Balancing Act: Clinical Practices That Respond to the Needs of Homeless People

by Marsha McMurray-Avila, M.C.R.P. Lillian Gelberg, M.D., M.S.P.H. William R. Brea ey, M.D.

Abstract
!his "a"er #escribes s"ecial a#a"$a$i%ns $% clinical "rac$ice necessary &%r a##ressing $he m%s$ c%mm%n heal$h "r%blems %& h%meless in#ivi#uals an# &amilies. A case is ma#e &%r $he in$egra$i%n %& "rimary care, men$al heal$h an# subs$ance abuse services as $he "re&erre# a""r%ach $% care &%r $his "%"ula$i%n, base# %n $he c%m"le'i$y %& mul$i"le in$errela$e# heal$h "r%blems $ha$ are seen. !hese "r%blems are e'amine# in a sec$i%n %n $he e"i#emi%l%gy %& heal$h "r%blems c%mm%n $% "e%"le (i$h%u$ h%mes. H%meless "e%"le &ace numer%us barriers $% access (hich can be %verc%me by a#a"$a$i%ns $% $he s$ruc$ure %& $he #elivery sys$em, inclu#ing e'$ensive %u$reach, m%bile si$es an# &le'ibili$y in "%licies an# "r%ce#ures. !he na$ure %& $he h%meless c%n#i$i%n als% calls &%r s"ecial a#a"$a$i%ns $% clinical "rac$ice in $he areas %& in$a e an# assessmen$, clinical "reven$ive services, #iagn%sis, &%ll%(-u" $% assure c%n$inui$y %& care, re&errals $% s"ecial$y care an# lin ages $% %$her services. S"eci&ic a#a"$a$i%ns &%r $rea$men$ %& "hysical an# men$al illnesses are "resen$e#, (i$h #iscussi%n %& "rimary care, $rea$men$ services &%r subs$ance use #is%r#ers, $rea$men$ services &%r seri%us an# "ersis$en$ men$al illnesses, an# s"ecial services &%r h%meless "e%"le (i$h #ual #iagn%ses. !he "a"er c%nclu#es (i$h c%mmen$s %n h%( $% a##ress $he $hrea$s $ha$ challenge success&ul c%n$inua$i%n %& $he uni)ue a""r%ach $% h%meless heal$h care $ha$ has ev%lve#, inclu#ing* ina#e)ua$e &un#ing $% &ully im"lemen$ $he in$egra$e# a""r%ach $% h%meless heal$h care+ im"ac$ %& mar e$-#riven manage# care+ lac %& &un#ing &%r accessible an# a""r%"ria$e subs$ance abuse $rea$men$+ limi$e# c%s$ an# %u$c%me #a$a+ $he #isc%nnec$ be$(een research an# "rac$ice+ an# $he scarci$y %& s ille# "rac$i$i%ners (illing $% serve $his "%"ula$i%n. increase# #eman# &%r services, #ecrease# ca"aci$y an# limi$e# res%urces, $he e&&ec$s %& Me#icai# manage# care, an# $he nee# &%r m%re )uali&ie# "rac$i$i%ners in $his &iel#.

Lessons for Practitioners, Policy Ma ers, and Researchers

A&$er m%re $han a #eca#e %& "rac$ice, $here is c%nsi#erable agreemen$ as $% (ha$ c%ns$i$u$es s$a$e %& $he ar$ clinical services &%r h%meless "e%"le. Base# %n research #em%ns$ra$i%n "r%grams s"%ns%re# by "ublic an# "riva$e &un#ing s%urces, an# e'"erience accumula$e# by &r%n$ line (%r ers in $he many heal$h care "r%grams acr%ss $he c%un$ry, nine general "rinci"les have emerge# as less%ns &%r "rac$i$i%ners inv%lve# in "r%vi#ing care &%r h%meless "e%"le*
h

!he im"%r$ance %& outreach $% engage clien$s in $rea$men$. Res"ec$ &%r the individuality of each person.

& $ $ s s

Cul$iva$i%n %& trust and rapport be$(een service "r%vi#er an# clien$. Flexibility in service "r%visi%n, inclu#ing l%ca$i%n an# h%urs %& service, as (ell as &le'ibili$y in $rea$men$ a""r%aches. !he nee# $% attend to the basic survival needs %& h%meless "e%"le an# $% rec%gni,e $ha$ un$il $h%se nee#s are me$, heal$h care may n%$ be an in#ivi#ual-s "ri%ri$y. !he im"%r$ance %& integrated service provision an# case management $% c%%r#ina$e $he nee#e# services. Clinical expertise $% a##ress c%m"le' clinical "r%blems, inclu#ing access $% s"eciali,e# care. .ee# &%r a range %& housing %"$i%ns, inclu#ing "r%grams c%mbining h%using (i$h services. A longitudinal perspective $ha$ ensures c%n$inuing care un$il $he "ers%n-s li&e si$ua$i%n is s$abili,e#.

!ntrod"ction
Physical an# men$al illnesses are im"lica$e# as b%$h causes an# c%nse)uences %& h%melessness &%r many in#ivi#uals. While $he sh%r$age %& sa&e, #ecen$, an# a&&%r#able h%using is $he m%s$ &un#amen$al cause %& h%melessness, un$rea$e# "hysical an#/%r men$al heal$h "r%blems crea$e vulnerabili$ies $ha$ can lea# $% l%ss %& inc%me an# h%me. A$ $he same $ime, $h%se (h% e'"erience h%melessness are sub0ec$ $% c%n#i$i%ns $ha$ can resul$ in #e$eri%ra$i%n %& heal$h %r e'acerba$e e'is$ing chr%nic %r acu$e illnesses, lea#ing $% ra$es %& illness an# in0ury &r%m $(% $% si' $imes higher $han &%r "e%"le (h% are h%use# 1Wrigh$, 23345. H%melessness als% severely c%m"lica$es $he #elivery %& heal$h services 16ns$i$u$e %& Me#icine, 23775. Wi$h%u$ access $% a""r%"ria$e heal$h care, acu$e an# chr%nic heal$h "r%blems may g% un$rea$e#, crea$ing me#ical c%m"lica$i%ns in mul$i"le c%-%ccurring c%n#i$i%ns an# ul$ima$ely im"e#ing $he in#ivi#ual-s abili$y $% %verc%me h%melessness. 8ailing $% "r%vi#e h%meless "e%"le (i$h heal$h care %& a s$an#ar# $ha$ is available $% %$her "e%"le, even (hen $hey nee# elab%ra$e %r e'"ensive $rea$men$s, c%ns$i$u$es a &%rm %& #iscrimina$i%n $ha$ sh%ul# be unacce"$able in a #em%cra$ic s%cie$y 1Bangsberg e$ al., 23395. A s$r%ng c%mmi$men$ by h%meless heal$h care "rac$i$i%ners $% res"%n# #irec$ly $% $hese c%m"le' mul$i"le heal$h care nee#s %& h%meless "e%"le has resul$e# in $he ev%lu$i%n %& an in$egra$e# a""r%ach $% "r%vi#ing clinical services. Primary heal$h care, men$al heal$h services an# subs$ance abuse $rea$men$ nee# $% be ma#e available ei$her &r%m %ne %rgani,a$i%n-s c%m"rehensive service sys$em, %r i& $his is n%$ &easible, $hr%ugh lin ages (i$h %$her agencies. !he "ur"%se %& $his "a"er is $% #escribe curren$ clinical "rac$ice (i$hin an in$egra$e# sys$em %& "rimary care, men$al heal$h an# subs$ance abuse services &%r "e%"le (i$h%u$ h%mes. Whenever "%ssible, research has been use# $% su""%r$ $he #iscussi%n. A signi&ican$ am%un$ %& research is available $% #escribe $he heal$h "r%blems %& h%meless "e%"le. H%(ever, less is &%un# in $he research li$era$ure rela$e# $% e&&icacy %& s"eci&ic clinical "rac$ices (i$h $his "%"ula$i%n. :'"erience in $he &iel# an# #escri"$ive acc%un$s by "rac$i$i%ners are $he basis &%r many %& $he s"ecial a#a"$a$i%ns $% clinical "rac$ices rec%mmen#e# here &%r a##ressing

$he m%s$ c%mm%n heal$h "r%blems %& h%meless in#ivi#uals an# &amilies. !he #iscussi%n is "resen$e# in $he &%ll%(ing sec$i%ns*
" ; : S

;u$c%mes* Wha$ #% (e (an$ %ur clinical in$erven$i%ns $% acc%m"lish< :"i#emi%l%gy* Wha$ are $he heal$h "r%blems %& h%meless "e%"le< Sys$em a#a"$a$i%ns #esigne# $% %verc%me access barriers. #Adapting clinical practices to the homeless condition$ S"eci&ic a#a"$a$i%ns &%r $rea$men$ %& "hysical an# men$al illnesses 1#escri"$i%ns %& $rea$men$ a""r%aches (i$hin each %& $he $hree s"eci&ic areas %& in$eres$* "rimary heal$h care, subs$ance abuse $rea$men$ an# men$al heal$h services, (i$h s"ecial c%nsi#era$i%n &%r #ealing (i$h "e%"le (h% are #ually #iagn%se#5.

%"tcomes: &hat 'o &e &ant %"r Clinical !nter(entions To Accomplish)

Al$h%ugh $here is a ma0%r m%vemen$ $% )uan$i&y ac$ual %u$c%mes %& heal$h care in$erven$i%ns, "r%vi#ers %& heal$h care $% h%meless "e%"le have ha# $% a#a"$ $heir %(n n%$i%ns %& success&ul %u$c%me $% $he reali$ies %& $he h%meless e'is$ence. A (%r ing gr%u" %n h%meless heal$h %u$c%mes (as c%nvene# in 233= by $he Heal$h Care &%r $he H%meless 1HCH5 Branch %& $he Divisi%n %& S"ecial P%"ula$i%ns/Bureau %& Primary Heal$h Care 1>.S. De"ar$men$ %& Heal$h an# Human Services, 233=5. !his gr%u" i#en$i&ie# seven sys$emslevel %u$c%mes an# seven clien$-level %u$c%mes $ha$ are g%als &%r &e#erally-&un#e# HCH "r%0ec$s. !he seven sys$em-level %u$c%mes are in$errela$e# in $ha$ HCH "r%0ec$s ?"r%vi#e access &%r h%meless "e%"le $% a range of comprehensive services. !hey %&&er continuity of care (i$hin an integrated system $% hel" contain costs an# prevent ne( %r recurring "r%blems. 6#eally, client involvement is evi#en$ in every s$e" %& $his "r%cess.@ !he seven clien$-level %u$c%mes are rela$e#, bu$ can be measure# in#e"en#en$ly %& %ne an%$her. !hese inclu#e* improved health status+ improved level of functioning+ improved quality of life+ involvement in treatment+ disease self-management+ client choice+ an# client satisfaction. H%(ever, $he gr%u" als% n%$e# $ha$ ?because h%meless "e%"le are a he$er%gene%us gr%u" (i$h mul$i"le an# c%m"le' nee#s, numer%us "ers%nal an# s%cie$al &ac$%rs %u$si#e $he clinicians- c%n$r%l may im"ac$ $he &inal %u$c%mes &%r in#ivi#ual "a$ien$s. Als%, $heir m%bili$y %&$en ma es i$ #i&&icul$ $% $rac h%meless "e%"le &%r &%ll%(-u" measures@ 1>.S. De"ar$men$ %& Heal$h an# Human Services, 233=, ".ii5. A cen$ral )ues$i%n in $his #iscussi%n is #e$ermining (ha$ )uali&ies as a ?success&ul %u$c%me@. Heal$h care "rac$i$i%ners (%r ing (i$h h%meless "e%"le are c%ncerne# (i$h im"r%ving heal$h s$a$us, level %& &unc$i%ning an# )uali$y %& li&e. ;bvi%usly, $he m%s$ signi&ican$ change a&&ec$ing all %& $hese (%ul# be ac)uiring "ermanen$ h%using. Al$h%ugh $his is cer$ainly a rec%mmen#e# g%al &%r heal$h "r%grams, usually un#er$a en (i$hin $he &rame(%r %& case managemen$ services, i$ is n%$ an %u$c%me $ha$ can be use# $% measure $he e&&ec$iveness %& clinical care. !his is "ar$icularly $rue given $he lac %& res%urces &%r a""r%"ria$e a&&%r#able h%using in m%s$ c%mmuni$ies, %ver (hich $he heal$h care "rac$i$i%ner has li$$le c%n$r%l.

!he na$ure %& h%melessness an# $he heal$h c%n#i$i%ns $ha$ acc%m"any i$ als% c%m"lica$e $he #e$ermina$i%n %& ?success&ul %u$c%me.@ H%meless "e%"le, "ar$icularly $h%se (i$h a##ic$i%ns an#/%r men$al illness, g% $hr%ugh vari%us s$ages %& change as $hey m%ve $%(ar#s $he #esirable im"r%vemen$s in heal$h s$a$us, &unc$i%ning an# )uali$y %& li&e. !hese s$ages inclu#e* "rec%n$em"la$i%n+ c%n$em"la$i%n+ ac$i%n+ main$enance+ an# rela"se 1Pr%chas a, DiClemen$e A .%rcr%ss, 233B5. !his is n%$ a linear "r%cess an# each in#ivi#ual changes a$ his %r her %(n ra$e. Chr%nic c%n#i$i%nsCes"ecially subs$ance abuse an# men$al illnessC are sub0ec$ $% regressi%ns an# rela"se. !his sh%ul# be e'"ec$e# an# nee#s $% be buil$ in$% "r%gram "lanning, as (ell as in$% %u$c%me evalua$i%n me$h%#%l%gies. 8%r e'am"le, (hile rec%gni,ing $ha$ $he incremen$al s$e"s may %ccur a$ #i&&eren$ "%in$s an# may s%me$imes g% bac (ar#s, a ?hierarchy %& %b0ec$ives@ can be c%ns$ruc$e# &%r h%meless "e%"le (h% are men$ally ill, beginning (i$h $he m%s$ basic $% $he m%s$ s%"his$ica$e# as &%ll%(s 1Brea ey, Susser A !imms, 233B5*
S A M A A P A S 6 A M 6 A P M ! P A

Acce"$s san#(ich &r%m %u$reach (%r er Main$ains eye c%n$ac$ (i$h %u$reach (%r er Acce"$s clean cl%$hing Acce"$s h%using/shel$er assis$ance Permi$s in$ervie( (i$h clinician Acce"$s me#ica$i%n S"%n$ane%usly a$$en#s $% "ers%nal hygiene 6& #anger%us, is br%ugh$ $% emergency &acili$y A$$en#s clinic regularly Mani&es$s re#uc$i%n in sym"$%ms 6m"r%vemen$ in sel&-care abili$y A#0us$s sa$is&ac$%rily $% shel$ere# living "r%gram Par$ici"a$es in s%cial ac$ivi$ies Main$ains mu$ually sa$is&ac$%ry rela$i%nshi" !rans&ers &r%m h%meless "r%gram $% generic "r%gram Par$ici"a$es in v%ca$i%nal rehabili$a$i%n "r%gram Able $% live in#e"en#en$ly Sus$ains c%m"e$i$ive em"l%ymen$

H%meless heal$h care "rac$i$i%ners are %&$en limi$e# $% measuring change in small incremen$s such as $hese. .e( s$ra$egies $% assess $hese incremen$al %u$c%mes are nee#e#, such as $he Service C%n$inuum ma$ri' being #evel%"e# by $he HCH .e$(%r , a "r%gram %& $he Sea$$le/Ding C%un$y De"ar$men$ %& Public Heal$h, $% $rac clien$s in $heir "r%gress $%(ar#s s$abili$y an# in#e"en#ence. !his assessmen$ ma$ri' is base# %n incremen$al change in $he areas %& rela$i%nshi", &inancial res%urces, heal$h/$rea$men$, s%cial su""%r$ ne$(%r an# resi#en$ial s$a$us in s$ages ranging &r%m $he ini$ial a""r%ach $hr%ugh c%m"ani%nshi", "ar$nershi" an# mu$uali$y $% s$abili$y an# in#e"en#ence 1HCH .e$(%r , 23375. ;$her signi&ican$ (%r has been ini$ia$e# $% #evel%" a""r%"ria$e %u$c%me measuremen$s &%r $he h%meless heal$h care se$$ing. As a &%ll%(-u" $% $he (%r ing gr%u" %n h%meless heal$h care %u$c%mes men$i%ne# ab%ve, B4 HCH "r%0ec$s (ere "r%vi#e# &e#eral &un#ing $% #evel%" %u$c%mes s$u#ies in a varie$y %& areas. 6$ is h%"e# $ha$ $he s$u#y resul$s an# less%ns

learne# (ill enc%urage &ur$her (%r in $his area by h%meless heal$h care "r%0ec$s 1>.S. De"ar$men$ %& Heal$h an# Human Services, 2337b5.

*pidemiology: &hat Are the Health Problems of Homeless People)

As a c%nse)uence %& $he "%%r nu$ri$i%n, lac %& a#e)ua$e hygiene, e'"%sure $% vi%lence an# $% $he elemen$s, increase# c%n$ac$ (i$h c%mmunicable #iseases, an# &a$igue $ha$ acc%m"any $he c%n#i$i%ns %& h%melessness, "e%"le (i$h%u$ h%mes su&&er &r%m ill heal$h a$ much higher ra$es $han "e%"le living in s$able h%using. Several s$u#ies have &%un# $ha$ %ne-$hir# $% %nehal& %& h%meless a#ul$s have s%me &%rm %& "hysical illness 1Bassu A R%senberg ,2377+ Bur$, 2373+ Gelberg A Linn, 2373+ M%rse A Calsyn, 237=+ R%$h A Bean, 237=5. A$ leas$ hal& %& h%meless chil#ren have a "hysical illness 1W%%# e$ al., 23345 an# $hey are $(ice as li ely as h%use# chil#ren $% have such illnesses 1Wrigh$ A Weber, 23795. !his lac %& heal$h $a es i$s $%ll by "reven$ing many h%meless "e%"le &r%m e'i$ing h%melessness. 8%r e'am"le, %ne-)uar$er %& h%meless a#ul$s re"%r$e# $ha$ $heir "%%r heal$h "reven$e# $hem &r%m (%r ing %r g%ing $% sch%%l 1R%ber$s%n A C%usineau, 237=5. :ven m%re seri%usly, ra$es %& m%r$ali$y are $hree $% &%ur $imes higher in $he h%meless "%"ula$i%n $han $hey are in $he general "%"ula$i%n 1Als$r%m, Lin#elius A Salum, 239E+ Han,lic A Parrish, 233F+ Hibbs e$ al., 233G+ M%rbi#i$y an# M%r$ali$y Wee ly Re"%r$, 2332 an# 233B+ Wrigh$ A Weber, 23795. !he m%s$ c%mm%n "hysical illnesses am%ng h%meless "ers%ns inclu#e u""er res"ira$%ry $rac$ in&ec$i%ns, $rauma, &emale geni$%urinary "r%blems, hy"er$ensi%n, s in an# ear #is%r#ers, gas$r%in$es$inal #iseases, "eri"heral vascular #isease, muscul%s ele$al "r%blems, #en$al "r%blems, an# visi%n "r%blems 1Wrigh$ A Weber, 2379+ Reuler e$ al., 237=+ Miller A Lin, 2377+ W%%# e$ al., 23345. 6na#e)ua$e immuni,a$i%n, (hile n%$ a "hysical illness, re&lec$s $he lac %& "reven$ive heal$h care in $his "%"ula$i%n 1Al"ers$ein e$ al., 2377+ W%%# e$ al., 2334+ Miller A Lin, 23775. H%(ever, $he $(% heal$h c%n#i$i%ns m%s$ li ely $% $ra" "e%"le in a s$a$e %& chr%nic h%melessness are subs$ance abuse #is%r#ers an# men$al illness. Heal$h "r%blems in $hese $hree #%mainsC"hysical illness, men$al illness an# subs$ance abuse #is%r#ersCare in$ima$ely rela$e#. 8%r e'am"le, surveys %& $he heal$h s$a$us %& h%meless "e%"le #em%ns$ra$e re"ea$e#ly $ha$ $he single m%s$ c%mm%n #is%r#er is subs$ance abuse. !his in $urn c%n$ribu$es $% a (i#e range %& %$her heal$h "r%blems resul$ing &r%m sel&neglec$ an# "%%r hygiene, nu$ri$i%nal #e&iciencies, $rauma, e'"%sure, acci#en$s, vic$imi,a$i%n, $%'ic e&&ec$s %& inges$e# subs$ances 1e.g., he"a$ic cirrh%sis #ue $% alc%h%l5 an# in&ec$i%ns 1e.g., bac$erial en#%car#i$is, he"a$i$is an# H6H in&ec$i%n #ue $% 6H #rug use5. S$u#ies als% #em%ns$ra$e $he "%%r general heal$h s$a$us %& severely men$ally ill h%meless "e%"le. !hey are m%re "r%ne $% neglec$ "ers%nal hygiene an# $heir basic heal$h care nee#s, an# $% have "%%r nu$ri$i%n. Seri%usly men$ally ill h%meless "e%"le have been &%un# $% be a$ higher ris &%r $ubercul%sis 1Sa ai e$ al., 23375 an# H6H in&ec$i%ns 1Susser e$ al., 233F5. An%$her e'am"le %& h%( many %& $hese "r%blems %verla" is in $he area %& im"airmen$ %& "hysical &unc$i%n. Des"i$e $heir y%ung age 1mean age in $he mi# F4Is5, hal& %& h%meless a#ul$s s$a$e $ha$ $hey are limi$e# in "er&%rming vig%r%us "hysical ac$ivi$ies 1Gelberg, Linn A Mayer-;a es, 23345. 8ur$her, many are limi$e# in m%#era$e "hysical ac$ivi$ies 1B2

