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The Aging of the Homeless Population:  Fourteen-year Trends in San Francisco

The Aging of the Homeless Population:  Fourteen-year Trends in San Francisco. Judy Hahn, Margot Kushel, David Bangsberg, Elise Riley, Andrew Moss. Background. Changes in homelessness in the US 1930’s Young transient men in search of work 1950’s to 1970’s:

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The Aging of the Homeless Population:  Fourteen-year Trends in San Francisco

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  1. The Aging of the Homeless Population:  Fourteen-year Trends in San Francisco Judy Hahn, Margot Kushel, David Bangsberg, Elise Riley, Andrew Moss

  2. Background Changes in homelessness in the US • 1930’s • Young transient men in search of work • 1950’s to 1970’s: • “Skid row”, single older low income white men, unstable housing (flophouses, SROs, missions) • 1980’s onward: • Loss of SRO hotels and affordable housing in urban centers • Shelter capacities nationwide increased • More families and minorities, younger • Poorer living conditions compared to Skid row Rossi, American Psychologist 1990

  3. Background In San Francisco, • Continued decline in the number of low cost housing and SRO units in the 1990s • Units lost due to earthquakes, fires and gentrification • The response to homelessness • Establishment of emergency shelters and soup kitchens and large shelters with services (1980s) • Policing programs (mid 1990s) • Supportive housing (some late 1990s, most starting 2004), leveraging Federal $ Ilene Lelchuk, San Francisco Chronicle September 7, 2003.

  4. Objectives • We have studied HIV and TB in the homeless and marginally housed in San Francisco from 1990 to 2003. • In this analysis, we sought to examine changes in the homeless population over time in: • Demographics – age, race, sex • Housing • Health status • Health service utilization • Drug use

  5. Methods • Four cross sectional studies (“waves”) conducted at shelters and free meal programs Wave 1: 1990-1994 Wave 2: 1996-1997 Wave 3: 1998-2000 Wave 4: 2003 • Over the entire study period we conducted sampling at a total of 13 shelters and 8 free meal programs

  6. Methods • Inclusion criterion: Age 18 and older • 45 minute interviewer-administered survey • HIV antibody testing and counseling, TB testing (waves 1 and 2) • $10-$20 remuneration for participating • Anonymous

  7. Analysis We included in this analysis: • Shelters and meal programs that were sampled in at least ¾ of the “waves” • 4 shelters and 2 free meal programs (78% of those sampled) • Study participants who were “literally homeless” in the prior year • 87% of those sampled

  8. RESULTS Demographics (n=3534) Male 77% Race African American 52% Caucasian 33% Other, or mixed race 15% Veterans (of the men) 33%

  9. Substance use and mental illness Psychiatric hospitalization, ever 23% Crack use, ever 63% Injection drug use, ever 38% Heavy alcohol use, prior 30 days 35% At least one of the above 80% Two or more of the above 49%

  10. Age trends

  11. Age trends by group 1% overall >= age 65

  12. Demographics

  13. Housing

  14. Self-reported health

  15. Hospital utilization

  16. Drug/alcohol use

  17. Aging in 6 cities

  18. Conclusions and Implications • The homeless population is getting older. • This aging indicates that the homeless population is static and not regenerating itself in time. • A dynamic population would have as many new young people joining the population as old people leaving the population and would have a constant age over time. • Good news: resources spent on housing the homeless now may be finite.

  19. Conclusions and Implications • Of concern: the homeless will increasingly need health care services -- either to control their chronic disease or to treat the more serious outcomes of unmanaged chronic disease. • Control of chronic disease will be very difficult to deliver to persons not in housing.

  20. Recommendations • Provide supportive housing with onsite medical services for those age 50 and older in order to intervene in the course of chronic disease early • Base on the model of San Francisco Department of Public Health’s Direct Access to Housing • Houses 1000 people in 12 buildings • 3 buildings dedicated to seniors • Psychiatrists, nurses, physicians assistants • Case worker : resident ratio: 1:20 • 80% stay at least 1 year

  21. Acknowledgments REACH field staff and study participants Grants: NIH 5R01DA004363, 1R01MH054907, R01DA010164, and K08HS11415. Contact info: Judy Hahn, Ph.D. Assistant Professor EPI-Center, Department of Medicine University of California, San Francisco San Francisco, CA 94143-1372 jhahn@epi-center.ucsf.edu

  22. Bonus data!Younger vs. older homeless 2003 data wave *p<0.05

  23. Younger vs. older homeless Housing *p<0.05

  24. Younger vs. older homeless Health *p<0.05

  25. Younger vs. older homeless Substance use *p<0.05

  26. Summary of bonus data • Many older homeless persons are using drugs or drinking heavy amounts of alcohol, though somewhat fewer than younger homeless persons • Older homeless persons have the same rate of ED visits and inpatient hospitalizations though higher rates of chronic disease

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