Pearls of Wisdom Sharing best practices, anecdotal experiences and clinical challenges in serving ho

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Pearls of WisdomSharing best practices,
anecdotal experiences and clinical challenges in
serving homeless youth and adolescents

• Peggy Akers (HCH Portland, ME)
• Isabella Christodoulou (The Drop In Center, New
  Orleans)
• Daneé Sergeant (The Drop In Center, New Orleans)
• Wayne A. Centrone (Outside In, Portland, OR)

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Christine Hanlon, 2007
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Social Instability Emotional Instability Mental
Instability
Sapolsky Marmot Adler
Persons Experiencing Homelessness
STRESS
? stress unmet HC needs rapid
decompensation from CC Dx
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Objectives (80 min)

• Describe the unique cohorts that are HY/A, HYA,
  and Hard to Serve (YIHA) (10 min didactic)
• Discuss a model program to reach HYA in New
  Orleans, LA with a special emphasis on the
  mental health needs of HYA (20 min didactic)
• Discuss a model program to reach hard to serve
  HY/A and HYA in Portland, ME (20 min didactic)
• Invite audience into a moderated discussion and
  QA session about model and unique approaches to
  serving HY and HYA (30 min QA session)

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The estimated number of street children and youth
in the world ranges from 30 to 170 million

• United Nations, Department of International
  Economic and Social Affairs, The Situation of
  Youth in the 1980s and Prospects and Challenges
  for the Year 2000. New York United Nations,
  1986.

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Homeless Abandon Youth

• 730,000 to 1.3 million nationally
• 25 Permanently homeless 50 Runaway secondary
  to abuse
• 75 Engaged in illegal activity 50 Involved
  with prostitution
• 50 Alcoholic, 80 Street Drugs, 35
  Intravenous Drug Use
• Often engage in survival sex which increases
  the likelihood of STDs and unintended
  pregnancies
• Noell J, et al. Childhood sexual abuse,
  adolescent sexual coercion and sexually
  transmitted infection acquisition among homeless
  female adolescents Child Abuse and Neglect
  25(1) 13748, Jan 2001.

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Why are U.S. Youth Homeless?

• Family conflict and abuse
• 60-75 report serious sexual and physical abuse
• Economic problems in the home of origin
• Aging out of foster care
• Gay, lesbian, bisexual, transgender, questioning
  (GLBTQ)
• Residential instability
• School and learning
• Powers J, Eckerd J, Jaklitsch B. Maltreatment
  among run away and homeless youth. Child Abuse
  Negl 19901487-98.

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Why are U.S. Adults Homeless?

• Lack of affordable housing
• Low paying jobs
• Substance abuse and lack of needed services
• Mental illness and lack of needed services
• Domestic violence
• Unemployment
• Poverty
• Prison release
• U.S. Conference of Mayors. A Status Report on
  Hunger and Homelessness in Americas Cities a
  27-city survey. December 2001.

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There are over 2,000 homeless youth in Portland,
ORCitizens Crime Commission Joint Homeless
Youth Assessment Committee March 1998 Portland,
OR.
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Background Data

• Persons experiencing homeless have
  disproportionate rates of chronic illness and
  death (OConnell, 2005)
• Higher morbidity burden in AEH (Richardson, 2003)
• Young adults experiencing homelessness are less
  likely to engage conventional care environments
  (Auerswald and Eyre, 2004)
• The provision of healthcare services to young
  adults experiencing homelessness must be
  specialized and targeted (Barry, 2002)
• There is a growing population of youth
  identified YAEH who require specialized and
  targeted care delivery (Theory)

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Housing Unsuitable for Habitation
Unsuitable for Habitation Living on street,
camping, living in vehicle, sleeping in
park/under bridge/freeway, travel with no fixed
home
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Credited to Dr. Seth Ammerman, Stanford
University Department of Pediatrics, Division of
Adolescent Medicine, Packard Childrens Hospital,
Palo Alto, California
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Who is a Road Warrior?