"ercen$5, (al ing several bl%c s 1B7 "ercen$5, ben#ing, li&$ing, %r s$%%"ing 1B7 "ercen$5, $y"e %r am%un$ %& (%r 1GF "ercen$5, %r all $y"es %& (%r 1B3 "ercen$5. 8unc$i%nal #isabili$y migh$ be #ue $% any acu$e %r chr%nic "hysical illness. Jus$ as li ely, $his im"airmen$ migh$ be $he resul$ %& men$al illness. 6n &ac$, i$ is #i&&icul$ $% $ease %u$ $he #i&&eren$ial e&&ec$s %& $hese $(% as"ec$s %& illness, since $hey are b%$h mul$i&ace$e# an# b%$h in&luence %ne an%$her. 8%r e'am"le, i& a h%meless "ers%n e'"eriences "hysical im"airmen$, $his migh$ be #ue $% car#i%"ulm%nary #isease, %r $% $he vege$a$ive sym"$%ms %& severe #e"ressi%n. !he remain#er %& $his sec$i%n (ill a##ress $he e"i#emi%l%gy %& heal$h "r%blems %& "e%"le (h% are h%meless. Al$h%ugh $here is %verla" am%ng $he #i&&eren$ "r%blems, $hey (ill be #ivi#e# &%r $he sa e %& clari$y in$% $he &%ll%(ing ca$eg%ries* acu$e illnesses+ chr%nic "hysical c%n#i$i%ns+ c%mmunicable #iseases+ #en$al "r%blems+ subs$ance abuse #is%r#ers+ chr%nic men$al illness+ an# vi%lence. Because %& s"ecial issues rela$e# $% gen#er an# age, sec$i%ns are als% inclu#e# %n* (%men-s heal$h+ heal$h %& chil#ren an# $eens+ an# heal$h %& $he el#erly. Ac"te !llnesses Ab%u$ $(%-$hir#s %& $he "r%blems h%meless "e%"le "resen$ $% "rimary heal$h care si$es are acu$e in na$ure 1Wrigh$, 23345. S%me %& $hese mala#ies, es"ecially min%r res"ira$%ry in&ec$i%ns, c%ul# easily be sel&-$rea$e# by "e%"le in h%mes, (i$h %ver-$he-c%un$er me#ica$i%ns, a""r%"ria$e nu$ri$i%n, be#res$ an# a li$$le bi$ %& me#ical a#viceCall %& (hich are inaccessible $% $h%se (i$h%u$ h%mes. !he $hree m%s$ c%mm%n acu$e illnesses $ha$ a&&lic$ h%meless "e%"le 1Wrigh$, 23345 are usually a #irec$ c%nse)uence %& $he h%meless c%n#i$i%n*
c r $

res"ira$%ry in&ec$i%ns 1ranging &r%m c%l#s $% in&luen,a, "neum%nia an# "leurisy5 $rauma 1lacera$i%ns, (%un#s, s"rains, c%n$usi%ns, &rac$ures, burns, e$c.5 min%r s in ailmen$s 1inclu#ing sunburn, c%n$ac$ #erma$i$is, "s%riasis, c%rns an# calluses5

:'"%sure $% $he elemen$s an# cr%(#e# shel$er c%n#i$i%ns increases $he ris %& c%n$rac$ing res"ira$%ry in&ec$i%ns an# $he ris %& c%m"lica$i%ns. M%s$ %& $he $rauma is #irec$ly rela$e# $% li&e %n $he s$ree$s. An# #erma$%l%gical "r%blems are &re)uen$ly #ue $% e'"%sure $% $he elemen$s, shel$er c%n#i$i%ns, lac %& hygiene &acili$ies, an# ina""r%"ria$e &%%$(ear, am%ng %$her &ac$%rs. ;$her acu$e "r%blems $ha$ can als% be $race# $% $he h%meless c%n#i$i%n inclu#e in&es$a$i%ns 1such as lice %r scabies5, nu$ri$i%nal #e&iciencies, an# acu$e gas$r%in$es$inal #is%r#ers. Chronic Physical Conditions !he %$her $hir# %& $he "hysical heal$h "r%blems %& h%meless "e%"le are chr%nic "r%blems, such as hy"er$ensi%n, #iabe$es, gas$r%in$es$inal "r%blems, neur%l%gical #is%r#ers, chr%nic %bs$ruc$ive "ulm%nary #isease, ar$hri$is an# %$her muscul%s ele$al "r%blems 1Wrigh$, 23345. Many %& $hese illnesses are als% c%mm%n am%ng $he h%use# "%"ula$i%n, bu$ are

ma#e (%rse by $he s$ress an# e'"%sure %& h%melessness as (ell as by $he lac %& access $% %ng%ing $rea$men$. S$u#ies c%m"aring h%use# an# h%meless "%"ula$i%ns have sh%(n $ha$ "e%"le (i$h%u$ h%mes are m%re li ely $% su&&er &r%m a chr%nic heal$h "r%blem 1Wrigh$, 23345. ;ne chr%nic "hysical #is%r#er c%nsi#ere# $% be classically charac$eris$ic %& $he h%meless c%n#i$i%n is "eri"heral vascular #isease 1Scanlan an# Bric ner, 23345Cven%us %r ar$erial #e&iciencies in $he e'$remi$ies, inclu#ing such #is%r#ers as varic%se veins, "hlebi$is, $hr%mb%sis, s(%llen an les, celluli$is %& $he e'$remi$ies an# gangrene. !his is "rimarily #ue $% "e%"le being %n $heir &ee$ all #ay, $he lac %& %""%r$uni$ies $% eleva$e &ee$ an# legs, an# %&$en having $% slee" in a si$$ing-u" "%si$i%n. Comm"nicable 'iseases C%mmunicable #iseases are %& "ar$icular c%ncern &%r $(% reas%ns* $he "%$en$ial &%r ra"i# s"rea# am%ng "e%"le living in cr%(#e# shel$ers %r unsani$ary c%n#i$i%ns+ an# $he heal$h ris $% $he general "ublic. Ab%u$ %ne %u$ %& every &ive HCH clien$s has an in&ec$i%us %r c%mmunicable #isease 1Wrigh$, 23345. M%s$ %& $hese #is%r#ers are rela$ively min%r, such as lice %r scabies in&es$a$i%ns, %$her s in #iseases, e$c. H%(ever, seri%us res"ira$%ry in&ec$i%ns (ere &%un# in alm%s$ &%ur "ercen$, se'ually-$ransmi$$e# #isease 1S!D5 in ab%u$ $hree "ercen$, an# ac$ive $ubercul%sis 1!B5 in&ec$i%n in ab%u$ %ne "ercen$ 1Wrigh$, 23345. C%n$agi%us #iseases, such as $ubercul%sis 1Bric ner e$ al., 237E+ Wrigh$ e$ al., 2379+ K%l%"a e$ al., 233G5 an# H6H in&ec$i%n 1!%rres e$ al., 2334+ K%l%"a e$ al., 233G5, are m%re c%mm%n am%ng h%meless "e%"le $han in $he general "%"ula$i%n. Tuberculosis 8ive &ac$%rs c%n$ribu$e $% a heigh$ene# ris &%r !B am%ng h%meless "ers%ns 1.a$i%nal Heal$h Care &%r $he H%meless C%uncil, 233G5* 2. 6nsu&&icien$ access $% "reven$ive services an# heal$h care, inclu#ing lac %& %u$reach, case managemen$ %r %$her enabling services (hich (%ul# im"r%ve $he li elih%%# %& receiving e&&ec$ive care. B. Prevalence an# inci#ence %& $ubercul%sis am%ng %$her h%meless "ers%ns, increasing "%ssibili$y %& e'"%sure. F. Cr%(#ing an# insu&&icien$ ven$ila$i%n in shel$er envir%nmen$s. G. 6ncrease# "revalence %& %$her heal$h c%n#i$i%ns (hich su""ress $he immune sys$em, such as H6H in&ec$i%n, "%%r nu$ri$i%n, un$rea$e# #iabe$es, chr%nic %bs$ruc$ive "ulm%nary #isease, alc%h%lism, #rug abuse an# "sych%l%gical s$ress. E. 6nc%m"le$e #rug $hera"y, #ue $% #i&&icul$ies %& c%m"liance in a h%meless envir%nmen$, (hich lea#s $% #evel%"men$ %& #rug resis$an$ bac$eria. As a resul$ %& $his increase# ris , $he "revalence %& !B in&ec$i%n am%ng h%meless a#ul$s ranges &r%m FB "ercen$ in San 8rancisc% 1K%l%"a e$ al., 233G5 $% GF "ercen$ in .e( L%r 1McA#am e$ al., 23345. !he ra$e %& ac$ive !B am%ng men in a .e( L%r shel$er clinic (as = "ercen$ 1K%l%"a e$ al., 233G5. !he ra$e %& "%si$ive !B s in $es$s has been &%un# $% be

rela$e# $% #ura$i%n %& h%melessness 1K%l%"a e$ al., 233G+ Gelberg e$ al., 23395, living in cr%(#e# shel$ers %r single-r%%m %ccu"ancy h%$els 1SR;s5 1McA#am, 2334+ K%l%"a e$ al., 233G+ Gelberg e$ al., 23395, area %& $he ci$y 1Gelberg e$ al., 23395, an# in0ec$i%n #rug use 1K%l%"a e$ al., 233G5. !he general "ublic is als% a$ ris . A h%meless "ers%n (i$h un#iagn%se# "ulm%nary !B (h% &re)uen$e# a neighb%rh%%# bar in&ec$e# GB "ercen$ %& $he regular cus$%mers %& $ha$ bar 1Dline e$ al., 233E5. !B is m%re #i&&icul$ $% $rea$ in a "ers%n (h% is h%meless because %& $he #i&&icul$y %& screening, &%ll%(ing, an# main$aining $rea$men$, an# because many have mul$i#rug-resis$an$ %rganisms 1Bernar#%, 237E+ Bru#ney an# D%b in, 23325. HIV/AIDS !he "revalence %& H6H in&ec$i%n am%ng $he h%meless "%"ula$i%n is als% higher $han in $he h%use# "%"ula$i%n. S$u#ies reveal an H6H in&ec$i%n ra$e %& 3 "ercen$ am%ng San 8rancisc%Is h%meless a#ul$s 1K%l%"a e$ al., 233G5, 2.F "ercen$ am%ng A&rican American h%meless (%men in L%s Angeles 1.yama$hi, 233B5, 23 "ercen$ am%ng h%meless "sychia$ric "a$ien$s in a .e( L%r Ci$y menIs shel$er 1Susser, Halencia an# C%n%ver, 233F5, =B "ercen$ am%ng h%meless men (h% visi$e# a .e( L%r Ci$y shel$er clinic 1!%rres e$ al., 23345, an# E "ercen$ am%ng h%meless y%u$h in a .e( L%r Ci$y shel$er clinic 1S$ric%& e$ al., 23325. Recen$ research 1Smerec an# H%c man, 23375 has als% sh%(n $ha$ ra$es are higher &%r h%meless "e%"le living %n $he s$ree$ 123 "ercen$ %& "%"ula$i%n s$u#ie#5 $han $h%se in %$her living si$ua$i%ns such as shel$ers 122.B "ercen$ %& $h%se s$u#ie#5. Ra$es als% #i&&ere# by gen#er an# race, (i$h e'ce"$i%nally high H6HM ra$es &%r %n-$he-s$ree$ h%meless His"anic males 1B3 "ercen$5 an# &emales 1FB "ercen$5 an# &%r %n-$he-s$ree$ h%meless blac &emales 1F7 "ercen$5. An%$her recen$ s$u#y 1S%mlai e$ al., 23375 &%un# $ha$ #i&&eren$ &ac$%rs (ere ass%cia$e# (i$h H6H ris levels am%ng h%meless men an# (%men. 6n men, high-ris "a$$erns (ere ass%cia$e# (i$h nega$ive a$$i$u#es $%(ar# c%n#%m use, l%( levels %& in$en$i%n $% use c%n#%ms, high "erceive# ris %& A6DS, an# l%( "erceive# sel&-e&&icacy &%r av%i#ing ris . W%men a$ high ris %& H6H in&ec$i%n ha# grea$er li&e #issa$is&ac$i%n+ (ere less %"$imis$ic an# hel# m%re &a$alis$ic vie(s ab%u$ $he &u$ure+ hel# m%re nega$ive c%n#%m a$$i$u#es+ "erceive# $hemselves $% be a$ ris + an# &re)uen$ly use# alc%h%l, mari0uana, an# crac c%caine. Hepatitis Hiral he"a$i$is has bec%me a ma0%r c%ncern $% clinicians "r%vi#ing care $% h%meless "ers%ns. !he he"a$i$is C virus 1HCH5 is n%( $he m%s$ c%mm%n chr%nic bl%%#-b%rne in&ec$i%n in $he >ni$e# S$a$es 1CDC, 23375. Al$h%ugh $he inci#ence %& HCH in&ec$i%n is #eclining in $he general "%"ula$i%n, i$s "revalence remains high in "ar$icular sub"%"ula$i%ns, es"ecially $h%se inv%lve# in high ris behavi%r %& in$raven%us #rug use an# un"r%$ec$e# se'. !here curren$ly is n% signi&ican$ b%#y %& research %n HCH s"eci&ic $% $he h%meless "%"ula$i%n, bu$ h%meless heal$h care clinicians have been seeing a ra"i# increase in $he number %& chr%nic cases, in "ar$ because %& increase# screening. Acc%r#ing $% $hese clinicians, $he inci#ence %& HCH in&ec$i%n is higher in heal$h care se$$ings serving a larger

"r%"%r$i%n %& in0ec$ing-#rug users %r H6H-in&ec$e# in#ivi#uals 1HCH Clinicians- .e$(%r , 23335. ?Since HCH-in&ec$e# "ers%ns can remain asym"$%ma$ic &%r B4-F4 years, many are una(are %& $heir c%n#i$i%n, c%m"lica$ing in&ec$i%n c%n$r%l an# "reven$i%n %& ul$ima$ely li&e$hrea$ening se)uelae.@ 1HCH Clinicians- .e$(%r , 23335 Due $% $he high "revalence %& in$raven%us #rug use an# un"r%$ec$e# se', h%meless y%u$h an# a#ul$s are a$ als% a$ grea$ ris &%r he"a$i$is B. Li$$le has been "ublishe# %n ra$es %& he"a$i$is B "%si$ivi$y (i$hin h%meless "%"ula$i%ns, bu$ $he limi$e# li$era$ure n%$es $ha$ h%meless a#%lescen$s are a$ high ris 1Busen an# Beech, 2339+ M%rey an# 8rie#man, 233F+ Wang e$ al., 23325. :'"erience sugges$s $ha$ all h%meless chil#ren, y%u$h, an# "r%bably m%s$ a#ul$s sh%ul# be immuni,e# agains$ he"a$i$is B an# high-ris "ers%ns sh%ul# be $es$e# &%r he"a$i$is B an# C in&ec$i%n. Pe%"le e'"eriencing h%melessness are als% a$ ris &%r he"a$i$is A, #ue $% %vercr%(#ing in shel$ers as (ell as ea$ing %u$ %& garbage cans, b%$h %& (hich heigh$en $he ris %& &ecal-%ral s"rea# %& $his #isease. 6n &ac$, an %u$brea %& he"a$i$is A (as &%un# in a shel$er in Hienna 1Dern e$ al., 237=5. Dental Problems ;ne %& $he m%re %ver$ i#en$i&iers %& "%ver$y in $he >ni$e# S$a$es is "%%r #en$al heal$h 1Gelberg, Linn A R%senberg, 23775 an# i$ is %ne %& $he ma0%r heal$h "r%blems re"%r$e# by h%meless in#ivi#uals 1M%(bray e$ al., 237=5. !en "ercen$ %& h%meless clinic "a$ien$s have been &%un# $% have "%%r #en$al heal$h, a ra$e $hir$y-%ne $imes $ha$ &%un# in $he general "%"ula$i%n 1Wrigh$ an# Weber, 23795. H%meless "ers%ns living in $he c%mmuni$y are %ne$hir# as li ely as #%micile# a#ul$s $% have %b$aine# #en$al care in $he "as$ year, an# c%nse)uen$ly are $(ice as li ely $% have gr%ss #en$al #ecay 1E9 "ercen$ versus BF "ercen$5 1Gelberg, Linn A R%senberg, 23775. M%re $han hal& %& h%meless "ers%ns have gr%ssly #ecaye# $ee$h 1Gelberg, Linn A R%senberg, 23775. Given $his high ra$e %& #en$al #isease, #en$al care sh%ul# be an in$egral "ar$ %& any heal$h care services "ac age #evel%"e# &%r h%meless "e%"le. >n&%r$una$ely, #en$al care is n%$ al(ays given $he signi&icance i$ #eserves (i$hin $he general heal$h care arena. S%me may even $hin #en$al care &%r "e%"le (h% are h%meless is a lu'ury. Le$ $he im"ac$ %& #en$al #isease an# l%s$ $ee$h g%es bey%n# $he general heal$h im"lica$i%ns %& in&ec$i%n an# "ain. .u$ri$i%n is a&&ec$e# because "e%"le (i$h%u$ $ee$h are severely limi$e# in (ha$ $hey can ea$, resul$ing in &a$igue an# a##i$i%nal heal$h "r%blems. !here is als% an im"%r$an$ lin be$(een $he c%n#i$i%n %& $he m%u$h an# $ee$h an# an in#ivi#ual-s sel&-es$eem, (i$h $he resul$ing im"ac$ %n $heir em%$i%nal heal$h an# s%cial in$erac$i%ns. !his in $urn &unc$i%nally a&&ec$s $heir abili$y $% %b$ain em"l%ymen$. As a &%rmerly e#en$ul%us clien$ a$ %ne HCH #en$al clinic c%mmen$e# a&$er ge$$ing a &ull se$ %& #en$ures, ?6$-s har# $% ge$ a 0%b i& y%u can-$ smileN 1McMurray-Avila, 23395. Substance Abuse Disorders

:"i#emi%l%gical research c%nsis$en$ly #em%ns$ra$es, an# service "r%vi#ers can c%n&irm, $he ma0%r im"ac$ %& subs$ance use #is%r#ers in h%meless "%"ula$i%ns. Base# %n cliniciansre"%r$s, Wrigh$ 123345 es$ima$e# $ha$ %& "e%"le see ing "rimary heal$h care &r%m HCH "r%grams, F7 "ercen$ (ere alc%h%l abusers an# 2F "ercen$ abuse# %$her #rugs. Surveys %& h%meless "e%"le in general sugges$ higher ra$es* $he Bal$im%re H%meless S$u#y 1Brea ey e$ al., 23735 "r%#uce# es$ima$es %& ra$es &%r alc%h%l use #is%r#ers %& =9 "ercen$ an# B= "ercen$ &%r men an# (%men res"ec$ively an# ra$es %& B3 "ercen$ an# 22 "ercen$ &%r men an# (%men &%r %$her #rug use #is%r#ers. R%ber$s%n e$ al.123395 &%un# li&e$ime ra$es %& alc%h%l use #is%r#ers %& 92 "ercen$ in men an# =F "ercen$ in (%men in Alame#a C%un$y, Cali&%rnia. Ra$es &%r %$her #rug use #is%r#ers (ere EF "ercen$ an# E2 "ercen$. An e'amina$i%n %& numer%us s$u#ies $% #a$e 1D%egel, Burnam A Baum%hl, 233=5 c%nclu#e# $ha$ ab%u$ hal& %& h%meless "e%"le s$u#ie# have ha# a #iagn%sable subs$ance abuse #is%r#er a$ s%me "%in$ in $heir lives, (i$h a his$%ry %& alc%h%l abuse %ccurring in alm%s$ hal& %& single a#ul$s (h% are h%meless, an# a his$%ry %& #rug abuse in a""r%'ima$ely %ne-$hir#. !he in$%'ican$s use# by h%meless "e%"le vary &r%m "lace $% "lace an# $ime $% $ime, &%ll%(ing $he $ren#s in $he (i#er s%cie$y. !hus, as $he c%caine abuse e"i#emic increase# $hr%ugh $he 2374s an# 2334s, $he am%un$ %& c%caine use an# abuse in $he h%meless "%"ula$i%n increase# als%. H%(ever, in nearly every re"%r$, alc%h%l is s$ill $he "rinci"al #rug %& abuse in m%s$ "laces. !he #rugs %& grea$es$ c%ncern in h%meless "e%"le, &r%m a "ublic heal$h s$an#"%in$, are alc%h%l, her%in an# c%caine. Alc%h%l abuse an# #e"en#ence are ass%cia$e# (i$h a (i#e range %& heal$h c%m"lica$i%ns inv%lving $he liver, $he nerv%us sys$em an# $he hear$. !his is in a##i$i%n $% $he s%cial #e$eri%ra$i%n, l%ss %& ec%n%mic "r%#uc$ivi$y, vulnerabili$y $% acci#en$s an# vic$imi,a$i%n $ha$ are c%mm%n %u$c%mes. Her%in #e"en#ence, in a##i$i%n $% i$s s%cial, legal an# ec%n%mic e&&ec$s %n $he "ers%n, in m%s$ cases inv%lves in$raven%us a#minis$ra$i%n, (i$h $he ha,ar#s %& in&ec$i%ns such as bac$erial en#%car#i$is, he"a$i$is an# H6H #isease (hich have a ma0%r im"ac$ %n an in#ivi#ualIs heal$h an# "%se ma0%r challenges &%r heal$h care services. C%caine, (hen i$ is a#minis$ere# in$raven%usly, "%ses similar ris s, in a##i$i%n $% $he s%cial an# men$al c%nse)uences %& i$s use. Chronic Mental Illness 6n $he mi#-2374s $here (ere several (ell-#esigne# "revalence s$u#ies using s$an#ar#i,e# #iagn%s$ic me$h%#s $% #e$ermine ra$es %& men$al illness in h%meless "%"ula$i%ns %& ma0%r American ci$ies 16ns$i$u$e %& Me#icine, 2377+ 8ischer an# Brea ey, 23325. Research in#ica$es $ha$ "revalence ra$es %& s"eci&ic "sychia$ric #is%r#ers vary in #i&&eren$ subgr%u"s %& h%meless "e%"le an# &r%m "lace $% "lace, bu$ a br%a# c%nsensus emerge# $ha$ %& h%meless "e%"le resi#ing in shel$ers, ab%u$ %ne $hir# ha# signi&ican$ men$al illnesses 1D%egel, Burnam A 8arr, 2377+ Brea ey e$ al., 2373+ Susser, S$ruening A C%n%ver, 2373+ Smi$h, .%r$h A S"i$,nagel, 233B, 233F5. Da$a &r%m $he Bal$im%re H%meless S$u#y 1Brea ey e$ al., 23735 are $y"ical* a""r%'ima$ely FE "ercen$ %& men an# G7 "ercen$ %& (%men (ere &%un# $% have a ma0%r men$al illness. Schi,%"hrenia (as #iagn%se# in 3 "ercen$ %& men an# 2= "ercen$ %& (%men, an# ma0%r m%%# #is%r#ers in 29 "ercen$ %& men an# BE "ercen$ %& (%men. .%$e $ha$ $hese men$ally ill "e%"le varie# in $heir #egree %& #isabili$y, as #% men$ally ill "e%"le in general. 6& cri$eria %&

