Older homeless persons were over 3 and one half times more likely to have a chronic medical comorbidity, and health care was the second most frequently cited need following housing assistance. Older homeless were also almost 3 times more likely to have health insurance that would presumably facilitate better and easier access to the health care system. However, it was surprising that older homeless persons accessed shelter- and street-based outreach for their usual care at much higher rates that reached significance with the χ2 analysis and approached significance after the Bonferroni correction when one would expect the trend to be in the opposite direction. These findings run counter to the assumption that health insurance alone is determining health access for older homeless adults, and suggests that other factors such as substance abuse, and capacity to navigate the system may be impacting when and where health care is sought.
The prevalence of medical and mental health conditions among older homeless persons is notable and underscores the importance of adequate health care outreach and readily available access to this cohort. These findings are also consistent with other reports in the literature that found an increase in the number of health problems among older homeless adults, both compared with their younger counterparts and age-matched individuals in the general population.3,6,7,9,14,20
The types of chronic health problems reported here, most notably hypertension, heart disease, hepatitis/cirrhosis, and diabetes, were also similar in nature to those reported in prior studies.5,6,7
The prevalence of psychiatric illness among older homeless persons in our survey was higher than previously reported; 74% of respondents over the age of 50 reported a psychiatric problem, which was also significantly higher than among younger homeless persons. In a metaanalysis of several studies, 22% of homeless men and 29% of homeless women were found to be suffering from major psychiatric disorders,21
with lower rates of mental illness reported among older homeless populations.5–7
The self-reported nature of our findings could possible explain this as an over-reporting bias; however, the stigma associated with reporting a mental health condition would typically direct this bias in the opposite direction.
With 85% of those homeless persons over age 50 reporting a chronic medical problem, it is unclear whether the 61% reporting “physical health care” as an important need is too high or too low. We do not know, based on these data, whether respondents view this as a “met” or “unmet” need. The higher rates of health insurance in our cohort of older homeless would suggest that the need is being addressed in traditional health care settings. However, if this were the case, we would have expected to see greater proportions reporting community- and hospital-based clinics as sources for their care and instead, 21% of older homeless respondents reported a shelter-based or street outreach source for usual medical care. This suggests that for some older homeless in our sample, this is a need that could perhaps be “better” met. However, without actual data on health service utilization, it is not possible to determine this fully. In the literature, Cohen and Sotolovsky found that older homeless adults were almost 3 times as likely as age contemporaries to be hospitalized and to report 3 to 4 times the number of physical symptoms; yet, 55% reported their health as excellent or good for someone of their age group.9,22
Gelberg found a similar attitude in her study of homeless adults in Los Angeles. Despite suffering from more illnesses, older homeless adults in her study population were no more likely than their younger counterparts to seek outpatient medical care.7
Hwang and colleagues looked at 558 homeless adults in Boston and found that in the year before their death, 27% of individuals did not have any contact with the health care system except during the circumstances leading to their death. Older homeless adults were especially unlikely to seek such care. Each decade increase in age was associated with a 20% decrease in the likelihood of health care contact in the year before death.23
It is also possible that the high rate of alcohol and heroin use among older homeless adults, which, for heroin use, was significantly higher than their younger counterparts, and the much lower reported need for substance abuse services reflect poor insight and difficulty accessing or navigating the health system. This would also explain why fewer respondents cited health care as a need relative to the degree of self-reported comorbidity and why nontraditional and informal sites for medical care were accessed at higher rates in this cohort. In a study of health services utilization, Stein and colleagues found that alcohol but not drug abuse predicted less utilization of outpatient medical services.24
However, in a similar study of health service use, Gallagher and colleagues did not find either chronic mental illness or chronic substance abuse to be related to having a source of regular health care.25
Regardless of the cause or effect of this disconnect between rates of alcohol and drug abuse and self-reported need for services, these findings highlight the need for greater outreach and efforts to engage this population in substance abuse treatment programs specifically suited for homeless persons.
One possible framework for explaining these findings is the Behavioral Model for Vulnerable Populations, which groups factors associated with health service utilization as predisposing, enabling, or needs oriented.26
Despite having more predisposing factors for seeking health care (i.e. increased age), as well as more need-oriented factors (i.e. higher rates of physical or mental illness) and enabling factors (i.e. a higher level of health insurance) than younger homeless persons, those homeless persons over age 50 also face a number of barriers to obtaining care that may override the demand, need, or resources available for accessing health care services. Gallagher and colleagues found that homeless individuals with health insurance were no more likely to seek care than those without insurance, suggesting that this may not be as influential a factor as in other domiciled settings.25
Gelberg and colleagues reported “competing priorities” among homeless persons, such as meeting the daily needs for food, shelter, and safety, can deprioritize health services.27
The higher burden of physical and mental illness among older homeless persons may make it more difficult to meet those sustenance needs, causing a paradoxical shift in their priorities away from seeking health care. Abdul-Hamid found that elderly homeless in London have a greater need for help with self-care, making daily subsistence a more challenging task.28
Social support networks of a homeless person have been positively associated with health services utilization,17
and older homeless may also have fewer social support networks in place or available to them, as suggested by the smaller proportion reporting financial support from family or friends.
There are specific policy and service recommendations supported by these data. Older homeless adults have specific physical, mental, and substance abuse needs at rates exceeding younger homeless persons. There is a need for specific, targeted, and ongoing outreach, particularly to those with underlying substance abuse needs who are treatment adverse, to connect them to appropriate services. This should include multidisciplinary shelter- and street-based teams that include substance abuse and mental health counselors and services that include both medical care and social services/entitlement assistance. It should also include the capacity to integrate street- and shelter-based care with that provided in better-equipped settings. The accelerated morbidity and mortality among older homeless persons underscore the importance and need for these types of targeted interventions.
This study has several notable limitations that need to be considered. First, our data were self-reported and subject to recall bias. Second, we are unable to report on actual utilization, satisfaction with care received, or perceived barriers to care. This prevents us from commenting beyond inference on how well or poorly the system is providing care for older homeless persons. Finally, the data were obtained from an urban homeless population and cannot be generalized to suburban or rural settings.
In summary, initiatives aimed at improving physical and mental health care to older homeless persons must consider not only the multitude of needs that this population has but also the complexity of interpersonal and systemic barriers to effective treatment. Effective interventions must include shelter-based and community outreach in order to reach the individuals who may be at the greatest risk.