• Anecdotal Definition
• lt25 year old (actuality 24-30 y/o)
• Homeless gt 30 days out of past year
• Not otherwise engaged in services (such as
  housing, case management, etc)
• Hard to reach/serve persistent mental illness
• Drug/alcohol dependent (much higher than
  housed-matched cohort and adult PEH)
• Socially isolated (chronically)
• Marginalized economically, academically,
  socially, and developmentally

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Who is a Road Warrior?

• Psycho-Social Information
• Physical Trauma/abuse
• Frequent physical/mental/sexual abuse and trauma
• Chronic Homelessness
• 81/144 (56) reported being homeless gt12 months
• Mental Illness
• High rates of depression, suicide
• Drug and Alcohol Use/Abuse
• gt40 report using injection drugs
• 44 reported needs for alcohol/drug treatment
• gt80 w/ self reported daily Etoh use
• Extracted from case manager reports, 2003

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Barriers to Accessing Services

• Kept late hours tended to be seeking engagement
  after most programs were closed
• Drug/Alcohol affected and dependent
• Isolated Rough Sleepers
• Disconnected from other street youth
• Counter-culture (distinctive)
• Disliked requirements
• for engagement
• Clinic too institutional

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Creating Bridges for Care Delivery

• Get the story dont be afraid to inquire about
  housing status vulnerability index (Kuhn,
  Culhane)
• Encourage ANY positive change (Hudson)
• Promote flexibility and creativity (Pires)
• Communicate with case managers and social workers
  (Kushel)
• Advocate make the hand off help to connect
  patient to a primary care relationship (Salit,
  Petterson)
• Promote professionalism and respect in every
  patient care interaction (Hwang)
• Recognize the continuum cohorts of risk w/in
  HY/A

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Literature Cited

• Abdalian SE. Street Youth Mortality Leaning
  With Intent to Fall. JAMA. 2004 292 624-626.
• Barkin SL, Balkrishnan R, Manuel J, Andersen RM,
  Gelberg L. Health care utilization among homeless
  adolescents and young adults. J of Adoles Health.
  2003 April32(4) 253-256.
• Dahl RE. Adolescent brain development A period
  of vulnerabilities and opportunities Keynote
  address. Annals of the New York Academy of
  Sciences. 200410211-22.
• Haldenby, et al. Homelessness and Health in
  Adolescents. Qual Health Res. 200717 1232-1244.
• Hwang SW. Is homelessness hazardous to your
  health? Obstacles to the demonstration of a
  causal relationship. Can J Public Health. 2002
  Nov-Dec93(6) 407-10.
• Lam JA, Rosenheck R. Street Outreach for Homeless
  Persons with Serious Mental Illness Is It
  Effective? Medical Care. 199937(9) 894-907.
• Neaigus A, Friedman SR, Sufian M, Stepherson B,
  Goldsmith D, Des Jarlais DC, Mota P. Peer culture
  and risk reduction among street IV drug users.
  Int Conf AIDS. 1990 Jun 20-236 226.
• Noell J, et al. Childhood sexual abuse,
  adolescent sexual coercion and sexually
  transmitted infection acquisition among homeless
  female adolescents Child Abuse and Neglect
  25(1) 13748, Jan 2001.
• O'Connell JJ. Dying in the shadows the challenge
  of providing health care for homeless people. Can
  Med Assoc J. 2004 April170(8) 1251-1252.
• OConnell JJ, Swain S. Rough Sleepers A Five
  Year Prospective Study in Boston, 1999-2003.
  Presentation, MHSA 10th Annual Ending
  Homelessness Conference, Waltham, MA, 2005.
• Pires SA, Silber JT. On Their Own-Runaway and
  Homeless Youth and Programs that Serve Them.
  Children and Youth at Risk Project. Georgetown
  University, 1991.