e'$ensive his$%ries %& in"a$ien$ a#missi%ns an# signi&ican$ &unc$i%nal im"airmen$ are a""lie#, $he number (h% are ?severely an# "ersis$en$ly@ men$ally ill is many &e(er. 6$ is $his gr%u" (h% "resen$ $he grea$es$ nee#s &%r $rea$men$ an# rehabili$a$i%n. !hey (ere es$ima$e# $% re"resen$ be$(een B4 an# BE "ercen$ %& h%meless "e%"le by D%egel, Burnam A Baum%hl 1233=5. 6n $he Bal$im%re sam"le, $hey c%m"rise# 29 "ercen$ %& men an# BG "ercen$ %& (%men 1Brea ey e$ al., 23735. Violence Hi%lence in $he lives %& h%meless "ers%ns is a ma0%r &ac$%r &%r un#ers$an#ing cri$ical "a$h(ays &r%m chil#h%%# an# a#ul$h%%# in$% h%melessness 1Bassu , Melnic an# Br%(ne, 2337+ Di" e e$ al., 2339+ Lin e$ al., 233E+ .%r$h, Smi$h an# S"i$,nagel, 233G+ !%r% e$ al., 233E5. Such vi%lence e'"erience# #uring chil#h%%# an# a#%lescence %&$en c%n$inues %nce in#ivi#uals bec%me h%meless as a resul$ %& $heir lac %& "r%$ec$i%n an# "ers%nal securi$y. !hese e'"eriences lea# $% b%$h acu$e an# chr%nic heal$h c%n#i$i%ns 1Gelberg, Linn an# Mayer-;a es, 23345 an# "%$en$ially a&&ec$ $rus$ buil#ing an# subse)uen$ a#herence (i$h "reven$ive an# %ng%ing heal$h care 1G%%#man e$ al., 23395. Womens Health Heal$h services &%r h%meless (%men are severely lac ing 16ns$i$u$e %& Me#icine, 23775, an# ye$ "regnancy an# recen$ bir$hs are ris &ac$%rs &%r bec%ming h%meless 1Wei$,man, 23735. .ine$y-&ive "ercen$ %& h%meless (%men are se'ually ac$ive 1.yama$hi, 233F5, an# ye$ 9B "ercen$ #% n%$ use bir$h c%n$r%l 1Gelberg A Linn, 237E5. Less $han 24 "ercen$ use c%n#%ms, #es"i$e li&es$yles $ha$ "lace $hem a$ grea$ ris &%r H6H/A6DS an# %$her se'ually $ransmi$$e# #iseases 1Gelberg A Linn, 237E+ Shuler e$ al., 233E+ Bric ner e$ al., 23345. !his is evi#ence# by $he &ac$ $ha$ =4 "ercen$ %& h%meless &amily "lanning clinic users ha# a his$%ry %& a se'ually $ransmi$$e# #isease 1S!D5, an# B7 "ercen$ ha# a his$%ry %& "elvic in&lamma$%ry #isease 1P6D5 1Shuler e$ al., 233E5. 6n a##i$i%n, m%re $han %ne-&i&$h have n%$ ha# a Pa" smear in $he "as$ &ive years 1Gelberg A Linn, 237E5 c%m"are# $% less $han 3 "ercen$ %& (%men in $he general "%"ula$i%n 1Hay(ar# e$ al., 23775. !his is alarming given $ha$ BF "ercen$ %& h%meless &amily "lanning clinic users ha# an abn%rmal Pa" smear 1Shuler, 23325. 6& $he h%meless c%n#i$i%n is unheal$hy &%r "e%"le in general, clearly i$ is even m%re #anger%us &%r a "regnan$ (%man. H%melessness brings high ris s &%r c%m"lica$i%ns #uring "regnancy #ue $% lac %& "rena$al care, "%%r nu$ri$i%n, s$ress an# e'"%sure $% vi%lence. .%rmal "hysi%l%gical changes %& "regnancy %&$en bec%me "a$h%l%gical, signs %& "%$en$ial c%m"lica$i%ns g% unn%$ice# %r una$$en#e#, an# $he min%r #isc%m&%r$s %& "regnancy are e'acerba$e# by $he h%meless envir%nmen$ 1Dilli%n, 233E5. !hese c%m"lica$i%ns bec%me even m%re "r%n%unce# (hen $he (%man is a subs$ance abuser, is men$ally ill %r is H6HM. Base# %n s$u#ies %& (%menIs %bs$e$rical his$%ry, 9G "ercen$ have ha# chil#ren 1Burnam A D%egel, 2373+ Shuler e$ al., 233E5 an# EG "ercen$ are curren$ly a$ ris &%r unin$en#e# "regnancy 1Shuler e$ al., 233E5. H%meless (%men are m%re li ely $% be "regnan$ 122 "ercen$ %& h%meless (%men age B4 an# %ver, an# BG "ercen$ %& 2=- $% 23-year-%l# h%meless y%u$h5 $han $heir "%%r bu$ h%use# "eers 1&ive "ercen$5 1Chav in e$ al., 23795. 6n

a##i$i%n, $hey are m%re li ely $% receive ina#e)ua$e "rena$al care $han "%%r bu$ h%use# (%men 1E= "ercen$ versus 2E "ercen$5 1Chav in e$ al., 23795. 6$ &%ll%(s $ha$ h%meless (%men are m%re li ely $han im"%verishe# h%use# (%men $% have "%%r bir$h %u$c%mes 1Pa$ers%n an# R%#eric , 2334+ Shuler e$ al., 233E+ Wei$,man, 2373+ Wrigh$ an# Weber, 23795, (i$h %ne s$u#y sh%(ing a #i&&erence in l%( bir$h (eigh$ ne(b%rns %& 2= "ercen$ &%r h%meless m%$hers versus seven "ercen$ &%r n%n-h%meless m%$hers 1Chav in e$ al., 23795. 6n .e( L%r Ci$y, in&an$ m%r$ali$y (as highes$ am%ng h%meless (%men 1BG.3 "er 2,444 live bir$hs5 as c%m"are# $% "%%r h%use# (%men 12=.= "er 2,444 live bir$hs5, an# n%n-"%%r h%use# (%men 12B.4 "er 2,444 live bir$hs5 1Chav in e$ al., 23795. 6n Grea$ Bri$ain, (hile h%meless (%men ha# higher ra$es %& "rema$ure bir$hs 122 "ercen$ vs. seven "ercen$ %& $he general "%"ula$i%n5, $heir ra$es %& in&an$ m%r$ali$y (ere $he same as $h%se %& h%use# (%men 1Pa$ers%n A R%#eric , 23345. H%melessness "u$s (%men a$ ris &%r $rauma #ue $% vi%lence, %&$en ech%ing abuse su&&ere# earlier in li&e. Physical an# se'ual abuse in &amily an# %$her in$er"ers%nal rela$i%nshi"s have been i#en$i&ie# as b%$h a cause an# a c%nse)uence %& h%melessness in $he lives %& (%men 1Hagen, 2379+ S$%ner, 237F5. 6n %ne s$u#y %& h%meless an# "%%r h%use# (%men, =9 "ercen$ re"%r$e# severe "hysical vi%lence by a chil#h%%# care$a er, GF "ercen$ re"%r$e# chil#h%%# se'ual m%les$a$i%n, an# =F "ercen$ re"%r$e# severe vi%lence by a male "ar$ner 1Br%(ne A Bassu , 23395. W%men %n $he s$ree$s are %&$en vic$ims %& assaul$, b%$h "hysical an# se'ual. !h%se (h% are men$ally ill %r un#er $he in&luence %& #rugs %r alc%h%l are even m%re vulnerable $% a$$ac , an# less li ely %r able $% see hel" a&$er(ar#s 1Burr%ughs e$ al., 23345. >n&%r$una$ely, even being in a shel$er #%es n%$ al(ays "r%$ec$ (%men &r%m vi%lence, es"ecially in large "ublic shel$ers $ha$ als% h%use men. An# h%meless (%men (h% are in rela$i%nshi"s are 0us$ as li ely as h%use# (%men $% be ba$$ere# by $heir "ar$ner, bec%ming vic$ims %& #%mes$ic vi%lence (i$h%u$ $he bene&i$ %& $he ?#%mes$ic@ #(elling 1Burr%ughs e$ al., 23345. Health of Children and outh H%meless chil#ren are m%re li ely $% su&&er &r%m acu$e heal$h "r%blems, $han &r%m chr%nic c%n#i$i%ns. !he m%s$ c%mm%n illnesses in chil#ren seen by HCH "r%0ec$s are, in a""r%'ima$e %r#er %& &re)uency* min%r u""er res"ira$%ry in&ec$i%ns+ min%r s in in&ec$i%ns+ ear in&ec$i%ns+ gas$r%in$es$inal "r%blems+ $rauma+ eye #is%r#ers+ an# lice in&es$a$i%ns 1Wrigh$, 23345. As migh$ be e'"ec$e# in &amilies $ha$ m%ve &re)uen$ly, h%meless chil#ren are %&$en behin# in $heir immuni,a$i%ns 1W%%#, 233B5. An# (i$h%u$ easy access $% heal$h care services, chr%nic illnesses such as anemia, as$hma an# recurren$ %$i$is me#ia %&$en g% un#iagn%se# an# un$rea$e#. P%ver$y has been seen $% have a signi&ican$ im"ac$ u"%n chil#ren-s heal$h, achievemen$, an# behavi%r 1Br%% s-Gunn an# Duncan, 23395. !he e&&ec$s %& h%melessness %n n%rmal chil#h%%# #evel%"men$ have been #%cumen$e# $% inclu#e aca#emic #i&&icul$y 1#ue $% missing sch%%l5 1:##ins, 233F5 an# behavi%r "r%blems 1W%%#, 233B5, as (ell as gr%($h #elay 18ierman e$ al, 23325, #evel%"men$al #elay, an'ie$y, #e"ressi%n an# learning #i&&icul$ies 1Aber e$ al., 2339+ Bassu , Rubin A Lauria$, 237=+ :##ins, 233F5.

H%melessness am%ng a#%lescen$s is m%re &re)uen$ $han is generally reali,e# 1Ring(al$ e$ al., 23375. H%meless y%u$h, s%me$imes n%(n as runa(ays, $hr%(a(ays %r sim"ly ?s$ree$ i#s,@ su&&er &r%m illnesses #irec$ly rela$e# $% a li&es$yle %n $he s$ree$s $ha$ is charac$eri,e# by vi%lence an# #e"riva$i%n 1Denne#y e$ al., 2334+ R%ber$s%n, 233=5. S$ree$ y%u$h have %&$en been vic$ims %& "hysical an# se'ual abuse an# &amily cha%s, an# have been &%un# $% have a grea$er number %& "sych%l%gical an# "hysical "r%blems $han $he general a#%lescen$ "%"ula$i%n 1Sherman, 233B5. Many engage in ?survival se',@ e'changing se'ual &av%rs &%r &%%#, cl%$hing %r shel$er, ma ing $hem vulnerable $% se'ually-$ransmi$$e# #iseases, inclu#ing H6H, as (ell as unin$en#e# "regnancies 1Re(, 233=5. Heal$h "r%blems m%s$ c%mm%nly seen by clinics serving $his "%"ula$i%n inclu#e 1in a""r%'ima$e %r#er %& &re)uency5* vi%len$ an# $rauma$ic in0ury+ subs$ance abuse+ se'ually-$ransmi$$e# #iseases, inclu#ing he"a$i$is an# H6H/A6DS+ "sychia$ric #is$urbances+ s in in&es$a$i%ns+ ign%re# "regnancies+ ?un(ell@ babies+ an# c%mm%n chr%nic illnesses $ha$ have been e'acerba$e# by $he lac %& sim"le care 1Denne#y e$ al., 23345. A s$u#y %& h%meless an# "%%r h%use# y%u$hs &%un# $ha$ a""r%'ima$ely FB "ercen$ ha# a curren$ men$al #is%r#er acc%m"anie# by im"airmen$ in &unc$i%n, bu$ use %& men$al heal$h services (as l%( 1Buc ner an# Bassu , 23395. Psychia$ric #is%r#ers are li ely $% be ign%re#, c%vere# u" %r #enie# by a#%lescen$s. !heir &re)uen$ "as$ his$%ries %& abuse an# neglec$, $heir inv%lvemen$ in an$is%cial li&es$yles an# neglec$ %& $heir e#uca$i%n have grave im"lica$i%ns &%r $heir "ers%nali$y #evel%"men$ an# ma$ura$i%n in$% a#ul$h%%#. Health of the !lderl" Rela$ively &e( h%meless "e%"le %ver age =E are seen in heal$h care si$es serving h%meless "e%"leC%nly B.9 "ercen$ in 233= 1>.S. De"ar$men$ %& Heal$h an# Human Services, 2337a5. !his c%ul# be #ue ei$her $% early m%r$ali$y %r $% $he a##i$i%nal bene&i$s an# assis$ance available %nce a "ers%n reaches =E 1all%(ing &%r access $% inc%me, h%using an# heal$h care5. Al$h%ugh $heir numbers are &e(, ?$he age# h%meless are %& s"ecial c%ncern because %& $heir vulnerabili$y $% vic$imi,a$i%n (hile %n $he s$ree$s an# in shel$ers, $heir &rail$y #ue $% "%%r "hysical heal$h, an# $he reluc$ance %& c%mmuni$y seni%r cen$ers $% acce"$ $hem as "ar$ici"an$s@ 1La#ner, 233B5. As (%ul# be e'"ec$e#, many %& $heir heal$h "r%blems are chr%nic c%n#i$i%ns ass%cia$e# (i$h aging, such as C;PD, PHD, hy"er$ensi%n an# hear$ #isease 1Bla eney, 2332+ Gelberg, Linn A Mayer-;a es, 2334+ ;-C%nnell, Summer&iel# an# Dell%gg, 2334 5. !he ma0%ri$y su&&er &r%m alc%h%lism, bu$ men$al illness is s%me(ha$ less c%mm%n $han in $he general h%meless "%"ula$i%n 1Bla eney, 23325.

+ystem Adaptations 'esigned To %(ercome Access Barriers

C%m"%un#ing $he increase# ris &%r illness %r in0ury, $here is evi#ence $ha$ h%meless "e%"le enc%un$er ma0%r %bs$acles $% %b$aining nee#e# me#ical an# "sychia$ric services. !he ma0%ri$y %& h%meless a#ul$s s$a$e $ha$ $hey #i# n%$ %b$ain nee#e# me#ical care in $he "revi%us year 1Gelberg an# Linn, 2377+ R%ber$s%n an# C%usineau, 237=5. :ven am%ng $h%se (i$h a chr%nic me#ical c%n#i$i%n, hal& ha# n%$ seen a #%c$%r (i$hin $he "revi%us year 1R%ber$s%n, R%"ers an# B%yer, 237E5. ;rgani,a$i%ns "r%vi#ing services $% h%meless "e%"le

have #escribe# numer%us #i&&icul$ies in accessing subs$ance abuse $rea$men$ &%r $heir clien$s 1Williams, 233B5. Since $he mi#-2374-s, signi&ican$ a#vances have been ma#e in $he #evel%"men$ %& e&&ec$ive #elivery sys$ems &%r heal$h services $% "e%"le (h% are h%meless. !he su""%r$ %& several agencies %& $he >.S. De"ar$men$ %& Heal$h an# Human ServicesC%&$en $hr%ugh "r%grams au$h%ri,e# by $he S$e(ar$ B. McDinney H%meless Assis$ance Ac$ %& 2379Chas been ins$rumen$al in $hese a#vances. !he Bureau %& Primary Heal$h Care-s Heal$h Care &%r $he H%meless 1HCH5 "r%gram has assis$e# m%re $han 2F4 c%mmuni$ies in "r%vi#ing c%m"rehensive heal$h services $% "e%"le (h% are h%meless, (i$h a s"ecial &%cus %n #evel%"ing sys$ems $ha$ #irec$ly a##ress $he barriers $% access h%meless "e%"le &ace. S%me %& $hese barriers $% access are rela$e# $% e'$ernal &ac$%rs such as lac %& $rans"%r$a$i%n 1R%ber$s%n A C%usineau, 237=5. ;$hers are in$ernal, &%r e'am"le, #enial %& e'is$ence %& a heal$h "r%blem, lac %& a(areness %& available services, %r ac$ive av%i#ance #ue $% &ear %r #is$rus$ %& large ins$i$u$i%ns. Because an e'hibi$i%n %& $%ughness is necessary in %r#er $% survive %n $he s$ree$s, h%meless "ers%ns may a$ $imes #eny $ha$ $hey have heal$h "r%blems in an a$$em"$ $% main$ain a sense %& $heir %(n en#urance. Pe%"le (i$h subs$ance abuse #is%r#ers %r men$al illness may #eny having a "r%blem %r be una(are %& $he severi$y %& i$. :ven (hen a(are %& $heir "r%blem an# %& available services, many h%meless "e%"le are #is$rus$&ul %& any %&&ers %& hel" #ue $% "revi%us nega$ive e'"eriences (i$h $he heal$h care an# s%cial services sys$ems. !hey may be $%% embarrasse# $% have me#ical "r%&essi%nals see $hem in a c%n#i$i%n %& "%%r "ers%nal hygiene. ;r $hey may av%i# see ing heal$h care because %& $he &ear %& having $heir meager &inancial res%urces $a en a(ay $% "ay &%r $he services $hey receive, %r &ear %& au$h%ri$y &igures 1S$ar , 233B5, inclu#ing 6mmigra$i%n an# .a$urali,a$i%n au$h%ri$ies, chil# "r%$ec$ive service (%r ers 1by runa(ay $eenagers an# h%meless (%men (i$h chil#ren5, an# "%lice 1by #rug abusers %r e'-c%nvic$s5 1Jahiel, 233B5. Ser#ice Deli#er" $ocations 6n %r#er $% %verc%me $hese barriers, heal$h care "r%0ec$s serving h%meless "e%"le have #evel%"e# a#a"$a$i%ns rela$e# $% l%ca$i%ns %& service #elivery, (i$h %"$i%ns ranging &r%m m%bile $% &i'e#-si$e services. M%bile a""r%achesCb%$h s$ree$ %u$reach an# use %& m%bile uni$sCres"%n# es"ecially (ell $% $he barriers men$i%ne# ab%ve, &in#ing an# engaging "e%"le (h% (%ul# %$her(ise n%$ receive heal$h services. 8i'e#-si$e l%ca$i%ns inclu#e* shel$er-base# services+ c%mmuni$y heal$h cen$er %r h%s"i$al-base# clinics (i$h s"ecial acc%mm%#a$i%ns &%r h%meless "e%"le+ an# &ree-s$an#ing HCH &acili$ies such as clinics, res"i$e uni$s, #r%"-in cen$ers %r resi#en$ial "r%grams. Curren$ &e#erally-&un#e# HCH "r%0ec$s $en# $% use m%re $han %ne a""r%ach, &re)uen$ly c%mbining s$ree$ %u$reach (i$h &i'e#-si$e l%ca$i%ns in shel$ers %r &ree-s$an#ing clinics 1C%usineau e$ al., 233E5. Schedulin% &f Ser#ices An%$her signi&ican$ %bs$acle $% access rela$es $% $imes (hen services are %&&ere#. Mains$ream services #e"en# %n sche#ule# a""%in$men$s, (hich are %&$en har# &%r h%meless

