice argument.

You know, the idea that, oh, they chose to be homeless.

Right.

They chose to drink.

So they lost their house or they should have just worked harder.

The text pushes back on that hard.

It notes that while people do make decisions, those decisions are made in highly contextualized conditions.

What does that mean?

Highly contextualized conditions.

It means if you are suffering from untreated schizophrenia or severe poverty since childhood or debilitating addiction, your free choice is severely limited.

You're choosing from a menu of bad options.

It's not the same kind of choice someone with a stable home and a good job has.

That's a really compassionate and I think accurate way to frame it.

OK, so we have these factors pushing people onto the streets.

Once they are there, what happens to their bodies?

Segment five is about health status.

And here we have to start with the World Health Organization definition of health.

The text brings this up for a reason.

Health isn't just not being sick.

It is a state of complete physical, mental and social well -being.

And for homeless populations, all three of those are under attack.

Constantly.

Let's start with adults.

Generally, they have higher morbidity rates than the general population.

Acute problems are common.

Trauma from violence, respiratory infections from sleeping in the cold or crowded shelters, things like trench foot, which we thought disappeared after World War I.

Wow.

But also chronic problems, hypertension,

poorly controlled diabetes, asthma,

musculoskeletal disorders from sleeping on hard surfaces.

The text mentions a study by Lebron Harris from 2013.

What did that find?

It was a really interesting comparison.

It compared homeless patients to domiciled, poor patients.

So poor people who did have homes.

So it controlled for poverty.

Exactly.

And even within that low income group, the homeless patients reported significantly higher substance use, food insufficiency and mental distress compared to the poor people who had a place to live.

Having a home is in itself a protective health factor.

Let's talk about women specifically.

The text highlights some terrifying risks for homeless women.

Yes.

Women face specific risks regarding reproductive health, higher rates of unintended pregnancy, preterm births and low birth weight infants.

But the most alarming statistic is violence.

Rates of intimate partner violence are reported between 30 % and 90%.

30 to 90%.

That range is huge, but even the low end is an epidemic.

It's an epidemic of violence.

And the text discusses survival sex.

What is that?

It's trading sex for money, food, a place to sleep or just for protection.

It is driven by pure desperation and exposes women and youth to extreme violence and exploitation.

And what about the children?

How does this impact them?

The health effects on children are devastating.

They have high rates of asthma, anemia, obesity and developmental delays.

And the educational impact is huge.

Missing school, not having a quiet place to do homework.

It leads to repeating grades and falling behind permanently.

There's another group the text spends time on.

Youth.

Specifically unaccompanied or runaway youth.

This is a highly,

highly vulnerable group.

The text estimates 1 .5 to 2 million per year.

Their health risks include early sexual debut, high HIV risk, substance abuse and suicide.

They're often disconnected from any supportive adult.

And LGBTQ youth are disproportionately represented here.

They are often on the streets due to family rejection after coming out.

They have much higher rates of suicide attempts than their heterosexual peers.

And what's the connection to the foster care system?

It's a direct pipeline for some.

The text notes that 11 % to 37 % of youth aging out of foster care experience homelessness within a short time.

That is a failure of the system to transition them to adulthood.

We just turned them out at 8 -2 with no support.

Finally, the text talks about the chronically homeless.

How does HUD define this and what is the vulnerability index?

HUD defines chronically homeless as an unaccompanied adult with a disabling condition like serious mental illness or substance use disorder who has been homeless for a long period, usually a year or more, or has had multiple episodes.

These are the most entrenched and often sickest individuals.

Yes.

The vulnerability index is a tool mentioned in the text that was developed to prioritize housing for those most likely to die on the street.

It's a triage tool.

What are the risk markers on that index?

They're grim.

Things like more than three ER visits or hospitalizations in a year, being over the age of 60, having conditions like cirrhosis, end -stage renal disease, HIV AIDS,

or having a history of frostbite or hypothermia.

It identifies the people on the brink of death.

That is just, it's grim, but it's necessary for allocating scarce resources.

So we have this massive complex problem.

Segment 6 asks, what do we do?

What is the public health nursing framework?

This is where the chapter pivots from identifying the problem to empowering the nurse to be part of the solution.

The first step is a mental shift.

Nurses need to move from a purely biological psychological view to a social health view, treating the situation, not just the diagnosis.

And this brings up two competing models of justice that the text explains, market justice versus social justice.

Yes.

And this is fundamental to public health.

Market justice is the dominant U .S.

model.

It emphasizes individual responsibility and self -determination.

In this view, people are entitled to the status and income they earn through their own effort.

Health care is a reward.

So if you don't have health care, it's seen as an individual failing.

In a pure market justice system, yes.

But social justice, which is the foundation of public health nursing, is the opposite.

It argues that all people are equally entitled to key ends like health protection and minimum income.

And health care is a right, not a privilege.

Exactly.

And society accepts a collective burden to ensure that right for everyone.

That mindset shift leads to what the text calls thinking upstream.

Yes.

It uses the river metaphor by John McKinley.

It's a classic public health analogy.

How did it go?

Imagine you're standing by a river and you see bodies floating by.

Your first instinct is to jump in and pull them out.

That's downstream, work treating illness, fixing injuries.

It's necessary.

But the bodies just keep coming.

They just keep coming.

So upstream thinking is walking up the river to find out who or what is throwing people in and stopping them at the source.

So for homelessness, downstream is treating frostbite in the ER.

Yes.

And upstream is advocating for affordable housing, higher minimum wages, and better mental health services.

And this connects to the social determinants of health.

Directly.

The text connects it to the healthy people 2020 goals.

Of the five dimensions, two are key for homelessness,

economic stability, things like poverty and employment, and health, and healthcare specifically, access.

The nurse's role is to address the causes of the causes.

The text presents one last model, the public health intervention wheel.

What is that?

It's a conceptual model with 17 different interventions that a public health nurse can use.

It breaks them down into downstream and upstream actions.

Give me an example of each.

Downstream practice on the wheel involves things you do with individuals and families.

Surveillance, screening for health issues, case management, health teaching.

That's the one -on -one work.

And upstream.

Upstream practice is systems level work.

Collaboration with other agencies, coalition building, advocacy for policy change, policy development.

This is working with communities and systems to change the conditions that lead to homelessness.

So a community health nurse needs to be able to do both.

They need to be able to suture a wound and also speak at a city council meeting.

Exactly.

They need to be a clinician and an advocate.

We have covered a massive amount of ground today.

I mean, we defined it both legally and inceptually.

We counted it with all the difficulties that entails.

We identified who is affected.

We understood why the housing income and services piece.

We look at the devastating health costs.

And we finished with the nursing toolkit.

It's a heavy chapter, but it is an essential one.

If there's one thing I want listeners, especially nursing students, to take away and really sit with, it's that question of justice.

Market justice versus social justice.

Yes.

Ask yourself, how does my personal view on this shape how I care for a patient in the ER who has nowhere to go after discharge?

Does it change my empathy?

Does it change my actions?

It's a question every health care provider has to answer for themselves.

That is a powerful thought to leave us with.

Thank you for listening to this deep dive into

It's been a pleasure.

Thank you for having me.

A warm thank you from the last minute lecture team.

We'll see you next time.