2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Mental Illness and Homeless Baby-Boomers: What Can Be Done?

Greater longevity combined with the aging of the baby-boom generation is rapidly increasing the 50-and-over age group in the United States. The greatest surge will be seen among the population aged 65 and over, which is expected to increase by 65% by 2030 (“Demographics of an aging America” Harvard University). This aging trend is also changing demographics within the homeless population. For example, in 2003, one third of homeless adults were aged 50 and over. However, by 2015, this percentage increased to 50% and is continuing to grow (Brown, Thomas, Cutler & Hinderlie, 2014). Furthermore, according to a study that looked at aging patterns within the homeless population of New York City baby-boomers born between 1954 and 1964 were at higher risk of homelessness than any other age cohort (Culhane, Metraux, Byrne, Stino & Bainbridge, 2004). Research shows that veteran status, substance use, and mental illness increase the risk of homelessness (National Alliance to End Homelessness). Baby boomers comprise the largest segment of the veteran population, and research indicates that by 2030, the number of people aged 65 and older with a mental illness, including substance abuse disorders, will equal or exceed the number with mental illness in younger age groups (Choi, DiNitto, & Marti, 2015 & Aging Veterans in the United States).

As the number of older adults experiencing homelessness continues to increase, addressing the unique care and housing needs of this population becomes increasingly important. In addition to problems typically associated with homelessness such as mental health and substance abuse, older adults also experience higher rates of chronic illness and geriatric comorbidities such as dementia, Parkinson’s disease and functional disability (“Ending homelessness among older adults and elders through permanent housing”). The age of onset of physical health conditions is also lower within the homeless population requiring chronic care management services at an earlier age than typically seen in the general population (Brown, et. al., 2014). Managing chronic disease entities and geriatric predispositions within shelter environments is challenging. Adapting the physical environment to accommodate limitations is not easily accomplished, and following medication regimes and adhering to medical advice is difficult due to the transient nature of the population (“Ending homelessness among older adults and elders through permanent housing”). Typical recovery and therapy counseling also may not address age-appropriate issues for the older and elderly population including grief counseling, medication management, health promotion, and other specific geriatric issues that can create unique challenges to managing recovery (Torres, 2014).

The Corporation of Supportive Housing (CSH), a group dedicated to finding housing solutions for the most vulnerable members of the community, and Hearth, Inc., a Boston-based non-profit dedicated to ending homelessness among older and elder adults through housing, outreach and advocacy jointly compiled a policy paper with recommendations on developing successful permanent housing for homeless older adults. Given the multiple, and clinically complex medical and psychiatric conditions often experienced by older homeless individuals, the policy paper recommends permanent supportive affordable and accessible housing linked to a comprehensive support system (Ending homelessness among older adults and elders through permanent housing”). This is a biopsychosocial approach to addressing homelessness through an integrated system of accessible housing with easy access to coordinated medical, mental health, substance abuse treatment, and social services. The goal is to create an environment where this population can age in place with easy access to age-appropriate supports and services.

In addition to developing housing and service solutions for the actively homeless population of older adults, given the size of the current and future aging population, developing prevention and early intervention strategies to prevent homelessness among at risk older adults is important (Choi et al., 2015). According to the “Homeless Older Adults Strategic Plan” developed by the Shelter Partnership, many formally homeless individuals who participated in the research stated that “discharge from hospital or illness/medical problems led to their homelessness” (“Ending homelessness among older adults and elders through permanent housing” p.6). A typically less robust support system combined with potential cognitive decline can make compliance with discharge instructions challenging for older adults (Torres, 2014). Also, given the complex needs of older adults a discharge plan following a hospitalization may require follow-up visits with multiple specialists. Mental health issues can further complicate compliance with follow-up care. According to the CDC, 20% of people age 55 and older are estimated to have some type of mental health condition (“The state of mental health in aging America”). Research suggests that coordinated discharge planning can be a building block for developing a comprehensive community homelessness prevention strategy (“Ending homelessness among older adults and elders through permanent housing”). Creating partnerships with local federally qualified health centers implementing the patient-centered medical home model can be key to a successful transition from hospital to home for this population.

Federally qualified health centers (FQHCs) have long served as a foundation for comprehensive, high quality, cost-effective care for low-income and underserved patient populations. In fact, it is estimated that 93% of FQHC patients are at or below the 200% and 76% are either covered by Medicaid/CHIP or uninsured (“Chronic care management for adults at FQHCs, Washington State University). Patient-centered medical homes (PCMH) provide holistic and comprehensive care, which includes coordinating the full range of medical, specialty, mental health and social services (Agency for HealthCare Research and Quality). Therefore, FQHC’s implementing the PCMH model of care are an ideal option managing the health care of individuals at-risk of homelessness. One-stop access to medical, behavioral and specialty care offered by these health care centers can significantly help increase compliance with discharge instructions for patients with complex conditions. Social service support provided through the PCMH model can also help at-risk older adults navigate the system for housing, and well as other services and eligible benefits. Hopefully this will lead to enhanced mental health care as well as stabilizing and optimizing the treatment of chronic physical illnesses. Older adults with substance abuse issues can be referred for treatment that would be followed by their primary care and behavioral health providers. Given the expected growth in the older population developing prevention and early intervention strategies for older adults at-risk for homelessness is critical. FQHC’s implementing the PCMH model can be a vital support in developing this prevention model.

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