"e%"le $% ee", #ue $% c%m"e$ing "ri%ri$ies &%r survival, such as &in#ing #ay lab%r, a &ree meal %r a shel$er be# &%r $he nigh$ 1Gelberg, Gallagher, An#ersen A D%egel, 23395. Pe%"le (h% are h%meless als% lac access $% $ele"h%nes $% ma e a""%in$men$s %r change $hem i& necessary. 8%r $his reas%n, sche#uling %& services nee#s $% c%inci#e (i$h $he m%s$ c%nvenien$ $imes &%r $he "%"ula$i%n being $arge$e#, an# sh%ul# n%$ c%n&lic$ (i$h $h%se $imes (hen h%meless "e%"le are n%rmally searching &%r a meal %r shel$er. Many HCH "r%0ec$s se$ asi#e cer$ain $imes &%r (al -in clinics, (hile %$her $imes are #esigna$e# &%r sche#ule# &%ll%(-u" a""%in$men$s (i$h clien$s (h% have an es$ablishe# his$%ry %& care. ;u$reach sche#ules nee# $% be even m%re &le'ible, %&$en $a ing "lace #uring early m%rning %r evening h%urs, #e"en#ing %n $he "%"ula$i%n an# $he se$$ing 1McMurray-Avila, 23395. 'inancial (arriers Lac %& &inancial res%urces %r heal$h insurance an# lac %& #%cumen$a$i%n c%ns$i$u$e a##i$i%nal access barriers $ha$ a&&ec$ h%( services nee# $% be s$ruc$ure# an# #elivere#. ;ne&i&$h %& h%meless a#ul$s (h% ha# n%$ %b$aine# nee#e# me#ical care s$a$e# $ha$ $his (as #ue $% inabili$y $% "ay &%r me#ical services 1C%hen, !eresi A H%lmes, 2377+ R%ber$s%n A C%usineau, 237=5. ;nly %ne-si'$h 1Bassu , Rubin A Lauria$, 237G+ 8arr, D%egel A Burnam, 237=+ R%ber$s%n, R%"ers A B%yer, 237E5 $% %ne-$hir# 18ischer, Sha"ir% A Brea ey, 237=+ Miller A Lin, 23775 %& "e%"le (h% are h%meless have any &%rm %& heal$h insurance, an# m%s$ have n% cash res%urces a$ all 1D%egel A Gelberg, 233B5. ;ne #eca#e a&$er m%s$ %& $hese s$u#ies (ere "er&%rme#, HCH "r%0ec$s s$ill re"%r$ $ha$ %ver 94 "ercen$ %& $he clien$s $hey see have n% &inancial res%urces &%r heal$h care 1>.S. De"ar$men$ %& Heal$h an# Human Services, 2337a5. H%meless "e%"le &re)uen$ly lac i#en$i&ica$i%n %r %$her #%cumen$a$i%n $% "r%ve in#igen$ s$a$us in %r#er $% )uali&y &%r &ree %r re#uce# services in mains$ream heal$h care se$$ings. !hey %&$en have ha# $heir i#en$i&ica$i%n #%cumen$s l%s$ %r s$%len, %r are living in $he s$ree$s an# shel$ers %& $he >.S. (i$h%u$ legal #%cumen$a$i%n. Heal$h care "r%grams &%r h%meless "e%"le mus$ $here&%re $a" in$% every available &un#ing s%urce $% elimina$e $his access barrier. Public &un#s, $hr%ugh Me#icai# an# %$her &un#ing s$reams, have su""%r$e# heal$h care &%r "%%r an# h%meless "e%"le. As "ublic "r%grams e'er$ "ressure $% c%n&%rm $% m%#els &irs$ #evel%"e# &%r manage# care in $he "riva$e sec$%r, e&&ec$ive HCH "r%0ec$s mus$ c%n$inue $% give "ri%ri$y $% res"%n#ing $% $he s"ecial nee#s an# reali$ies %& $heir clien$s. A$ $he same $ime $hey mus$ s$rive $% a##ress $he increase# nee#s &%r #e$aile# in$a e, au$h%ri,a$i%n an# billing "r%ce#ures, #es"i$e $he #rain %n res%urces %& s$a&& an# $ime. !hese c%n&lic$ing "ri%ri$ies may be a s%urce %& c%nsi#erable s$ress $% clinicians an# $% "r%gram a#minis$ra$%rs. S$ric$ a#herence $% a business men$ali$y (ill crea$e &rus$ra$i%n &%r s$a&& an# aliena$i%n &%r clien$s. Cultural Competence Access $% services is als% a&&ec$e# by language an# cul$ural barriers an# by a$$i$u#es %& "r%vi#ers %& care. While a "%si$ive, %"en a$$i$u#e %& being cul$urally sensi$ive is necessary, i$ %nly bec%mes cul$ural c%m"e$ence (hen i$ is "u$ in$% "rac$ice. Prac$icing cul$ural c%m"e$ence inv%lves a c%mbina$i%n %& attitude, knowledge an# skills 1CASSP5. An attitude %& res"ec$ is essen$ial (hen (%r ing (i$h "e%"le (h% are h%meless, as (ell as main$aining

an acce"$ance %& cul$ural #i&&erences am%ng "e%"le. Pe%"le &r%m all cul$ural bac gr%un#s bec%me h%meless, s% "rac$i$i%ners nee# $% be (illing $% (%r (i$h clien$s %& #i&&eren$ e$hnic min%ri$y gr%u"s an# cul$ures. Knowledge %& $he his$%ry, $ra#i$i%ns, values, an# &amily sys$ems %& $hese cul$ures is im"%r$an$, es"ecially an un#ers$an#ing %& $he e&&ec$s %& "ar$icular cul$ures %n $he hel"-see ing behavi%rs %& "e%"le (h% are h%meless, as (ell as $he s"eci&ic heal$h belie&s an# healing "rac$ices %& $he cul$ures inv%lve#. 6n a##i$i%n $% $he %bvi%us skill %& language c%m"e$ency, s ill is als% nee#e# $% a#0us$ clinical "rac$ice $% acc%mm%#a$e cer$ain heal$h belie&s an# healing "rac$ices %& #i&&eren$ cul$ures. Cul$ural belie&s a&&ec$ a$$i$u#es $%(ar# #isease an# heal$h, as (ell as %&&ering e'"lana$i%ns &%r causes %& ill heal$h, inclu#ing men$al illness an# subs$ance abuse. Wha$ may be labele# ?n%n-c%m"liance@ by a heal$h care "r%vi#er c%ul# in reali$y be #ue $% cul$ural #i&&erences in in$er"re$ing $he #iagn%sis an#/%r $rea$men$. Dealin% With Disrupti#e (eha#ior An a##i$i%nal barrier $% access is crea$e# (hen h%meless "e%"le (i$h his$%ries %& #isru"$ive behavi%r are ac$ually barre# &r%m services. H%meless heal$h care "r%vi#ers c%n$inually have $% assess $he na$ure %& #isru"$ive behavi%rCis $he "ers%n ac$ing %u$ #ue $% a men$al illness bey%n# his %r her c%n$r%l, %r is $he behavi%r in$en$i%nal an# mean$ $% #% harm< Again a #elica$e balance mus$ be main$aine# be$(een &le'ibili$yC"ar$icularly (i$h regar# $% e'amining an# changing rules %r "%licies $ha$ may be ina""r%"ria$e &%r $he "%"ula$i%n in )ues$i%nCan# $he sa&e$y %& $he clien$, %$her clien$s an# $he s$a&&. Wha$ may s%me$imes be labele# a sh%r$c%ming %& $he clien$ in $erms %& being ?n%n-c%m"lian$@ may ac$ually be a sh%r$c%ming %& $he sys$em %& servicesCn%n-c%m"liance (i$h $he a""r%aches nee#e# $% e&&ec$ively serve $he clien$s. Multidisciplinar" Teams ;ne &inal a#a"$a$i%n $% service #elivery $ha$ heal$h care "r%vi#ers mus$ ma e (hen (%r ing (i$h h%meless "e%"le rela$es bac $% $he c%nce"$ %& in$egra$e# services #iscusse# in $he in$r%#uc$i%n. M%s$ mains$ream heal$h care %rgani,a$i%ns are "rimarily single&%cuse#. !hey ei$her "r%vi#e me#ical care, men$al heal$h services %r subs$ance abuse $rea$men$. 8e( are %rgani,e# $% #eal (i$h $he mul$i"le issues $ha$ are "ar$ %& being h%meless. When "e%"le are $rea$e# %nly &%r $he ?"resen$ing "r%blem,@ $he un#erlying cause %& $ha$ "r%blem may n%$ be a##resse#. Clinical in$erven$i%ns (i$h h%meless "e%"le are m%s$ e&&ec$ive (hen carrie# %u$ by mul$i#isci"linary $eams 1Burness Gleicher e$ al., 23345. !he "rac$ice %& clinicians &r%m #i&&eren$ #isci"lines (%r ing $%ge$her %&&ers m%re chance %& arriving a$ a""r%"ria$e #iagn%sis an# $rea$men$ c%nclusi%ns. Health Ser#ices for Homeless ouths Pr%vi#ers %& heal$h care mus$ be a(are %& all %& $hese "%$en$ial barriers, ma ing a#a"$a$i%ns as necessary an# "aying s"ecial a$$en$i%n $% $he charac$eris$ics %& $he "%"ula$i%n $hey are serving. Designing heal$h services &%r h%meless y%u$hs "r%vi#es a g%%# e'am"le %& $his. A#%lescen$s (h% are h%meless an# a"ar$ &r%m $heir &amilies "resen$ signi&ican$ "r%blems

&%r heal$h care because %& $he #i&&icul$y in engaging $hem, bu$ als% because %& $heir &re)uen$ reluc$ance $% ac n%(le#ge $heir nee#. !heir s$a$us as min%rs, issues %& c%nsen$ an# c%n&i#en$iali$y an# $heir #is$rus$ %& a#ul$s "r%vi#e a##i$i%nal barriers $% care 1R%ber$s%n, 233=5 Clinicians (%r ing (i$h $his gr%u" sh%ul# be (ell-verse# in $he usual heal$h nee#s %& a#%lescen$s, bu$ "ar$icularly "re"are# $% #eal (i$h $he "hysical an# em%$i%nal e&&ec$s %& vi%lence, c%mm%n an# e'%$ic se'ually $ransmi$$e# #iseases, "regnancy an# men$al illness. Denne#y e$ al. 123345 #escribe a number %& "rinci"les in #elivery %& heal$h care $% ?s$ree$ i#s.@ !hese inclu#e outreach $% "laces (here a#%lescen$s c%ngrega$e+ immediacy, $he abili$y $% res"%n# (i$h%u$ #elay, because a $eenager may n%$ (ai$ %r c%me bac again, having %nce e'"resse# (illingness $% acce"$ $rea$men$+ networking, $% "r%vi#e $he nee#e# lin ages in$% a range %& hel"ing services+ an# sanctuary, in $erms %& "rivacy an# "r%$ec$i%n. Services sh%ul# be available in y%u$h shel$ers, bu$ als% %n $he s$ree$, $hr%ugh %u$reach, because many h%meless a#%lescen$s #% n%$ use shel$ers 1.e( L%r S$a$e C%uncil %n Chil#ren an# 8amilies, 237G+ R%ber$s%n, 233=5. Heal$h "r%m%$i%n, #isease "reven$i%n an# harm re#uc$i%n s$ra$egies &%cuse# %n $his gr%u" are essen$ial.

Adapting Clinical Practices to the Homeless Condition

Base# %n $he br%a# sc%"e %& heal$h "r%blems #escribe# ab%ve, i$ is clear $ha$ a &ull array %& services mus$ be ma#e available an# accessible &%r "e%"le (h% are h%meless. ;$her(ise, $he care can easily rever$ in$% ?Ban#-Ai# me#icine@ an# miss un#erlying %r c%-%ccurring c%n#i$i%ns. !he &%ll%(ing #iscussi%n c%vers elemen$s %& heal$h care enc%un$ers c%mm%n $% me#ical, men$al heal$h %r subs$ance abuse services, inclu#ing* in$a e an# assessmen$+ clinical "reven$ive services+ #iagn%sis+ re&errals &%r s"ecial$y an# in"a$ien$ care+ lin ages $% n%n-heal$h services+ an# &%ll%(-u" $% ensure c%n$inui$y %& care. 6$ is im"%r$an$ $% remember $ha$ $he elemen$s may n%$ necessarily %ccur in $his %r#er, %r be "r%vi#e# in a $y"ical clinical se$$ing. !nta e and Assessment Proced"res A sys$em $ha$ &ea$ures mul$i"le "%in$s %& en$ry is $erme# $he ?n% (r%ng #%%r@ a""r%ach. 6n such a sys$em, a h%meless "ers%n is %&&ere# $he %""%r$uni$y $% lin (i$h all nee#e# services $hr%ugh $he ini$ial c%n$ac$C(he$her $hr%ugh a me#ical %r #en$al "r%gram, s$ree$ %u$reach, %r any "%in$ in $he c%n$inuum %& subs$ance abuse %r men$al heal$h services. !% i#en$i&y nee#e# services, an a#e)ua$e assessmen$ %& heal$h an# s%cial "r%blems is necessary, inclu#ing h%using s$a$us an# access $% basic nee#s 1&%%#, cl%$hing, e$c.5. 6n a##i$i%n $% $he s$an#ar# clinical his$%ry )ues$i%ns, $he in$a e "r%ce#ure sh%ul# "ay s"ecial a$$en$i%n $% $he clien$-s living si$ua$i%n, inclu#ing )ues$i%ns rela$e# $% slee"ing l%ca$i%n, s%urces %& &%%#, su""%r$ sys$ems 1&rien#s %r &amily5, his$%ry %& men$al illness, use %& alc%h%l %r s$ree$ #rugs, e'"%sure $% vi%lence %r abuse, cause %& h%melessness, an# "lans &%r ge$$ing %u$ %& $he h%meless si$ua$i%n 1>sa$ine e$ al., 233G5. Ans(ers $% $hese )ues$i%ns (ill hel" #e$ermine $he a""r%"ria$e c%urse %& ac$i%n, regar#less %& (he$her $he ini$ial enc%un$er inv%lves me#ical %r #en$al services, men$al heal$h %r subs$ance abuse "r%blems. Pr%vi#ers %& care $% h%meless "e%"le als% nee# $% be aler$ &%r any "%ssible un#erlying c%n#i$i%ns $ha$ c%ul# a&&ec$ $he #iagn%sis, "r%"%se# $rea$men$ %r even$ual %u$c%me %& each

clien$-s case. 6$ is im"%r$an$ $% n%$e, h%(ever, $ha$ $he nee# &%r a c%m"rehensive assessmen$ mus$ al(ays be (eighe# agains$ $he "%ssibili$y %& aliena$ing %r in$imi#a$ing $he "ers%n being assesse#. Clinical Pre(enti(e +er(ices Preven$i%n ac$ivi$ies &all in$% several ca$eg%ries* Screenings &%r acu$e an# chr%nic "hysical c%n#i$i%ns, c%mmunicable #iseases, men$al illness an# subs$ance abuse #is%r#ers+ m Well child exams+ + !mmuni"ations 1&%r a#ul$s an# chil#ren5+ Special services for women, inclu#ing &amily "lanning an# "erina$al care+ " #ealth education$health promotion inclu#ing sel&-care in&%rma$i%n &%r "a$ien$s (i$h "ar$icular c%n#i$i%ns 1ranging &r%m #iabe$es $% a##ic$i%ns5 an# enc%uraging changes in behavi%r $ha$ (ill im"r%ve %r main$ain heal$h %r "reven$ #isease.
P

Screening. Wi$h%u$ %ver(helming clien$s (i$h "r%bing )ues$i%ns unrela$e# $% $he s$a$e# "ur"%se %& $heir visi$, screening &%r b%$h "hysical an# men$al chr%nic c%n#i$i%ns sh%ul# be inclu#e# (henever "%ssible, even in acu$e care visi$s. Prac$i$i%ners (%r ing (i$h h%meless "e%"le c%ns$an$ly have $% balance $he im"%r$ance %& "reven$ive ac$ivi$ies 1(he$her screening %r "r%m%$ing behavi%r change5 (i$h $he men$al %r em%$i%nal s$a$e %& $heir clien$s, as (ell as sensi$ivi$y $% $heir "as$ e'"eriences (i$h $he ?sys$em.@ 6n %r#er $% engage h%meless "e%"le in %ng%ing care i$ is necessary $% av%i# aliena$ing $hem an# $% &%cus %n es$ablishing $rus$ 1C%usineau e$ al., 233E5. H%(ever, screening "r%ce#ures are (elc%me# by many h%meless "e%"le 1L%ng e$ al., 23375 an# sh%ul# be a "ar$ %& each clinical enc%un$er (i$hin a clinical "r%gram. S%me heal$h care "r%grams &%r h%meless &%r "e%"le have als% "er&%rme# screenings in shel$ers, s%u" i$chens an# %$her l%ca$i%ns, $% i#en$i&y "%$en$ially $rea$able c%n#i$i%ns in "e%"le (h% %$her(ise migh$ n%$ ge$ clinical care. Bl%%# "ressure screening &%r hy"er$ensi%n is r%u$ine (i$h any "hysical e'am. H%meless "e%"le sh%ul# als% be %&&ere# !B s in $es$ing 1CDC, 233E5, (hile rec%gni,ing $he li elih%%# %& &alse nega$ives (i$h "e%"le (h% are H6HM 1M%rr%( e$ al., 23395+ r%u$ine $es$ing &%r S!Ds, inclu#ing H6H/A6DS+ breas$, cervical, s in, "r%s$a$e an# c%l%n e'amina$i%ns+ screening &%r glauc%ma+ an# $es$ing &%r ch%les$er%l levels 1Weinreb, 233B5. 6n a##i$i%n $% screening &%r "hysical illness, "rimary care "r%vi#ers als% nee# $% be aler$ &%r signs %& subs$ance abuse an# men$al illness 1>sa$ine e$ al., 233G5. !he CAG: is a sim"le bu$ e&&ec$ive screening $%%l &%r alc%h%lism 1:(ing, 237G5. Heal$h care "r%vi#ers mus$ als% be $raine# in r%u$ine screening %& "a$ien$s &%r vic$imi,a$i%n his$%ries, as (ell as in $he rec%gni$i%n %& $he "hysical an# men$al sym"$%ms an# signs %& vi%lence am%ng $heir "a$ien$s 1e.g., in0uries an# "%s$ $rauma$ic s$ress #is%r#er5 1Harris A Lan#is, 2339+ Lam A R%senhec , 2337+ M%y A Sanche,, 233B+ .%r$h A Smi$h, 233B+ Pa#ge$$ A S$ruening, 233B5. Well-Child Exams. Li e any %$her chil#ren, h%meless chil#ren re)uire regular e'amina$i%ns an# immuni,a$i%ns. W%r ing (i$h h%meless &amilies (h% have chil#ren

raises a##i$i%nal screening issues. Acc%r#ing $% W%%#, ?H%meless &amilies %&$en ci$e benign acu$e "r%blems as $he reas%n &%r a clinic visi$. :ach enc%un$er, h%(ever, sh%ul# inclu#e a his$%ry %& "reven$ive heal$h care, #evel%"men$al "r%blems, sch%%l "r%blems, me#ical "r%blems an# "as$ chil# abuseN 1W%%#, 233B5. Because h%meless &amilies e'"erience many "r%blems $ha$ c%ul# lea# $% chil# abuseCinclu#ing e'$reme &amily s$ress, e'"%sure %& $he chil# $% mul$i"le care$a ers, &amily vi%lence, an# #rug %r alc%h%l abuseC clinicians sh%ul# screen &%r chil# abuse 1neglec$, "hysical an# se'ual5 in $he his$%ry an# "hysical e'amina$i%n %& every chil# 1W%%#, 233B5. All h%meless chil#ren sh%ul# receive a PPD s in $es$ &%r !B annually. H%meless chil#ren (h% are A&rican American sh%ul# receive a sic le cell screening $es$. An# chil#ren (i$h a his$%ry %& "ica %r anemia sh%ul# be screene# &%r lea# e'"%sure 1W%%#, 233B5. Immunizations. 6mmuni,a$i%ns $% "reven$ #i"h$heria, $e$anus, in&luen,a, "neum%c%ccal "neum%nia an# he"a$i$is A an# B sh%ul# be ma#e available $% all h%meless a#ul$s 1Weinreb, 233B5. Rubella vaccina$i%n sh%ul# be %&&ere# $% h%meless (%men %& chil#bearing age (h% are n%$ "regnan$ an# (h% are an$ib%#y nega$ive, an# (h% have n% %$her c%n$rain#ica$i%ns &%r vaccina$i%n 1Weinreb, 233B5. H%meless chil#ren sh%ul# receive $he H6B 1Haem%"hilus 6n&luen,a B5, DP! 1Di"$heria, Per$ussis, !e$anus5, ;PH 1;ral P%li% Haccine5, an# MMR 1Measles, Mum"s an# Rubella5 vaccines acc%r#ing $% $he r%u$ine gui#elines %& $he American Aca#emy %& Pe#ia$rics C%mmi$$ee %n 6n&ec$i%us Disease 1W%%#, 233B5. Womens ealth. !he im"%r$ance %& "reven$ive care &%r h%meless (%men 1gynec%l%gical e'ams, &amily "lanning an# "erina$al care5 is ma#e %bvi%us by $he research ci$e# ab%ve. Mc.ally an# W%%# 1233B5 rec%mmen# a c%m"rehensive a""r%ach $% "r%vi#ing "erina$al care an# &amily "lanning &%r h%meless (%men, (i$h s"ecial em"hasis %n a(areness %& "%$en$ial c%m"lica$i%ns, screening &%r alc%h%l/#rug use, H6H/A6DS an# %$her S!Ds, an# use %& mul$i#isci"linary $eams $% inclu#e %u$reach an# case managemen$, as (ell as clinical care 1Mc.ally A W%%#, 233B5. ealth Education! ealth "romotion. Heal$h e#uca$i%n an# heal$h "r%m%$i%n $% "reven$ c%mmunicable #iseases is es"ecially vi$al in $he h%meless "%"ula$i%n, given $he increase# ris &ac$%rs, ye$ $he charac$eris$ics an# lac %& res%urces %& h%meless "e%"le "resen$ an unusual challenge $% heal$h e#uca$%rs. Many h%meless "e%"le are "re%ccu"ie# (i$h $heir curren$ #i&&icul$ies an# by $em"eramen$ are n%$ &u$ure-%rien$e#. !hey may &in# i$ #i&&icul$ $% ma e a sh%r$ $erm sacri&ice &%r a l%ng $erm bene&i$. 6$ is clearly unrealis$ic $% e'"ec$ "e%"le (h% are h%meless $% ma e changes in behavi%r base# %nly %n $he n%(le#ge $ha$ i$-s ?ba# &%r $heir heal$h.@ 8%r e'am"le, an %ver-reliance %n #is$ribu$i%n %& "rin$e# ma$erials (%ul# n%$ be e&&ec$ive (i$h $his "%"ula$i%n. H%(ever, "r%visi%n %& res%urces 1such as c%n#%ms, bleach i$s %r syringes5 (ill &acili$a$e $he changes %& behavi%r necessary $% "reven$ H6H/A6DS %r %$her S!Ds. Sel&-hel" a""r%aches, such as $h%se use# in men$al heal$h sel&-hel" agencies 1Segal e$ al., 23375 %r2B-s$e" "r%grams, are %ne (ay $% reach "e%"le an# "r%vi#e %ng%ing su""%r$ &%r behavi%r changes. Ac$ivi$ies $ha$ inv%lve %ne-$%-%ne "ers%nal in$erac$i%n %r gr%u"

in$erac$i%n, such as su""%r$ gr%u"s, can be success&ul, given $he is%la$i%n many h%meless "e%"le &eel an# $he nee# &%r meaning&ul human c%n$ac$ 1!semberis, 233=5. !he use %& ?"eer e#uca$%rs@ in #rug abuse "reven$i%n (i$h h%meless y%u$h 18%rs A Jarvis, 233E5 an# ?"eer heal$h a#vis%rs@ $% im"r%ve c%m"liance (i$h ini$ial clinic visi$s &%r h%meless a#ul$s ne(ly $es$e# "%si$ive &%r !B %r H6H 1Pe$ers%n e$ al., 233F5 are e'am"les %& success&ul an# inn%va$ive heal$h e#uca$i%n a""r%aches $ha$ inv%lve $he $arge$ "%"ula$i%n #irec$ly. An%$her avenue $% heal$h "r%m%$i%n is $hr%ugh e#uca$i%n %& %$her service "r%vi#ers. 8%r e'am"le, $eaching shel$er an# meal "r%vi#ers ab%u$ "re"ara$i%n %& heal$hy meals (ill "r%bably have m%re im"ac$ %n $he nu$ri$i%n %& h%meless "e%"le $han giving $hem br%chures %n $he im"%r$an$ &%%# gr%u"s. Surveillance %& heal$h an# sa&e$y c%n#i$i%ns in shel$ers an# %$her service si$es (ill hel" av%i# "%$en$ial acci#en$s an# in0uries, as (ell as "reven$ing c%mmunicable #iseases, such as $ubercul%sis 1May% e$ al., 233=5. Heal$h care %r shel$er s$a&& (h% (%r (i$h &amilies als% nee# $% be a(are %& "%$en$ial chil# abuse an# neglec$, arme# (i$h s$ra$egies &r%m e#uca$i%n $% inci#en$ re"%r$ing. 'iagnosis 6n $he "rac$ice %& #iagn%sis, $hree s"eci&ic acc%mm%#a$i%ns (ill be men$i%ne# here rela$e# $%* 25 $he clinical e'am+ B5 rec%gni,ing mul$i"le #iagn%ses+ an# F5 availabili$y %& #iagn%s$ic $%%ls such as lab%ra$%ry $es$ing an# ra#i%l%gy. Clinical Exam. Me#ical care "r%vi#ers nee# $% be es"ecially sensi$ive $% issues %& hygiene (hen inv%lve# in "hysical e'ams (i$h "e%"le (h% are h%meless. Al$h%ugh s%me clien$s, "ar$icularly $h%se (i$h severe men$al illness, may be %blivi%us $% $heir un(ashe# c%n#i$i%n, many are )ui$e embarrasse#. A high $%lerance an# un#ers$an#ing %n $he "ar$ %& $he "r%vi#er, c%mbine# (i$h availabili$y %& sh%(er &acili$ies 1as (ell as clean s%c s an# %$her cl%$hing5, (ill g% a l%ng (ay $%(ar#s #evel%"ing an envir%nmen$ in (hich h%meless "e%"le can &eel c%m&%r$able an# (elc%me. !his issue c%n$inues $% s$an# as a ma0%r barrier &%r h%meless "e%"le a$$em"$ing $% receive care in mains$ream se$$ings. During $he clinical e'am, $he "r%vi#er (ill nee# $% be aler$ &%r $h%se c%n#i$i%ns (hich c%mm%nly %ccur as a resul$ %& h%melessnessCu""er res"ira$%ry $rac$ in&ec$i%ns, $rauma, s in #is%r#ers, muscul%s ele$al "r%blems an# #en$al #iseaseCregar#less %& (ha$ (as "resen$e# as $he chie& c%m"lain$. 6n a##i$i%n, "r%vi#ers sh%ul# be %n $he l%% -%u$ &%r c%mm%n chr%nic c%n#i$i%ns such as hy"er$ensi%n, gas$r%in$es$inal an# neur%l%gical "r%blems, "eri"heral vascular #isease an# %bs$e$ric/gynec%l%gic c%n#i$i%ns 1>sa$ine e$ al., 233G5. Because h%meless "e%"le &re)uen$ly have l%s$ glasses %r ha# $hem br% en %r s$%len, visi%n sh%ul# als% be chec e#. Seri%us visi%n "r%blems have been re"%r$e# by nearly %ne)uar$er %& "e%"le (h% are h%meless 1Gelberg A Linn, 23735. Evaluating "sychiatric Symptoms #equires Sensitivity $o Each "ersons Special Situation. !here may be a ris %& ei$her %ver-#iagn%sing %r un#er-#iagn%sing $rea$able c%n#i$i%ns. 8%r e'am"le, sus"ici%usness in a h%meless "ers%n #%es n%$ necessarily in#ica$e "aran%ia, bu$ may be an un#ers$an#able c%nse)uence %& living %n $he s$ree$s. C%nversely,

l%( m%%# an# #is$urbe# slee" sh%ul# n%$ rea#ily be #ismisse# as n%rmal reac$i%ns $% ba# circums$ances+ $hey may be sym"$%ms %& a $rea$able #e"ressive illness. #ecognizing %ultiple &iagnoses. Primary care "rac$i$i%ners nee# $% "ay s"ecial a$$en$i%n $% i#en$i&ying mul$i"le #iagn%ses, av%i#ing is%la$e# #iagn%ses $ha$ may miss c%-%ccurring %r un#erlying issues. !his is $rue (he$her $he c%-%ccurring #iagn%ses are all "hysical in na$ure %r c%mbine "hysical, men$al heal$h an#/%r subs$ance abuse #iagn%ses. 'vaila(ility of &iagnostic $ools. Accura$e #iagn%sis %&$en #e"en#s %n $he availabili$y %& lab%ra$%ry $es$ing an# ra#i%l%gy. Ma ing $hese services easily accessible is essen$ial (hen (%r ing (i$h h%meless "e%"le. 6n s%me cases $his may inclu#e "r%vi#ing $rans"%r$a$i%n $% a si$e (here $he $es$ing can be "er&%rme# %r '-rays $a en. 'ollo)*+p to Assure Continuit" of Care Success&ul %u$c%me (hen (%r ing (i$h h%meless "e%"le #e"en#s %n m%re $han 0us$ accura$e #iagn%sis an# )uali$y $rea$men$. 8re)uen$ly, success hinges %n $he clien$-s abili$y $% &%ll%( $hr%ugh (i$h $he rec%mmen#e# $rea$men$. Care "r%vi#ers &ace numer%us %bs$acles in su""%r$ing $his abili$y an# es$ablishing c%n$inui$y %& care. 6n a##i$i%n $% barriers alrea#y lis$e#, a##i$i%nal c%m"lica$ing &ac$%rs inclu#e* Competing )eeds and "riorities. Pe%"le (h% are h%meless may "lace a grea$er "ri%ri$y %n &ul&illing $heir basic nee#s &%r &%%#, shel$er, hygiene, an# inc%me $han %n %b$aining nee#e# heal$h services %r &%ll%(ing $hr%ugh (i$h a "rescribe# $rea$men$ "lan 1Ball A Havassy, 237G+ Gelberg A Linn, 2377+ Gelberg, Gallagher, An#ersen A D%egel, 2339+ R%ber$s%n A C%usineau, 237=+ Sac s, Philli"s A Ca""elle$$y, 23795. Dee"ing &%ll%(-u" a""%in$men$s necessary &%r c%n$inu%us, c%m"rehensive care is als% #i&&icul$ &%r h%meless "e%"le #ue $% $heir c%m"e$ing nee#s an# #i&&eren$ $ime %rien$a$i%n 1D%egel A Gelberg, 233B5. Al$h%ugh (e $y"ically $hin %& h%meless "e%"le as having an in%r#ina$e am%un$ %& $ime %n $heir han#s, %&$en $hey mus$ #eal (i$h $he varie# sche#ules an# l%ca$i%ns %& several service &acili$ies $% ensure $ha$ all $heir nee#s are me$ 1D%egel A Gelberg, 233B5. %o(ility. While many h%meless "ers%ns are l%ng-$erm resi#en$s %& $heir c%mmuni$ies, %$hers are )ui$e m%bile (i$hin %r be$(een ci$ies %r s$a$es in $heir search &%r subsis$ence res%urces. !his m%bili$y ma es c%n$inui$y %& care #i&&icul$ 1Bric ner e$ al., 237G+ D%egel A Gelberg, 233B5. &ifficulty *eeping and Storing %edication!+ood.!he c%n#i$i%ns %& s$ree$ li&e a&&ec$ c%m"liance (i$h me#ical care. !here is usually a lac %& "r%"er sani$a$i%n 1Ba'$er A H%""er, 23725+ lac %& a s$able "lace $% ee" me#ica$i%ns sa&e, in$ac$, an# re&rigera$e# 1Bric ner e$ al., 237G+ Wrigh$ A Weber, 23795+ an# an inabili$y $% %b$ain $he "r%"er &%%# &%r a me#ically in#ica$e# #ie$ $% #eal (i$h c%n#i$i%ns such as #iabe$es melli$us %r hy"er$ensi%n 1Bric ner e$ al., 237G+ Wrigh$ A Weber, 237E5. &ischarge "lanning$ H%meless "e%"le (h% have been h%s"i$ali,e# are %&$en #ischarge# #irec$ly &r%m $he h%s"i$al $% $he s$ree$s (i$h ina#e)ua$e #ischarge "lanning $% assure

c%n#i$i%ns &%r sa&e recu"era$i%n. :ven h%meless m%$hers are #ischarge# $% $he s$ree$s (i$h $heir ne(b%rn in&an$s s%%n a&$er chil#bir$h. Rea#missi%n %& h%meless "a$ien$s $% h%s"i$als is n%$ unc%mm%n 1S$ar , 233B5. 'ttitudes of ealth Care "roviders. Pe%"le (h% are h%meless may sense &r%m $he me#ical "r%&essi%n a reluc$ance $% $rea$ $hem #ue $% $heir "%%r hygiene %r men$al illness, %r because %& assum"$i%ns $ha$ $hey c%me $% h%s"i$als &%r shel$er an# n%$ &%r a me#ical "r%blem 1Ba'$er A H%""er, 23725. Being $rea$e# (i$h a lac %& res"ec$ #%es n%$ enc%urage &%ll%(u" care %r c%m"liance (i$h care. #espite Care. ;ne %& $he m%s$ valuable ac$ivi$ies &%r "r%m%$ing c%n$inui$y %& care is $he availabili$y %& res"i$e care &acili$ies &%r h%meless "ers%ns (h% are n%$ c%nsi#ere# sic en%ugh $% be h%s"i$ali,e#, bu$ are $%% sic $% s$ay %n $he s$ree$s. Shel$ers an# s$ree$s are %&$en $he si$es $% (hich h%meless "a$ien$s are #ischarge# &r%m h%s"i$als 1G%e$cheus e$ al., 2334+ S$ar , 233B5. Since shel$ers are usually %"en %nly a$ nigh$, (here #% ill h%meless "ers%ns g% &%r res$, nu$ri$i%n an# sim"le basic care< C%nvalescen$ &acili$ies are nee#e# s% $ha$ h%meless "ers%ns, a&$er being "r%vi#e# me#ical, surgical %r %bs$e$rical care are n%$ #ischarge# &r%m %u$"a$ien$ se$$ings %r h%s"i$als $% $he s$ree$s (hen $heir recu"era$i%n re)uires running (a$er, a be#, re&rigera$i%n, %r "r%"er nu$ri$i%n 1S$ar , 233B5. Res"i$e care ensures $ha$ h%meless "ers%ns receive care $ha$ m%s$ %$hers, (i$h h%mes an# &amilies, receive r%u$inely 1G%e$cheus e$ al., 23345. #eferrals for Specialty Care and Inpatient Care$ Al$h%ugh $he &%cus here has m%s$ly been %n "rimary care an# $he im"%r$ance %& early in$erven$i%n, $he reali$ies %& h%melessness %&$en resul$ in illnesses %r in0uries being le&$ un$rea$e#, resul$ing in numer%us c%m"lica$i%ns re)uiring m%re s"eciali,e# a$$en$i%n. H%meless "e%"le nee# easy access $% s"ecial$y care an# h%s"i$ali,a$i%n $% #eal (i$h $hese si$ua$i%ns. H%meless heal$h care "r%vi#ers (%r har# $% es$ablish rela$i%nshi"s (i$h "ublic an# "riva$e heal$h care ins$i$u$i%ns $% %b$ain $his access. H%(ever, "r%vi#ers in $h%se ins$i$u$i%ns (h% are n%$ &amiliar (i$h $he h%meless "%"ula$i%n may nee# su""%r$, a#vice %r $raining &r%m h%meless heal$h care "r%vi#ers. 6n s%me cases, clien$ a#v%ca$es &r%m a h%meless heal$h care "r%0ec$ may nee# $% acc%m"any clien$s (hen $hey are re&erre# $% $h%se ins$i$u$i%ns, $% assure a""r%"ria$e care. ,in-ages to .ther Services. !he c%m"rehensive assessmen$ men$i%ne# earlier "r%vi#es $he &%un#a$i%n &%r #e$ermining (ha$ lin ages are nee#e#. :s$ablishmen$ %& re&erral rela$i%nshi"s (i$h %$her service "r%vi#ers, an# a sys$em %& case managemen$ $% c%%r#ina$e $h%se services, hel" assure $he e&&ec$iveness %& care given &%r "hysical %r men$al heal$h "r%blems. Given $he nega$ive im"ac$ $ha$ h%melessness has %n heal$h an# heal$h care %u$c%mes, clearly $he m%s$ signi&ican$ #i&&erence be$(een $rea$ing h%meless "e%"le an# $he general "%"ula$i%n is $he nee# $% inclu#e elimina$i%n %& h%meless c%n#i$i%ns as "ar$ %& any $rea$men$ "lan. 8%r $his reas%n, lin ages $% %$her servicesCinclu#ing $ransi$i%nal %r "ermanen$ h%usingCis an essen$ial elemen$ %& care. 1!he sec$i%ns bel%( %n services &%r subs$ance abuse an# men$al illness (ill #eal (i$h $his in m%re #e$ail.5

+pecific Adaptations for Treatment of Physical and Mental !llnesses

6n $he sec$i%ns $ha$ &%ll%(, "rimary care 1me#ical an# #en$al5, $rea$men$ &%r subs$ance use #is%r#ers, $rea$men$ %& seri%us an# "ersis$en$ men$al illnesses an# $rea$men$ %& "a$ien$s (i$h c%-e'is$ing men$al illness an# subs$ance use #is%r#ers 1$he ?#ually #iagn%se#@5 (ill be c%nsi#ere# in $urn. Primary Care +er(ices Clinical "r%$%c%ls &%r "rimary care $rea$men$ %& s"eci&ic "hysical illnesses %r in0uries are &re)uen$ly $he same &%r h%meless "e%"le as &%r $he general "%"ula$i%n. Haria$i%ns &r%m s$an#ar# "r%$%c%l are m%s$ %&$en rela$e# $% im"r%ving $he "%ssibili$y %& c%m"liance (i$h $rea$men$ by $a ing in$% c%nsi#era$i%n c%m"lica$i%ns %& $he "a$ien$-s living si$ua$i%n %r c%%ccurring #iagn%ses, inclu#ing mul$i"le "hysical illnesses, subs$ance abuse %r men$al illness. Medications ;ne %& $he m%s$ c%mm%n changes in $rea$men$ is &%un# in "rescribing "rac$ices $ha$ are a#0us$e# $% acc%mm%#a$e $he h%meless envir%nmen$. 8%r e'am"le, me#ica$i%ns $ha$ can be given in larger #%ses %ver a sh%r$er "eri%# %& $ime may be m%re e&&ec$ive 1e.g., in0ec$i%ns vs. %ral me#ica$i%ns5. Pe%"le (i$h%u$ h%mes usually have $% carry $heir bel%ngings (i$h $hem a$ all $imes an# su""lies %& me#ica$i%n $ha$ mus$ be $a en %ver a l%ng "eri%# %& $ime may be l%s$ %r s$%len. An%$her al$erna$ive is $% c%nsi#er giving $he "a$ien$ 0us$ en%ugh me#ica$i%n $% las$ un$il $he ne'$ sche#ule# visi$. !he "r%mise %& receiving me#ica$i%ns a$ a &u$ure visi$ may be an incen$ive &%r $he "a$ien$ $% re$urn. When "%ssible, %nce-#aily #%sing is bes$ 1>sa$ine e$ al., 233G5. Me#ical an# #en$al "r%vi#ers als% nee# $% be sensi$ive $% "%ssible subs$ance abuse issues (hen "rescribing me#ica$i%ns. C%llab%ra$i%n (i$h subs$ance abuse s$a&& is essen$ial in %r#er $% av%i# "rescribing narc%$ics %r %$her me#ica$i%ns ina""r%"ria$ely, (hile s$ill assuring a#e)ua$e "ain managemen$. !he im"%r$ance %& c%m"liance (i$h me#ica$i%n regimens &%r !B in %r#er $% "reven$ #evel%"men$ %& mul$i-#rug resis$ance has resul$e# in "r%grams %& #irec$ly-%bserve# $hera"y 1D;!5 &%r clien$s (i$h ac$ive !B an# #irec$ly-%bserve# "reven$ive $hera"y 1D;P!5 &%r $h%se (h% have been in&ec$e#. 6n b%$h cases, "a$ien$s are given each #%se %& me#ica$i%n #irec$ly by heal$h care "r%vi#ers, s%me$imes even i& i$ means &in#ing $he "a$ien$ %n $he s$ree$ 1Caminer% e$ al., 233=+ Chaul e$ al., 233E+ McA#am e$ al., 2334+ Pabl%s-Men#e, e$ al., 23395. 6ncen$ives have als% been use# $% enhance D;! 1Mangura e$ al., 23395, inclu#ing m%ne$ary incen$ives 1Pil%$e e$ al., 233=5. Describing all $he "%ssible al$erna$ive $rea$men$ "r%$%c%ls &%r every illness %r si$ua$i%n (%ul# &ill u" numer%us v%lumes 1e.g., see ;-C%nnell A Gr%$h, 2332, &%r a c%m"le$e manual %& in&%rma$i%n %n c%mm%n c%mmunicable #iseases in shel$ers5. 6ns$ea# (e (ill illus$ra$e s%me %& $he "r%blema$ic si$ua$i%ns enc%un$ere# in $rea$ing h%meless "e%"le by revie(ing s%me %& $he rec%mmen#a$i%ns clinicians have ma#e &%r $rea$men$ %& &%ur c%mm%n chr%nic me#ical c%n#i$i%ns an# #en$al heal$h

ypertension. 8leischman an# 8arnham 1233B5 s$a$e $ha$ $he #i&&icul$y %& &%ll%(-u" in $he h%meless "%"ula$i%n ren#ers im"rac$ical $he $ra#i$i%nal rec%mmen#a$i%n %& mul$i"le bl%%# "ressure #e$ermina$i%ns be&%re $rea$men$ &%r hy"er$ensi%n. Beginning $rea$men$ (i$h #ie$ary changes is als% &u$ile, since &%%# a$ shel$ers an# in s%u" lines is high in s%#ium an# &a$. !hresh%l#s &%r s$ar$ing #rug $hera"y mus$ be in#ivi#uali,e#, c%nsi#ering #iminishe# c%m"liance, "%%r &%ll%(-u", an# c%m"%un#ing li&e-s$yle variables, such as alc%h%l abuse. 6n h%meless alc%h%lics (i$h hy"er$ensi%n, re&erral &%r alc%h%l #e$%'i&ica$i%n/$rea$men$ may be m%re a""r%"ria$e $han me#ica$i%ns &%r hy"er$ensi%n. Many "a$ien$s (ill re&use #iure$ics because %& "%%r access $% ba$hr%%m &acili$ies 1Pian$eri e$ al., 23345. Pr%"er s$%rage an# sa&e- ee"ing %& "ills is an issue, (i$h "ills %&$en being l%s$ %r s$%len. 6& e"$ in a "%c e$, $hey may be "ulveri,e# by $he m%vemen$ %& c%ns$an$ (al ing 18ilar#%, 237E5. When use#, $he i#eal me#ica$i%n sh%ul# inc%r"%ra$e $he &%ll%(ing c%nsi#era$i%ns* %nce#aily #%sing, limi$e# nee# &%r lab%ra$%ry &%ll%(-u" 1i.e., av%i# "%$assium-l%sing #iure$ics5, an# n% reb%un# "hen%men%n 1since "%%r c%m"liance an# l%s$ me#ica$i%ns may bring %n $his c%m"lica$i%n5 18leischman A 8arnham, 233B5. An al$erna$ive &%r h%meless hy"er$ensives is $he cl%ni#ine $rans#ermal "a$ch, (hich #elivers a s$ea#y $hera"eu$ic level %& $he me#ica$i%n &%r seven #ays 1Michael A Brammer, 2377+ Pian$eri e$ al., 2334+ P%"li e$ al., 237=5. 1See Hicic A Weber 1233B5 &%r a##i$i%nal gui#elines &%r $rea$men$ %& hy"er$ensi%n in h%meless "e%"le.5 &ia(etes. !igh$ c%n$r%l %& #iabe$es may be a #anger%us g%al in h%meless "ers%ns, because %& $heir uns$able ea$ing an# ac$ivi$y "a$$erns 1>sa$ine e$ al., 233G5. !eaching a h%meless "ers%n $% use insulin re)uires &re)uen$ &%ll%(-u" a""%in$men$s an# care&ul m%ni$%ring. M%s$ shel$ers #% n%$ "r%vi#e clean, accessible an# sa&e s$%rage "laces &%r insulin, me#ica$i%ns, %r bl%%# gluc%se m%ni$%ring #evices. 6n a##i$i%n, "%ssessi%n %& syringes %r alc%h%l s(abs %n $he s$ree$ %r in shel$ers can ma e h%meless "e%"le in$% $arge$s &%r $he&$ 1Scanlan A Bric ner, 23345. !hus, in a h%meless a#ul$ "a$ien$ (i$h n%ninsulin-#e"en#en$ #iabe$es, i$ may be bes$ $% av%i# insulin $hera"y by "rescribing %ral hy"%glycemic agen$s a$ ma'imum #%sages an# $%lera$e less $igh$ c%n$r%l %& serum gluc%se 1>sa$ine e$ al., 233G5. "eripheral /ascular &isease. ?!he m%s$ im"%r$an$ in$erven$i%n &%r "eri"heral vascular #isease is a change in li&es$yle. :leva$i%n %& legs, a$ leas$ #uring slee", is $he ey $% $rea$men$. A ne$(%r %& shel$er re&errals &%r be#s 1n%$ "e(s5, res"i$e be#s, %r h%$el v%uchers may be re)uire# i& $he clinic is $% hel" $he h%meless clien$ &in# a "lace $% eleva$e his %r her legs. Bus $% ens sh%ul# be given $% limi$ $he nee# &%r (al ing l%ng #is$ances@ 18leischman A 8arnham, 233B5. A similar "rac$ical a""r%ach can be use# (hen a##ressing any %& $he %r$h%"e#ic %r "%#ia$ric "r%blems %& h%meless "e%"le. M%re $han 24 "ercen$ %& h%meless a#ul$s have im"aire# abili$y $% (al an# =4 "ercen$ have "r%blems (i$h $heir &ee$ 1Gelberg, Linn A Mayer-;a es, 2334+ Wrenn, 23345. !hese "r%blems are rela$e# $% %s$e%ar$hri$is, c%mm%n in $he general "%"ula$i%n as (ell, bu$ als% are #ue $% $he li&e c%n#i$i%ns $ha$ h%meless in#ivi#uals en#ure. !hey have $% (al $hr%ugh%u$ $he #ay $% %b$ain $heir basic nee#s &%r shel$er, &%%#, an# cl%$hing, %&$en in "%%rly &i$$ing sh%es, (i$h%u$ s%c s. Pr%vi#ing (ell

&i$$ing sh%es, changes %& s%c s, an# a be# $% slee" %n migh$ seem li e small in$erven$i%ns, bu$ can grea$ly im"r%ve a h%meless "ers%n-s abili$y $% &unc$i%n. eart &isease. !rea$men$ %& hear$ #isease in h%meless a#ul$s is )ui$e #i&&icul$. H%meless "ers%ns may nee# $% be a#mi$$e# m%re %&$en $% $he h%s"i$al an# a$ a l%(er clinical $hresh%l# $han $he #%micile# "%"ula$i%n. 8%r e'am"le, c%n$r%lling s%#ium in$a e an# en&%rcing be#res$, mains$ays %& $hera"y in $he #%micile# "%"ula$i%n, are vir$ually im"%ssible. H%s"i$ali,a$i%n is %&$en re)uire# $% achieve a#e)ua$e #iuresis in a c%n$r%lle# envir%nmen$ (here elec$r%ly$es can be m%ni$%re# 18leischman A 8arnham, 233B5. &ental
. " a e r "

ealth. Pe%"le (h% are h%meless nee# access $% a &ull array %& #en$al services* "reven$i%nC#en$al hygiene+ e#uca$i%n+ &ree $%%$hbrushes, $%%$h"as$e an# &l%ss assessmen$Ce'ams an# screening 1inclu#ing screening &%r %ral cancer5+ '-rays emergency careCemergency e'$rac$i%ns+ $rea$men$ %& in&ec$i%n res$%ra$ive careC&illings+ r%%$ canals+ cr%(n an# bri#ge (%r "r%s$he$icsC#en$ures an# "ar$ials %ral surgeryC&%r m%re c%m"le' cases $ha$ re)uire a s"ecialis$

6#eally each in#ivi#ual (%ul# be engage# in a c%m"rehensive $rea$men$ "lan $% a##ress all %& $he #en$al "r%blems $ha$ have buil$ u" %ver $he years. >n&%r$una$ely, $he h%meless c%n#i$i%n is n%$ al(ays c%n#ucive $% &%ll%(-u" (i$h such a l%ng-$erm ven$ure. Den$al s$a&& nee# $% have clear cri$eria &%r #e$ermining $he a""r%"ria$e level %& care $% be "r%vi#e#. Wi$h a "ers%n (h% is clearly $ransien$ an# "lanning $% m%ve %n, a sh%r$-$erm res"%nse such as an e'$rac$i%n may be m%re a""r%"ria$e $han ini$ia$ing a &ull $rea$men$ "lan. 6& #en$ures are nee#e#, a #e$ermina$i%n nee#s $% be ma#e regar#ing $he abili$y %& $he clien$ $% care &%r an# main$ain $hem. Se$$ing u" a c%m"le$e $rea$men$ "lan is m%s$ realis$ic &%r clien$s (h% are m%re li ely $% be able $% &%ll%( $hr%ugh, %r (h% have been s$abili,e# in $ransi$i%nal h%using %r $rea$men$ "r%grams. Par$icular c%nsi#era$i%n als% nee#s $% be given $% (%r ing (i$h "e%"le (i$h men$al #is%r#ers an# "e%"le (h% are n%(n $% be H6HM. S"ecial acc%mm%#a$i%ns may als% be necessary $% care &%r chil#ren 1McMurray-Avila, 23395. Treatment +er(ices for +"bstance ,se 'isorders A (i#e varie$y %& %"$i%ns an# $rea$men$ m%#els can be use# $% #evel%" a res"%nsive ne$(%r %& subs$ance abuse services &%r "e%"le (h% are h%meless. A subs$ance abuse services c%n$inuum sh%ul# be #esigne# $% mee$ l%cal nee#s, c%nsis$en$ (i$h available res%urces an# $he s"ecial nee#s %& h%meless "e%"le 1Schu$$ A Garre$$, 233B5. Barriers $% acc%m"lishing $his are "%li$ical, such as $he .6MBL res"%nse 1?.%$-6n-My-Bac -Lar#@5, %r #ue $% $he limi$e# res%urces available &r%m "ublic an# "riva$e &un#ing agencies. 6n general, $he #evel%"men$ %& services &%r h%meless a##ic$s has lagge# behin# $he #evel%"men$ %& "rimary heal$h care services an# services &%r $rea$ing men$al illness. !% a##ress $his lac , $he .a$i%nal 6ns$i$u$e %n Alc%h%l Abuse an# Alc%h%lism 1.6AAA5

su""%r$e# $(% r%un#s %& c%mmuni$y #em%ns$ra$i%n "r%0ec$s (i$h &un#ing &r%m $he S$e(ar$ B. McDinney H%meless Assis$ance Ac$ $% i#en$i&y e&&ec$ive a""r%aches &%r "r%vi#ing subs$ance abuse $rea$men$ $% h%meless "e%"le 1Argeri%u A McCar$y, 2334+ C%nra#, Hul$man A Ly%ns, 233F5. !he &%ll%(ing general c%nclusi%ns (ere #ra(n regar#ing necessary an# #esirable "r%gram charac$eris$ics 1S$ahler, 233E5* .ee# $% #evel%" $rea$men$ "r%grams $ha$ &%cus n%$ %nly %n $he a##ic$i%n, bu$ als% address the tangible needs %& "e%"le (i$h%u$ h%mes. % .ee# $% #evel%" flexible, low demand interventions $ha$ can acc%mm%#a$e clien$s (h% are n%$ ini$ially (illing $% c%mmi$ $% m%re e'$en#e# care. ( .ee# &%r longer term, continuous interventions &%r $his "%"ula$i%n. A&$ercare nee#s $% a##ress n%$ %nly $he main$enance %& s%brie$y, bu$ als% $he $angible nee#s an# s%cial is%la$i%n %& clien$s. s .ee# $% match clients to appropriate treatment services base# %n charac$eris$ics such as e#uca$i%nal a$$ainmen$, cul$ural bac gr%un#, severi$y %& subs$ance use, criminal inv%lvemen$ an# level %& s%cial is%la$i%n.
n

Al$h%ugh $he #ynamics, #em%gra"hics an# legal im"lica$i%ns %& a##ic$i%ns $% #i&&eren$ subs$ances may vary, $he "rinci"les %& $rea$men$ are $he same* m%$iva$i%n %& $he "ers%n $% s$%" using $he subs$ance, #e$%'i&ica$i%n $% su""%r$ $he "ers%n $hr%ugh $he (i$h#ra(al "r%cess, an# rehabili$a$i%n $% main$ain s%brie$y $hr%ugh a "r%cess %& rec%very. H%meless "ers%ns have "ar$icular nee#s a$ each %& $hese s$ages, h%(ever i$ is im"%r$an$ $% rec%gni,e $ha$ $hese are n%$ necessarily linear s$ages. :ngaging a h%meless "ers%n in $he rec%very "r%cess is a l%ng-$erm un#er$a ing, mar e# by numer%us rela"ses an# &lui# m%vemen$ in an# %u$ %& s$ages. Moti(ating $he a##ic$e# "ers%n $% rec%gni,e his %r her nee# &%r $rea$men$ may be $he m%s$ #i&&icul$. S$ree$ %u$reach (%r ers, "%lice %&&icers, s%cial (%r ers, emergency me#ical s$a&& an# "rimary heal$h care (%r ers in in#ivi#ual cases have im"%r$an$ r%les in "ersua#ing a h%meless in#ivi#ual $% see $rea$men$. %utreach is "ar$icularly im"%r$an$ because %& $he reluc$ance %& many h%meless "e%"le $% see $rea$men$ %n $heir %(n behal&. 6ni$ia$ing c%n$ac$ (i$h h%meless subs$ance abusers %n $he s$ree$, in shel$ers, #r%"-in cen$ers, s%u" i$chens, e$c., "r%vi#es in&%rma$i%n ab%u$ available services an# begins $he m%$iva$i%n an# engagemen$ %& $he "ers%n in$% $he sys$em %& services. :&&ec$ive %u$reach (%r ers are %&$en &%rmerly h%meless subs$ance abusers (h% un#ers$an# $he si$ua$i%ns an# #ilemmas %& h%meless "e%"le an# can "r%vi#e su""%r$ an# enc%uragemen$, #ra(ing %n $heir %(n e'"eriences. 8%r h%meless "e%"le $he li elih%%# %& rela"se, #isc%uragemen$ an# &a$alism is grea$ &%r b%$h "a$ien$ an# $rea$men$ "r%vi#er. 6$ is "ar$ %& $he %u$reach &unc$i%n $% ins$ill h%"e in $he a##ic$ $ha$ rec%very is "%ssible. Sobering up stations "r%vi#e an%$her &%rm %& %u$reach. 6n $hese small &acili$ies, a clean sani$ary, sa&e an# su""%r$ive envir%nmen$ is "r%vi#e# $% h%meless subs$ance abusers (h% may n%$ ye$ be rea#y $% c%n$em"la$e #e$%'i&ica$i%n. !hey are %&$en s$a&&e# by in#ivi#uals (h% are $hemselves rec%vering a##ic$s. 8%r a "r%"%r$i%n %& $he users %& $he s$a$i%n i$ "r%vi#es a &irs$ s$e" in a rec%very "r%cess.

'eto-ification is $echnically $he sim"les$ "hase %& $rea$men$, al$h%ugh n%$ al(ays $he m%s$ rea#ily available. 6$ re)uires a se$$ing (here $he "ers%n can g% $hr%ugh (i$h#ra(al (i$h $he necessary su""%r$ $% $%lera$e $he un"leasan$ an# s%me$imes #anger%us (i$h#ra(al syn#r%mes. &edical detoxification inv%lves "rescribing me#ica$i%ns $% "r%$ec$ $he "a$ien$ &r%m $he (i$h#ra(al sym"$%ms an# c%m"lica$i%ns. 6$ is m%s$ c%mm%nly #%ne in a resi#en$ial %r in"a$ien$ se$$ing, bu$ can be #%ne in an ambula$%ry "r%gram i& a#e)ua$e su""%r$ can be "r%vi#e# &%r $he "a$ien$. Social model detoxification av%i#s use %& me#ica$i%ns i& "%ssible an# relies %n mu$ual su""%r$, s%cial learning an# $he 2B-s$e" "rinci"les %& AA/.A. S%cial m%#el "r%grams are less e'"ensive $% run $han me#ical #e$%'i&ica$i%n "r%grams an# re"%r$e# $% be e)ually sa&e &%r $heir clien$s 1Whi$&iel# e$ al., 2397+ La"ham e$ al., 233=5. ;nce #e$%'i&ica$i%n has been acc%m"lishe# %n a resi#en$ial %r ambula$%ry basis, a l%ng "r%cess %& rehabilitation is re)uire#. During $his "eri%# $he "ers%n nee#s "r%$ec$i%n &r%m his %r her $en#ency $% rela"se, "r%vi#e# $hr%ugh "eer an# "r%&essi%nal su""%r$ an# a""r%"ria$e su""%r$ive living si$ua$i%ns. !he in#ivi#ual nee#s %""%r$uni$ies &%r ac)uisi$i%n %& ne( s ills &%r every#ay living, rela$i%nshi"s an# em"l%ymen$ an# $he es$ablishmen$ %& a #rug-&ree li&es$yle. !his "hase %& $rea$men$ is $he m%s$ $ime-c%nsuming, m%s$ c%s$ly an# leas$ li ely $% be available an# accessible &%r h%meless "e%"le. :lemen$s %& $rea$men$ may inclu#e in#ivi#ual %r gr%u" c%unseling an# e#uca$i%n $% hel" clien$s #e&ine $heir nee#s, un#ers$an# $heir a##ic$i%n1s5 an# #evel%" $heir $rea$men$ "lan. Case managemen$ is "ar$icularly valuable &%r h%meless "e%"le in rec%very $% assis$ $hem in c%%r#ina$ing an# neg%$ia$ing $he %&$en &ragmen$e# sys$ems %& care $ha$ e'is$. Case managers can hel" i#en$i&y res%urces, ac)uire me#ical %r #en$al heal$h care services, e$c. S%me$imes several elemen$s such as c%unseling, e#uca$i%n, case managemen$, gr%u" (%r , e$c. may be c%mbine# in$% an in$ensive #ay $rea$men$ "r%gram &%r "e%"le (h% have s$able arrangemen$s &%r (here $hey (ill s$ay a$ nigh$. Al$h%ugh many c%mmuni$ies have m%ve# $%(ar# %u$"a$ien$ $rea$men$ $% save c%s$s, "e%"le (i$h%u$ h%mes are less li ely $% bene&i$ &r%m such a "r%gram. !rea$men$ an# rehabili$a$i%n are unli ely $% be e&&ec$ive as l%ng as $he "ers%n lives %n $he s$ree$s %r in $he general shel$er sys$em (here $he #aily "ressure $% use #rugs %r #rin remains high. A range %& a""r%"ria$e %""%r$uni$ies &%r supportive housing mus$ $here&%re be available 1.6AAA, 2332a+ .6AAA, 2332b+ Wi$$man A Ma##en, 23775. Resi#en$ial rec%very "r%grams can be #esigne# &%r $he #i&&eren$ s$ages %& rec%very, inclu#ing #e$%'i&ica$i%n, "rimary $rea$men$ %r as a hal&-(ay h%use %r )uar$er(ay h%use. Rec%very h%uses can be base# %n a s%cial m%#el #esign (here resi#en$s are res"%nsible &%r running $he h%use %r %n a $hera"eu$ic m%#el (i$h grea$er s$a&& inv%lvemen$. 8%r s%me h%meless "e%"le in rec%very, a gr%u" h%me %r a#ul$ &%s$er care arrangemen$ may be a""r%"ria$e. S%ber h%usingCh%using $ha$ is alc%h%l/#rug&reeCis an essen$ial &%ll%(-u" $% $he $rea$men$ "r%cess. M%n$hs %& har# (%r in $rea$men$ an# rec%very can be l%s$ i& $he clien$ mus$ $hen re$urn $% $he s$ree$s. S%ber h%using may inclu#e su""%r$ive services %r sim"ly be a $ransi$i%nal s$age $% in#e"en#en$ h%using in $he c%mmuni$y.

!hr%ugh%u$ $he en$ire "r%cess %& rec%very, peer gro"p s"pport is %& grea$ im"%r$ance, usually "r%vi#e# by gr%u"s such as Alc%h%lics An%nym%us %r .arc%$ics An%nym%us, $ha$ "r%vi#e b%$h a $he%re$ical m%#el &%r $he "r%cess %& rec%very an# $he em%$i%nal su""%r$ %& %$her a##ic$s. Gr%u"s e'is$ in every ci$y an# mee$ings %ccur every #ay %& $he (ee . !%$al abs$inence has $ra#i$i%nally been $he g%al %& subs$ance abuse services, bu$ in many cases, a##ic$s are un(illing %r unable $% c%n$em"la$e abs$inence. S$ra$egies &%r harm red"ction serve $% re#uce $he ris %& c%m"lica$i%ns %r %$her a#verse e&&ec$s un$il such $ime as $he "ers%n is (illing an# able $% en$er $he rec%very "r%cess 1Marla$$, S%mers A !a"er$, 233F+ Marla$$ e$ al., 23395. !hus methadone maintenance programs "r%vi#e a subs$i$u$e &%r her%in %n a #aily basis, (i$h $he aim %& enabling $he "ers%n $% av%i# #rug #ealing an# %$her crimes, an# als% $% av%i# s%me %& $he %$her heal$h ha,ar#s %& s$ree$ #rug use. 'eedle exchange programs &%r 6H #rug users are e&&ec$ive in re#ucing $he inci#ence %& bl%%#b%rne in&ec$i%ns such as He"a$i$is B %r C an# H6H, bu$ are n%$ legal in all s$a$es. Many "r%grams als% ma e bleach kits available $% 6H #rug users s% $ha$ $hey can "er&%rm a ru#imen$ary s$erili,a$i%n %& $heir syringes an# nee#les. As a l%(-#eman# a""r%ach $% ee"ing "e%"le sa&e an# alive un$il $hey are rea#y &%r $rea$men$, wet housing all%(s resi#en$s $% #rin in $heir r%%m, (hile damp housing #%es n%$ all%( #rin ing %n-si$e, bu$ #%es all%( &%r rela"ses. Wet shelters, similarly, "r%vi#e shel$er &%r alc%h%lics (h% can n%$ c%n$em"la$e abs$inence, an# $hus enable $hem $% av%i# s%me %& $he #angers %& s$ree$ li&e (hile "ermi$$ing $hem $% c%n$inue #rin ing. H%meless heal$h care "r%vi#ers can ma e use %& all $hese harm re#uc$i%n $echni)ues $% su""%r$ an# assis$ $h%se clien$s (h% are n%$ ye$ (illing %r able $% en$er a $rea$men$ "r%cess %& #e$%'i&ica$i%n an# rehabili$a$i%n. Treatment +er(ices for +erio"s and Persistent Mental !llnesses Wi$hin $he br%a# sc%"e %& men$al heal$h, many #is%r#ers can be #iagn%se# by $he "rimary care "rac$i$i%ner 1Slavney, 23375 an# in many cases $rea$e# e&&ec$ively, (i$h %r (i$h%u$ $he assis$ance %& a $hera"is$ %r c%unsel%r %r su""%r$ gr%u". !his is "ar$icularly s% in rela$i%n $% $he #e"ressi%n an# an'ie$y $ha$ are $he na$ural an# un#ers$an#able acc%m"animen$s %& li&e %n $he s$ree$s. Heal$h care "r%0ec$s can als% e'"an# $heir clien$s- access $% $hera"y by lin ing (i$h %$her agencies $ha$ %&&er s"eciali,e# c%unseling, inclu#ing ra"e crisis services, #%mes$ic vi%lence "r%grams, an# "r%grams &%r ve$erans. !he $rea$men$ %& ma(or mental illnesses in a#ul$s re)uires e'"er$ise $ha$ in general can %nly be "r%vi#e# by a $eam %& "r%&essi%nals inclu#ing a "sychia$ris$. 6llnesses in $his ca$eg%ry inclu#e ma0%r a&&ec$ive #is%r#ers, inclu#ing recurren$ ma0%r #e"ressi%n an# bi"%lar #is%r#er, schi,%"hrenia an# rela$e# "aran%i# #is%r#ers, severe "ers%nali$y #is%r#ers an# #emen$ia. .ever$heless in s%me si$ua$i%ns "rimary care "rac$i$i%ners may &in# $hemselves (here "sychia$ric c%nsul$a$i%n is n%$ available, %r a "a$ien$ is un(illing $% acce"$ a re&erral. !here may be n% l%cal c%mmuni$y men$al heal$h cen$ers %r $hey may n%$ be res"%nsive $% $he nee#s %& h%meless "e%"le. 6n $his si$ua$i%n $he clinician sh%ul# be able $% "r%vi#e a$ leas$ basic "harmac%l%gical $rea$men$ &%r a men$al illness an# "%ssibly enlis$ $he assis$ance

%& a s%cial (%r er %r %$her c%lleagues %r agencies $% a$$em"$ $% a##ress s%me %& $he "ers%n-s %$her nee#s. Psychia$ric s"ecialis$s may als% be calle# u"%n $% assis$ in #iagn%sing #is%r#ers ass%cia$e# (i$h "hysical illness, al$h%ugh $he "rimary $rea$men$ res"%nsibili$y remains (i$h $he general "hysician 1e.g., #elirium ass%cia$e# (i$h liver &ailure5 1Slavney, 23375. 6$ is im"%r$an$, $here&%re, $ha$ "rimary care "rac$i$i%ners have $he nee#e# n%(le#ge an# s ill $% ma e $his #iagn%s$ic #is$inc$i%n an# have access $% "sychia$ric c%nsul$a$i%n (hen nee#e#. Services &%r h%meless "e%"le (i$h seri%us men$al illnesses are #is$inc$ &r%m "sychia$ric services &%r %$her l%(-inc%me "e%"le in $ha$ $hey have $(% "rinci"al g%als* remissi%n %& $he illness an# res%lu$i%n %& $he "ers%n-s h%melessness. Services &%r h%meless "e%"le are als% #is$inc$ive in $ha$ $hey mus$ $a e in$% acc%un$ $he "a$ien$s- $ransience, $he har#shi" %& $heir living circums$ances, $heir #is$rus$ %& &%rmal service sys$ems, $heir lac %& e&&ec$ive s%cial su""%r$s, an# $heir e'$reme "%ver$y 18ischer, C%ls%n A Susser, 233=5. Essential Elements of a #esponsive Service System. !he 8e#eral !as 8%rce %n H%melessness an# Severe Men$al 6llness, in a 233B re"%r$, %utcasts on &ain Street 18e#eral !as 8%rce %n H%melessness, 233B5, rec%mmen#e# $he &%ll%(ing essen$ial elemen$s %& a sys$em $ha$ (%ul# be res"%nsive $% h%meless "e%"le (i$h severe men$al illness*
i A 6 S H A H 6 R C

Asser$ive %u$reach 6n$egra$e# care managemen$ Sa&e Havens H%using Alc%h%l an#/%r %$her #rug abuse $rea$men$ Heal$h care 6nc%me su""%r$ an# bene&i$s Rehabili$a$i%n, v%ca$i%nal $raining, an# em"l%ymen$ assis$ance C%nsumer an# &amily inv%lvemen$ Legal "r%$ec$i%ns

6n each area, clinicians an# %$her "r%&essi%nals (%r ing (i$h h%meless "e%"le mus$ $eam $%ge$her $hr%ugh alliances, c%%"era$ive agreemen$s an# c%ali$i%ns $% "r%vi#e $he array %& services in $he &%rm bes$ sui$e# &%r $heir l%cal si$ua$i%n, cul$ure an# available res%urces. $reatment "rocess. !here are &%ur "rinci"al s$ages in "r%vi#ing "sychia$ric services &%r h%meless "e%"le 1Brea ey an# !h%m"s%n, 23395* Engagement. H%meless men$ally ill "e%"le %&$en #% n%$ (an$ $he $rea$men$ $ha$ $hey ba#ly nee#. Primary care "rac$i$i%ners, shel$er (%r ers an# %$hers may have vi$al r%les in gen$ly "ersua#ing "a$ien$s $% acce"$ hel". ;u$reach $eams are vi$al. !hey may ei$her (%r $% m%$iva$e $he "ers%n $% c%me in $% a $rea$men$ cen$er, %r may bring $he $rea$men$ res%urces $% $he h%meless "ers%n ?%n $he s$ree$.@. ;u$reach (%r ers g% $% shel$ers an# s%u" i$chens, $% $he s$ree$s an# alleys, "ar s an# railr%a# s$a$i%ns 1Susser, Halencia A G%l#&inger, 233B5.

6n s%me cases %u$reach may be li&e saving, (here in#ivi#uals ris #ea$h %r in0ury $hr%ugh e'"%sure. !he "r%cess %& engagemen$, h%(ever, is %&$en sl%( an# %u$reach (%r ers mus$ be "re"are# $% #ev%$e many h%urs %ver many (ee s %r m%n$hs %n %ccasi%n, using much crea$ivi$y, $% es$ablish $rus$ an# ra""%r$. ;u$reach is an i#eal s$a&& r%le &%r &%rmerly h%meless "e%"le, (h%se n%(le#ge %& $he $erri$%ry an# abili$y $% es$ablish ra""%r$ (i$h h%meless "e%"le is &re)uen$ly su"eri%r $% $ha$ %& m%s$ "r%&essi%nals 1Han !%sh, 233F5. 0asic Service "rovision. Shel$er, &%%#, inc%me su""%r$, cl%$hing, an# general heal$h care (ill be nee#e# in m%s$ cases, in a##i$i%n $% (ha$ever "sychia$ric $rea$men$ may be in#ica$e#. 6$ is unrealis$ic $% e'"ec$ h%meless "e%"le $% "ar$ici"a$e in $rea$men$ "r%grams un$il $heir basic survival nee#s have been me$. C%%r#ina$ing $he vari%us s%cial an# heal$h agencies is &re)uen$ly a ma0%r "r%blem+ case managemen$ has c%me $% be $he ma0%r s$ra$egy em"l%ye#. 1Billig A Levins%n, 2379+ G%ering A Wasylen i, 233=+ S(ay,e, 233B5. Clinical men$al heal$h services nee#e# &%r h%meless "e%"le c%ver $he &ull range %& services generally "r%vi#e# by a c%mmuni$y men$al heal$h cen$er* #iagn%sis an# evalua$i%n, "harmac%l%gical an# "sych%$hera"eu$ic $rea$men$s, an# lin age $% in"a$ien$ services (hen nee#e#. !rea$men$ $eams nee# $% have $he s ills necessary $% un#ers$an# an# $rea$ s%me %& $he m%s$ #i&&icul$ cases $hey are li ely $% enc%un$er in clinical "rac$ice. :m"a$hic a""r%aches are nee#e# $% gain $he c%%"era$i%n %& "e%"le (h% may have ha# ba# e'"eriences (i$h $rea$men$ %r i$s si#e-e&&ec$s in $he "as$, as is res"ec$ &%r $he in#ivi#uali$y an# in$egri$y %& each "ers%n. S%"his$ica$i%n in "sych%"harmac%l%gy is essen$ial. H%meless "e%"le may be m%re in$%leran$ %& si#e-e&&ec$s %& me#ica$i%ns $han many %$her "a$ien$s. Dr%(siness, neur%muscular abn%rmali$ies %r #iminishe# aler$ness may e'"%se a "ers%n $% increase# ris %& vic$imi,a$i%n. A "sychia$ris$ mus$ be care&ul $% av%i# such "r%blems &%r "a$ien$s (hile ge$$ing ma'imum $hera"eu$ic bene&i$. :&&ec$ive me#ica$i%ns (i$h "%$en$ial &%r ha,ar#%us si#e e&&ec$s may have $% be av%i#e# i& "a$ien$s are n%$ able $% have bl%%# $es$s a$ regular in$ervals. ;ral me#ica$i%ns may be l%s$, s% $ha$ l%ng-ac$ing in0ec$able "re"ara$i%ns are "re&erable (here &easible. S%me me#ica$i%ns (i$h s$ree$ resale value (ill have $% be av%i#e#. 6n s%me cases arrangemen$s can be ma#e &%r shel$er s$a&& %r %$hers $% ac$ as cus$%#ians %& a "ers%n-s me#ica$i%ns. $ransition and Integration. C%mmuni$y men$al heal$h "r%grams un#ers$an# $ha$ $heir "a$ien$s (i$h severe an# "ersis$en$ men$al illnesses in all "r%babili$y (ill re)uire $rea$men$ &%r li&e. ;n $he %$her han#, "r%grams &%r h%meless "e%"le can n%$, by #e&ini$i%n, "r%vi#e in#e&ini$e care &%r "e%"le. ;nce a "ers%n has been engage#, an# basic service nee#s me$, he %r she mus$ be m%ve# in$% $he mains$ream men$al heal$h service sys$em. H%meless heal$h care "r%grams sh%ul# (%r a$ #evel%"ing c%llab%ra$ive "r%&essi%nal rela$i%nshi"s an# es$ablishing lin ages $% c%mmuni$y men$al heal$h "r%grams in $heir areas. !here are many ins$ances (here $he h%meless heal$h care "r%gram, (i$h i$s s"ecial e'"er$ise, can be %& assis$ance $% s$a&& %& $he men$al heal$h cen$er, 0us$ as $here are ins$ances (here $he h%meless "r%gram s$a&& (ill l%% $% $he men$al heal$h cen$er &%r l%ng $erm su""%r$ an# $rea$men$ %& $heir clien$s. !% &acili$a$e $ransi$i%n $he $hera"is$ in $he h%meless "r%gram may

c%n$inue $% (%r (i$h $he "ers%n a&$er $hey bec%me se$$le# in a h%me. A s"ecial m%#el &%r $his a""r%ach has been #escribe# ?Cri$ical !ime 6n$erven$i%n@ 1Susser e$ al., 23395. !ransi$i%ning care in$% $he mains$ream sys$em may "r%ve e'$remely #i&&icul$ %r im"%ssible in s%me cases %r si$ua$i%ns, crea$ing a #ilemma &%r $he h%meless "r%gram. :i$her $he mains$ream sys$em may n%$ be rece"$ive, %r $he "a$ien$ may n%$ (an$ $% ma e $he $ransi$i%n &r%m a clinical si$ua$i%n he %r she &eels c%m&%r$able (i$h, $% %ne $ha$ is un n%(n. 6n $he la$$er case, $he clinical $eam mus$ (%r $h%ugh $his #i&&icul$y (i$h $he "a$ien$ e'"lici$ly, "erha"s em"hasi,ing $he &ac$ $ha$ %$her "e%"le may nee# $% have access $% $he bene&i$s he %r she has en0%ye#. Where $he mains$ream sys$em is unrece"$ive, $he %nly s%lu$i%ns are "ers%nal bri#ge-buil#ing an# "%li$ical a#v%cacy a$ (ha$ever level is necessary $% c%m"el $he sys$em $% res"%n# $% $he nee#s %& all ci$i,ens. ousing Sta(ilization$ !rea$men$ %& severe men$al illness is #i&&icul$ %r im"%ssible un$il $he "ers%n has s%me measure %& s$abili$y in his %r her h%using. 6ni$ially, s%me $y"e %& emergency shel$er mus$ be &%un# un$il res%urces are %b$aine# $% "r%vi#e a $ransi$i%nal h%using arrangemen$ an#, in #ue c%urse, m%re "ermanen$ h%using. Many in#ivi#uals (i$h severe "sychia$ric #isabili$ies nee# much su""%r$ in c%"ing (i$h even $he sim"le $as s %& every#ay living, s% su"ervisi%n an# case managemen$ su""%r$ (ill be nee#e#. S%me emergency shel$ers are able $% "r%vi#e $his level %& su""%r$. Su"ervise# gr%u" h%mes may be %& value &%r s%me clien$s, bu$ many are s%li$ary in#ivi#uals (h% "re&er $% be %n $heir %(n. Single r%%m %ccu"ancy 1SR;5 h%$els may be i#eal &%r such "e%"le, "r%vi#e# $ha$ $hey mee$ acce"$able s$an#ar#s an# "r%vi#e nee#e# su""%r$ services. Safe #avens "r%vi#e sa&e envir%nmen$s an# basic nee#s (i$h l%( #eman# %n a#herence $% rules %r "ar$ici"a$i%n in $rea$men$ 18e#eral !as 8%rce, 233B5. !he De"ar$men$ %& H%using an# >rban Devel%"men$-s Sec$i%n 7 h%using subsi#ies have been #em%ns$ra$e# $% increase $he li elih%%# $ha$ men$ally ill &%rmerly h%meless "e%"le (ill remain h%use# 1H%ugh e$ al., 23395. An%$her H>D "r%gram, Shel$er Plus Care, "r%vi#es h%using subsi#ies lin e# $% $rea$men$ an# case managemen$. Service Integration. !he $rea$men$ "r%cess #escribe# ab%ve re)uires $ha$ "a$ien$s have access $% a &ull range %& $rea$men$, rehabili$a$ive an# su""%r$ services, inclu#ing nee#s assessmen$, #iagn%sis an# $rea$men$ "lanning, me#ica$i%n managemen$, c%unseling an# su""%r$ive $hera"y, h%s"i$ali,a$i%n an# in"a$ien$ care, BG-h%ur crisis-res"%nse services, rehabili$a$i%n an# s%cial s ills $raining, inc%me su""%r$, h%using an# case managemen$. Ca$eg%rical &e#eral an# %$her g%vernmen$al &un#ing, as (ell as $he s$ruc$ure %& human service %rgani,a$i%ns a$ $he l%cal level, have l%ng been $he s%urce %& service &ragmen$a$i%n (hich in$er&eres (i$h $he sm%%$h an# c%%r#ina$e# "r%visi%n %& $his c%m"le' array %& services. A series %& recen$ ini$ia$ives have $here&%re &%cuse# %n $he "r%visi%n %& c%m"rehensive services. Beginning in $he early 2334s, $he Cen$er &%r Men$al Heal$h Services 1Subs$ance Abuse an# Men$al Heal$h Services A#minis$ra$i%n5 &un#e# $he Pr%0ec$s &%r Assis$ance in !ransi$i%n &r%m H%melessness 1PA!H5 Pr%gram, (hich has been success&ul in "r%vi#ing %u$reach an# case managemen$ $% h%meless men$ally ill in#ivi#uals. !% $es$ a varie$y %& services in$egra$i%n s$ra$egies, $he Cen$er &%r Men$al Heal$h Services subse)uen$ly a(ar#e# ACC:SS 1Access $% C%mmuni$y Care an# :&&ec$ive Services an# Su""%r$s5 gran$s $% nine s$a$es. !hese s$ra$egies range &r%m an inn%va$ive

v%ucher sys$em $% c%-l%ca$i%n %& services, cr%ss-$raining %& s$a&&, an# $he use %& in$eragency, mul$i#isci"linary $rea$men$ 1Call%(ay A M%rrisey, 2337+ Ran#%l"h e$ al., 2339+ R%senhec e$ al., 23375. A$ $he clinical level, $he use %& in$er#isci"linary $eams $% "r%vi#e c%%r#ina$e# care is bes$ e'em"li&ie# by $he Asser$ive C%mmuni$y !rea$men$ 1AC!5 m%#el, (hich has been e'$ensively evalua$e# an# &%un# e&&ec$ive &%r #%micile# in#ivi#uals (i$h seri%us an# "ersis$en$ men$al illnesses 1Burns an# San$%s, 233E+ ;l&s%n, 2334+ Primm, 233=5. !his a""r%ach has als% been &%un# e&&ec$ive &%r (%r (i$h h%meless "e%"le. M%bile $eams c%nsis$ing %& clinicians, case managers an# a#v%ca$es, accessible $% "a$ien$s BG h%urs "er #ay an# 9 #ays "er (ee "r%vi#e l%ng $erm care an# are "re"are# $% (%r (i$h $he "ers%n in (ha$ever is $he m%s$ a""r%"ria$e se$$ing 1Di'%n e$ al.,2339+ Lehman e$ al., 23395 !he .a$i%nal 6ns$i$u$e &%r Men$al Heal$h an# $he Cen$er &%r Men$al Heal$h Services s"%ns%re# a series %& research #em%ns$ra$i%n "r%0ec$s in &ive ci$ies in $he 2334s. !his series %& e'"erimen$s $es$e# a varie$y %& s$ra$egies &%r case managemen$, $ransi$i%n %u$ %& shel$ers, rehabili$a$i%n an# h%using in$egra$i%n, an# #em%ns$ra$e# $ha$ (i$h a""r%"ria$e me$h%#s, such as $h%se lis$e# ab%ve, 74 "ercen$ %& seri%usly men$ally ill h%meless "e%"le can be assis$e# $% remain sa$is&ac$%rily h%use# in $he c%mmuni$y 1Shern e$ al., 2339+ !h%m"s%n an# Brea ey, 23395. +pecial +er(ices for Homeless People .ith '"al 'iagnoses Pe%"le (h% su&&er b%$h &r%m a ma0%r men$al illness an# a subs$ance use #is%r#er "%se ma0%r challenges $% #evel%"ing services $ha$ (ill success&ully a##ress b%$h $y"es %& #is%r#er. !heir $rea$men$ is "ar$icularly "r%blema$ic because %& $he his$%ric se"ara$i%n be$(een a##ic$i%n an# men$al heal$h services, (hich e'$en#s as &ar as $he &e#eral agencies c%ncerne#. Bringing $%ge$her res%urces an# $rea$men$ "hil%s%"hies in $he service %& a "ar$icular "a$ien$ has "r%ve# #i&&icul$, bu$ $he curren$ "r%&essi%nal %"ini%n is $ha$ in$egra$e# $rea$men$ an# rehabili$a$i%n a""r%aches are m%s$ e&&ec$ive an# m%#el $rea$men$ "r%grams "r%vi#e subs$ance abuse an# men$al illness $rea$men$ simul$ane%usly 1Min %&& A Dra e, 23325. 6n h%meless "ers%ns, $he "revalence %& subs$ance use #is%r#ers in men$ally ill "ers%ns is a$ leas$ as high as in $h%se (i$h%u$ men$al illnesses. :s$ima$es are &airly c%nsis$en$ $ha$ be$(een 24 "ercen$ an# BE "ercen$ %& h%meless "e%"le have #ual #iagn%ses 1Brea ey e$ al., 2373, D%egel A Burnam,2377+ !essler A Dennis, 23735. !he Cen$er &%r Men$al Heal$h Services an# $he Cen$er &%r Subs$ance Abuse !rea$men$ s"%ns%re# a C%llab%ra$ive Dem%ns$ra$i%n Pr%gram a$ 2= si$es &%r services &%r #ually #iagn%se# h%meless "e%"le. !he re"%r$ %& $his "r%gram #e&ines &ive cri$ical clien$ charac$eris$ics $ha$ in&luence "r%gram #esign*
c D M

Disa&&ilia$i%n+ Mul$i"le, c%m"le' nee#s+ 6m"%verishe# envir%nmen$s+

:&&ec$s %& illness an# a##ic$i%n+ an# : L%( m%$iva$i%n &%r change/l%( sel&-es$eem. Ma0%r in$erven$i%ns em"l%ye# by $he 23 "r%grams (ere similar $% $h%se $ha$ have been em"l%ye# &%r %$her h%meless subgr%u"s* %u$reach, case managemen$, #e$%'i&ica$i%n, #ay $rea$men$, resi#en$ial $rea$men$ an# sys$em-(i#e c%%r#ina$i%n. !he ini$ia$ive clearly es$ablishe# $he im"%r$ance %& c%llab%ra$i%n be$(een "r%&essi%nals in $he subs$ance abuse an# men$al illness &iel#s $% "r%vi#e in$egra$e# services &%r $his "ar$icularly vulnerable gr%u" (h% c%ns$i$u$e a signi&ican$ segmen$ %& $he h%meless "%"ula$i%n 1Winars i A Dubus, 233=5. 6#eally $rea$men$ &%r subs$ance abuse an# men$al illness sh%ul# be "r%vi#e# simul$ane%usly in $he same &acili$y. Where $his is n%$ "%ssible, cl%se re&erral agreemen$s sh%ul# be es$ablishe# s% $ha$ $he ma'imum level %& c%%r#ina$i%n can be a$$aine#.

Concl"sion
Des"i$e $he $remen#%us am%un$ %& n%(le#ge an# e'"erience $ha$ has been gaine# %ver $he "as$ #eca#e in a#a"$ing clinical "rac$ice $% $he nee#s %& h%meless "e%"le, $here is s$ill much $% be learne#, as (ell as numer%us $hrea$s $ha$ challenge $he success&ul c%n$inua$i%n %& $his (%r . Rec%mmen#a$i%ns $% a##ress research an# "%licy $ha$ (ill s$reng$hen %ur n%(le#ge an# #iminish $he $hrea$s &%ll%(* Contin"e to +"pport !ncreased /"nding for !ntegrated Health Programs A#vances have been ma#e in "rimary care, men$al heal$h an# subs$ance abuse services &%r h%meless "e%"le, %nly $% be se$ bac by $he inabili$y $% main$ain e&&ec$ive m%#els. Dem%ns$ra$i%n "r%0ec$s nee# $he %"$i%n %& %ng%ing &un#ing, i& $he "r%gram "r%ves $% be success&ul. 8un#ing is als% nee#e# $% e'"an# in$% areas n%( rec%gni,e# as vi$al &%r im"r%ving an# main$aining heal$h, such as #en$al services, res"i$e care #uring c%nvalescence, an# in$egra$i%n %& h%using in$% men$al heal$h an# subs$ance abuse "r%grams. !his is es"ecially relevan$ in an envir%nmen$ %& increasing nee# an# #ecrease# ca"aci$y $% mee$ $ha$ nee# 1;-C%nnell, L%,ier an# Gingles, 23395. &or /or ,ni(ersal Health Care Co(erage to *liminate the Negati(e !mpact of Mar et !nfl"ences on 'eli(ery of Health Care !he rush by many heal$h care %rgani,a$i%ns $% s$ay a&l%a$ by increasing Me#icai# revenue has resul$e# in l%ss %& access $% services &%r uninsure# h%meless "e%"le. :ven &%r $h%se (h% #% have insurance, c%nversi%n %& Me#icai# $% a manage# care sys$em has ma#e access m%re "r%blema$ic. 6$ is in$eres$ing $% n%$e in $he #iscussi%n %& clinical $rea$men$ ab%ve $ha$ $he rec%mmen#a$i%ns &re)uen$ly inclu#e a l%(er $hresh%l# &%r ini$ia$ing $rea$men$ %r h%s"i$ali,a$i%n, necessi$y %& &re)uen$ &%ll%(-u" visi$s 1s%me$imes #aily5, use %& al$erna$ive me#ica$i%ns (hich may be m%re e'"ensive 1e.g., %nce-#aily #%sing5, #ivergence &r%m s$ric$ "r%$%c%ls, &le'ibili$y in service l%ca$i%n an# easy access $% a (i#e range %& in$egra$e# services, inclu#ing s"ecial$y care. 6n %$her (%r#s, $he in#s %& a#a"$a$i%ns $% clinical care

nee#e# by h%meless "e%"le are in many cases $he very "rac$ices $ha$ manage# care #isc%urages. Wunsch 123375 summari,es $he challenges %& inv%lving h%meless "e%"le in manage# care*
m $

!he s%cial circums$ances %& h%meless "e%"le are %&$en n%$ c%m"a$ible (i$h $he $igh$ly c%n$r%lle# access $% heal$h care $ha$ charac$eri,es manage# care. !he heal$h s$a$us %& h%meless "e%"le is mar e#ly in&eri%r $% $ha$ %& $ra#i$i%nal manage# care enr%llees, an# is charac$eri,e# by c%m"le', in$errela$e# c%n#i$i%ns, inclu#ing n%n-me#ical &ac$%rs n%$ usually a##resse# by manage# care en$i$ies 1MC:s5.

'e(elop a /ederally0/"nded +"bstance Ab"se Program Targeted to Homeless People As a s%cie$y, (e c%n$inue $% #eny $he vas$ e'$en$ %& $he "a$h%l%gy an# s%cial #isl%ca$i%n a$$ribu$able $% alc%h%l an# #rugs 1Wilhi$e, 233B5. !he im"ac$ %& subs$ance abuse in causing an# "er"e$ua$ing h%melessness cann%$ be a#e)ua$ely a##resse# (i$h%u$ signi&ican$ a##i$i%nal res%urces. :'is$ing c%mmuni$y res%urces are n%$ su&&icien$Can# %&$en n%$ a""r%"ria$eC$% mee$ $he nee#s %& h%meless "e%"le (i$h subs$ance abuse #is%r#ers, es"ecially $h%se (i$h c%-%ccurring men$al illness. 'e(elop *ffecti(e Methodologies to Collect and Analy1e Cost and %"tcome 'ata$ Da$a %n heal$h care u$ili,a$i%n, c%s$ an# %u$c%mes have n%$ been c%llec$e# an# analy,e# &%r h%meless "e%"le as a gr%u", un#ermining $he abili$y %& s$a$es $% e&&ec$ively serve $hem $hr%ugh manage# care arrangemen$s 1Wunsch, 23375. !here is a c%nsensus in $he &iel# $ha$ m%re in&%rma$i%n is nee#e# %n c%s$s %& caring &%r h%meless "e%"le, as (ell as (hich "rac$ices resul$ in $he bes$ %u$c%mes &%r (hich $y"es %& "e%"le (h% are h%meless. !he BPHC ini$ia$ive %n %u$c%mes men$i%ne# earlier is %ne "%$en$ial s%urce &%r #evel%"ing a""r%aches $% measuring %u$c%mes 1>.S. De"ar$men$ %& Human Services, 233=5. Al$h%ugh li$$le has been #%ne in $he #i&&icul$ arena %& accura$ely #e$ermining c%s$s %& care, $here is evi#ence %& $he c%s$ %& n%$ "r%vi#ing $he care $ha$ resul$s in e'"ensive h%s"i$ali,a$i%n 1Sali$ e$ al., 23375. !mpro(e 'issemination to the /ield of Res"lts of Research and Practice A##i$i%nal research (ill n%$ be use&ul (i$h%u$ be$$er s$ra$egies &%r inc%r"%ra$ing research &in#ings in$% ac$ual "rac$ice in $he &iel#. Heal$h care is a ra"i#ly changing an# ev%lving &iel#, (i$h ne( $echn%l%gies, me#ica$i%ns an# $rea$men$ a""r%aches being #evel%"e# c%ns$an$ly. .%$ %nly #% ne( "rac$ices nee# $% be $es$e# &%r relevance (i$h "e%"le (h% are h%meless, mechanisms nee# $% be #evel%"e# $% assure $ha$ h%meless heal$h "rac$i$i%ners receive $ha$ in&%rma$i%n in a &%rma$ $ha$ is use&ul an# "rac$ical, inclu#ing a me$h%# $% "r%vi#e &ee#bac an# engage in %ng%ing #ial%gue (i$h researchers. !ncrease Training for Recr"itment and Retention of + illed Practitioners

C%mmi$$e# "rac$i$i%ners (h% are s ille# in (%r ing (i$h h%meless "e%"le an# (illing $% acce"$ $he #i&&icul$ies %& $he (%r are scarce. !here is a nee# $% c%n$inue $raining &%r "r%vi#ers alrea#y in $he &iel#Cb%$h $% c%n$inually im"r%ve )uali$y an# s$ay abreas$ %& curren$ "rac$ices, as (ell as $% enhance re$en$i%n by "reven$ing burn%u$. .e( "rac$i$i%ners als% nee# $% be $raine#. !he re&%rm in me#ical e#uca$i%n $%(ar# a m%re humanis$ic "rimary care m%#el (ill h%"e&ully resul$ in $he crea$i%n %& a ca#re %& me#ical "r%vi#ers (h% are $raine# $% care &%r vulnerable "%"ula$i%ns such as "e%"le (i$h%u$ h%mes. M%re men$al heal$h "r%&essi%nals are als% nee#e# in heal$h care "r%grams $rea$ing h%meless "ers%ns. !heir $raining sh%ul# inclu#e "lacemen$ in c%mmuni$y-base# heal$h "r%grams s% $ha$ $hey can learn $% (%r han#-in-han# (i$h generalis$ "hysicians in $rea$ing $he in$er$(ine# "hysical an# men$al heal$h "r%blems %& h%meless "e%"le. Since a grea$ #eal %& care is als% "r%vi#e# $% h%meless "e%"le in emergency r%%ms, all me#ical an# surgical $rainees in me#ical sch%%l, resi#ency, an# &ell%(shi" "r%grams mus$ be $raine# $% #evel%" an a""recia$i%n &%r $heir "a$ien$sI h%using an# "%ver$y s$a$us, an# vic$imi,a$i%n his$%ry. >nless $hey are res%lve#, all %& $he ab%ve &ac$%rsCina#e)ua$e &un#ing $% &ully im"lemen$ $he in$egra$e# a""r%ach $% h%meless heal$h care, im"ac$ %& mar e$-#riven manage# care, lac %& &un#ing &%r accessible an# a""r%"ria$e subs$ance abuse $rea$men$, limi$e# c%s$ an# %u$c%me #a$a, $he #isc%nnec$ be$(een research an# "rac$ice, an# $he scarci$y %& s ille# "rac$i$i%ners (illing $% serve $his "%"ula$i%nC$hrea$en $he survival %& $he uni)ue in$egra$e# a""r%ach $% care $ha$ has ev%lve# $% $rea$ $he heal$h %& h%meless "e%"le. >n$il such $ime as $here is universal heal$h care c%verage an# a#e)ua$e h%using &%r all, "e%"le e'"eriencing h%melessness (ill nee# access $% a heal$h care sys$em #esigne# s"eci&ically $% res"%n# $% $heir uni)ue nee#s.

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8arr, R. D., D%egel, P. A Burnam, A. 1237=5. ) Study of #omelessness and &ental !llness in the Skid *ow )rea of >os )ngeles. L%s Angeles* L%s Angeles De"ar$men$ %& Men$al Heal$h. 8e#eral !as 8%rce %n H%melessness an# Men$al 6llness. 1233B5. %utcasts on &ain Street. *eport of the Federal /ask Force on #omelessness and Severe &ental !llness. Washing$%n, DC* 6n$eragency C%uncil %n $he H%meless. 8ierman, A. H., Dreyer, B. P., Quinn, L., Shulman, S., C%ur$lan#$, C. D. A Gu,,%, R. 123325. Gr%($h Delay in H%meless Chil#ren. +ediatrics --* 327-3BE. 8ilar#%, !. 1237E5. Chr%nic Disease Managemen$ in $he H%meless. 6n P. W. Bric ner, L. D. Scharer, B. C%nanan, A. :lvy A M. Savarese 1:#s.5 #ealth Care of #omeless +eople. .e( L%r * S"ringer Publishing C%m"any. 8ischer, P. J. A Brea ey, W. R. 123325. !he :"i#emi%l%gy %& Alc%h%l, Drug an# Men$al Dis%r#ers Am%ng H%meless Pers%ns. )merican +sychologist <=* 222E-22B7. 8ischer, P. J., C%ls%n A Susser, :. 1233=5. H%melessness an# Men$al Heal$h Services. 6n Brea ey, W. R. 1:#.5 !ntegrated &ental #ealth Services. &odern Community +sychiatry. .e( L%r * ;'&%r# >niversi$y Press. 8ischer, P. J., Sha"ir%, S. A Brea ey, W. R. 1237=5. Men$al Heal$h an# S%cial Charac$eris$ics %& $he H%meless. )merican 2ournal of +ublic #ealth 3=* E23-EBG. 8leischman, S. A 8arnham, !. 1233B5. Chr%nic Disease in $he H%meless. 6n W%%#, D. 1:#.5, Aelivering #ealth Care to #omeless +ersons. .e( L%r * S"ringer Publishing C%m"any. 8%rs, S. W. A Jarvis, S. 1233E5. :valua$i%n %& a Peer-Le# Drug Abuse Ris Re#uc$i%n Pr%0ec$ &%r Runa(ay/H%meless L%u$hs. 2ournal of Arug Fducation, BE1G5* FB2-FFF. Gelberg, L. A Linn, L. S. 1237E5. Heal$h %& H%meless A#ul$s. >n"ublishe#. Gelberg, L. A Linn, L. S. 123735. Assessing $he Physical Heal$h %& H%meless A#ul$s. 2ournal of the )merican &edical )ssociation :=:* 239F-2393. Gelberg, L. A Linn, L. S. 123375. S%cial an# Physical Heal$h %& H%meless A#ul$s Previ%usly !rea$e# &%r Men$al Heal$h Pr%blems. #ospital and Community +sychiatry 8D* E24-E2=. Gelberg, L., Gallagher, !. C., An#ersen, R. M. A D%egel, P. 123395. C%m"e$ing Pri%ri$ies As a Barrier $% Me#ical Care Am%ng H%meless A#ul$s in L%s Angeles. )merican 2ournal of +ublic #ealth -31B5* B29-BB4.

Gelberg, L., Linn, L. S. A Mayer-;a es, S. A. 123345. Di&&erences in Heal$h S$a$us Be$(een ;l#er an# L%unger H%meless A#ul$s. 2ournal of )merican @eriatrics Society 8-* 2BB4-2BB3. Gelberg, L., Linn, L. S. A R%senberg, D. J. 123775. Den$al Heal$h %& H%meless A#ul$s. Special Care in Aentistry -* 2=9-29B. Gelberg, L., Panari$es, C. J., M%rgens$ern, H., Lea e, B., An#ersen, R. M. A D%egel, P. 123395. !ubercul%sis S in !es$ing Am%ng H%meless A#ul$s. 2ournal of @eneral !nternal &edicine ,:* BE-FF. G%ering, P. .. A Wasylen i, D. 1233=5. Case Managemen$. 6n Brea ey, W.R. 1:#.B !ntegrated &ental #ealth Services. &odern Community +sychiatry. .e( L%r * ;'&%r# >niversi$y Press. G%e$cheus, J., Gleas%n, M., Sars%n, D., Benne$$, !. A W%l&e, P. 123345. C%nvalescence &%r !h%se (i$h%u$ a H%me* Devel%"ing Res"i$e Services in Pr%$ec$e# :nvir%nmen$s. 6n Bric ner, P.W. 1:#.5 e$ al., 1nder the Safety 'et. /he #ealth and Social Welfare of the #omeless in the 1. S. .e( L%r * W.W. .%r$%n. G%%#man, L. A. 123325. !he Prevalence %& Abuse in $he Lives %& H%meless an# H%use# P%%r M%$hers* A C%m"aris%n S$u#y. )merican 2ournal of %rthopsychiatry, ,=* G73-E44. G%%#man, L., R%senberg, S., Mueser, D. A Dra e, R. 123395. Physical an# Se'ual Assaul$ His$%ry in W%men (i$h Seri%us Men$al 6llness* Prevalence, C%rrela$es, !rea$men$ an# 8u$ure Research Direc$i%ns. Schi"ophrenia 4ulletin :81G5* =7E-=3=. Hagen, J. L. 123795. Gen#er an# H%melessness. Social Work. F2B-F2=. July-Augus$. Han,lic , R. A Parrish, R. 1233F5. Dea$h Am%ng $he H%meless in 8ul$%n C%un$y, Ge%rgia, 2377-2334. +ublic #ealth *eports ,5-* G77-G32. Harris, M. A Lan#is, C. L. 123395. 'ew Airections in /herapeutic !ntervention. 0olume :. Sexual )buse in the >ives of Women Aiagnosed with Serious &ental !llness. Ams$er#am, $he .e$herlan#s* Harr%(e# Aca#emic Publishers. Hay(ar#, R., Sha"ir%, M., 8reeman, H. A C%rey, C. 123775. Wh% Ge$s Screene# &%r Cervical an# Breas$ Cancer< Resul$s 8r%m a .e( .a$i%nal Survey. )rchives of !nternal &edicine ,<-* 2299-2272. HCH Clinicians- .e$(%r . 123335. Chr%nic He"a$i$is C* Silen$ 6n$ru#er, 6nsi#i%us !hrea$. #ealing #ands 81B5. March. HCH .e$(%r . 123375. #C#' Service Continuum. Sea$$le, WA* Sea$$le/Ding C%un$y De"ar$men$ %& Public Heal$h, 1un"ublishe#5.

Hibbs, J. R., Benner, L., Dlugman, L., S"encer, R., Macchia, 6., Mellinger, A. D. A 8i&e, D. 1233G5. M%r$ali$y in a C%h%r$ %& H%meless A#ul$s in Phila#el"hia. 'ew Fngland 2ournal of &edicine 88,1E5* F4G-F43. H%ugh, R. L., Harm%n, S., !ar e, H., e$ al. 123395. Su""%r$e# 6n#e"en#en$ H%using* 6m"lemen$a$i%n 6ssues an# S%lu$i%ns in $he San Dieg% Pr%0ec$. 6n Brea ey, W.R. A !h%m"s%n, J.W. 1:#s.5 &entally !ll and #omeless. Special +rograms for Special 'eeds, 3E-227. Ams$er#am* Har(%%# Aca#emic Publishers. 6ns$i$u$e %& Me#icine. 123775. #omelessness, #ealth, and #uman 'eeds. Washing$%n, D.C.* .a$i%nal Aca#emy Press. 6n$eragency C%uncil %n $he H%meless. 1233G5. +riority. #omeG /he Federal +lan to 4reak the Cycle of #omelessness. Washing$%n, DC* >. S. De"ar$men$ %& H%using an# >rban Devel%"men$ H>D-2GEG-CPD. Jahiel, R. 6. 1233B5. Heal$h an# Heal$h Care %& H%meless Pe%"le. 6n R%ber$s%n, M. A Greenbla$$, M. 1:#s.5, #omelesssness. ) 'ational +erspective. .e( L%r * Plenum Press. Denne#y, J. !., Pe$r%ne, J., Deisher, R. W., :mers%n, J., Hesl%", P., Bas$ible, D., A Ar %vi$,, M. 123345. Heal$h Care &%r 8amilyless, Runa(ay S$ree$ Di#s. 6n P. W. Bric ner, L. D. Scharer, B. A. C%nanan, M. Savarese, A B. C. Scanlan 1:#.5, 1nder the Safety 'et. /he #ealth and Social Welfare of the #omeless in the 1nited States. .e( L%r * W. W. .%r$%n, 7B-229. Dern, G., 8risch-.iggemeyer, W., We(al a, G., Bruns, C. 1237=5. He"a$i$is a ;u$brea in a Shel$er &%r $he H%meless in Hienna. Wiener Klinische Wochenschrift D-12G5* GE9-G=2. Dilli%n, C.M. 1233E5. S"ecial Heal$h Care .ee#s %& H%meless Pregnan$ W%men. )dvances in 'ursing Science ,-1B5* GG-E=. Di" e, M. D., M%n$g%mery, S. B., Sim%n, !. R., A 6vers%n, :. 8. 123395. Subs$ance Abuse Dis%r#ers Am%ng Runa(ay an# H%meless L%u$h. Substance 1se &isuse 8:19-75* 3=3-37=. Dline, S., He#emar , L., A Davis, S. 1233E5. ;u$brea %& !ubercul%sis Am%ng Regular Pa$r%ns %& a .eighb%rh%%# Bar. 'ew Fngland 2ournal of &edicine 888* BBB-BB9. D%egel P, Burnam M. A., Baum%hl J. 1233=5. /he Causes of #omelessness in #omelessness in )merica. :#. Jim Baum%hl, .e( L%r , .L* ;ry' Press. D%egel, P. A Burnam, A. 1233B5. Pr%blems in $he Assessmen$ %& Men$al 6llness Am%ng $he H%meless. 6n R%ber$s%n, M.J. A Greenbla$$, M. 1:#s.5, #omelessness. ) 'ational +erspective. .e( L%r * Plenum Press. D%egel, P. A Gelberg, L. 1233B5. Pa$ien$-;rien$e# A""r%ach $% Pr%vi#ing Care $% H%meless Pers%ns. 6n D. W%%#, 1:#.5 Aelivering #ealth Care to #omeless +ersons. )

@uide to the Aiagnosis and &anagement of &edical and &ental #ealth Conditions. .e( L%r , .L* S"ringer Publishing C%m"any. D%egel, P., A Burnam, A. 123775. Alc%h%lism Am%ng H%meless A#ul$s in $he 6nner Ci$y %& L%s Angeles. )rchives of @eneral +sychiatry <9* 2422-2427. D%egel, P., Burnam, A. A 8arr, R.D. 123775. !he Prevalence %& S"eci&ic Psychia$ric Dis%r#ers Am%ng H%meless 6n#ivi#uals in $he 6nner Ci$y %& L%s Angeles. )rchives of @eneral +sychiatry <9* 247E-243B. La#ner, S. 1233B5. !he :l#erly H%meless. 6n R%ber$s%n, M.J. A Greenbla$$, M. 1:#s.5, #omelessness. ) 'ational +erspective. .e( L%r * Plenum Press. Lam, J. A R%senhec , R. 123375. !he :&&ec$ %& Hic$imi,a$i%n %n Clinical ;u$c%mes %& H%meless Pers%ns Wi$h Seri%us Men$al 6llness. +sychiatric Services <D1E5* =97-=7F. La"ham, S. C., Hall, M., Sny#er, J., S i""er, B., McMurray-Avila, M., Pulvin%, S. A D%,eny, !. 1233=5. Dem%ns$ra$i%n %& a Mi'e# S%cial/Me#ical M%#el De$%'i&ica$i%n Pr%gram &%r H%meless Alc%h%l Abusers. Contemporary Arug +roblems :8, Summer. Lehman A. 8., Di'%n, L. B., Dernan, :., De8%rge, B. R. A P%s$ra#%, L. !. 123395. A Ran#%mi,e# !rial %& Asser$ive C%mmuni$y !rea$men$ &%r H%meless Pers%ns Wi$h Severe Men$al 6llness. )rchives of @eneral +sychiatry 9<* 24F7-24GF. Lin B., Phelan J., Bresnahan M., S$ueve A., M%%re R., A Susser :. 1233E5. Li&e$ime an# 8ive-Lear Prevalence %& H%melessness in $he >ni$e# S$a$es* .e( :vi#ence %n an ;l# Deba$e. )merican 2ournal of %rthopsychiatry =91F5* FG9-FEG. L%ng, H. L., !uls y, J. P., Chambers, D. B., e$ al. 123375. Cancer Screening in H%meless W%men* A$$i$u#es an# Behavi%rs. 2ournal of #ealth Care for the +oor and 1nderserved D* B9=-B3B. Mangura, B. !., Passannan$e, M. R. A Reichman, L. B. 123395. An 6ncen$ive in !ubercul%sis Preven$ive !hera"y &%r an 6nner Ci$y P%"ula$i%n. !nternational 2ournal of /ubercular >ung Aisease, ,E=B* E9=-E97, December. Marla$$, G. A., S%mers, J. M. A !a"er$, S. 8. 1233F5. Harm Re#uc$i%n* A""lica$i%n $% Alc%h%l Abuse Pr%blems. '!A) *esearch &onograph, ,83* 2G9-2==. Marla$$, G. A., !uc er, J. A., D%n%van, D. M. A Huchinich, R. :. 123395. Hel"-See ing By Subs$ance Abusers* !he R%le %& Harm Re#uc$i%n an# Behavi%ral-:c%n%mic A""r%aches $% 8acili$a$e !rea$men$ :n$ry an# Re$en$i%n. '!A) *esearch &onograph, ,=9* GG-7G. May%, D., Whi$e, S., ;a$es, S. D. A 8ran lin, 8. 1233=5. C%mmuni$y C%llab%ra$i%n* Preven$i%n an# C%n$r%l %& !ubercul%sis in a H%meless Shel$er. +ublic #ealth 'ursing ,8* 2B4-9, A"ril.

McA#am, J., Bric ner, P., Scharer, L., Cr%cc%, J., A Du&&, A. 123345. !he S"ec$rum %& !ubercul%sis in a .e( L%r Ci$y MenIs Shel$er Clinic 1237B-23775. Chest D3* 937-74E. McMurray-Avila, M. 123395. %rgani"ing #ealth Services for #omeless +eople. .ashville, !.* .a$i%nal Heal$h Care &%r $he H%meless C%uncil. Mc.ally, :. A W%%#, J. 1233B5. ;bs$e$rical Care an# 8amily Planning &%r H%meless W%men. 6n W%%#, D. 1:#.5 Aelivering #ealth Care to #omeless +ersons. .e( L%r , .L* S"ringer Publishing C%m"any. Michael, M. A Brammer, S. 123775. Me#ical !rea$men$ %& H%meless Hy"er$ensives. )merican 2ournal of +ublic #ealth 3-* 97-3G. Miller, D. A Lin, :. 123775. Chil#ren in Shel$ere# H%meless 8amilies* Re"%r$e# Heal$h S$a$us an# >se %& Heal$h Services. +ediatrics -,* ==7-=9F. Min %&&, D. A Dra e, R. :. 1:#s.5 123325. Dual Diagn%sis %& Ma0%r Men$al 6llness an# Subs$ance Dis%r#er. 'ew Airections for &ental #ealth Services 95* 3E-249. San 8rancisc%* J%ssey-Bass. M%rbi#i$y an# M%r$ali$y Wee ly Re"%r$. 123325. Dea$hs Am%ng H%meless Pers%ns R San 8rancisc%, 237E-2334. &orbidity and &ortality Weekly *eport <5* 799-774. M%rbi#i$y an# M%r$ali$y Wee ly Re"%r$. 1233B5. Dea$hs Am%ng H%meless Pers%ns R San 8rancisc%. 2ournal of the )merican &edical )ssociation :=3* G7G-G7E. Morey, M$ A$, /riedman, L$ +$ 234456$ Health Care Needs of Homeless Adolescents$ +ee Comments 0 Current .pinion in "ediatrics 1276: 5480544$ M%rr%(, R., 8an$a, J. A Derlen, S. 123395. !ubercul%sis Screening an# Anergy in a H%meless P%"ula$i%n. 2ournal of the )merican 4oard of Family +ractitioners, ,5* 2-E, Jan.-8eb. M%rse, G. A. A Calsyn, R. J. 1237=5. !he S$. L%uis Men$ally Dis$urbe# H%meless* .ee#y, Willing, Bu$ >n#erserve#. !nternational 2ournal of &ental #ealth ,<* 9G-3G. M%(bray, C., J%hns%n, H., S%lar,, A., C%mbs, C. 1237=5. &ental #ealth and #omelessness in Aetroit. ) *esearch Study. Michigan De"ar$men$ %& Men$al Heal$h. M%y, J. A Sanche,, M. 1233B5. !he Cu$ane%us Mani&es$a$i%ns %& Hi%lence an# P%ver$y. )rchives of Aermatology ,:-1=5* 7B3-7F3. .a$i%nal Heal$h Care &%r $he H%meless C%uncil. 1233G5. Combating /uberculosis and #omelessness. *ecommendations for +olicy and +ractice. .ashville* .a$i%nal HCH C%uncil.

.e( L%r S$a$e C%uncil %n Chil#ren an# 8amilies. 1237G5. &eeting the 'eeds of #omeless ?outh. Albany, .e( L%r * Au$h%r. .6AAA. 12332a5. ) @uide to #ousing for >ow !ncome +eople *ecovering from )lcohol and %ther Arug +roblems. Washing$%n, DC* .6AAA, January. .6AAA. 12332b5. H%using 6ni$ia$ives &%r H%meless Pe%"le (i$h Alc%h%l an# ;$her Drug Pr%blems* Pr%cee#ings %& a .a$i%nal C%n&erence R 8ebruary B3-March B, 2332 in San Dieg%. Washing$%n, DC* .6AAA, .%vember. .%r$h, C. A Smi$h, :. 1233B5. P%s$$rauma$ic S$ress Dis%r#er Am%ng H%meless Men an# W%men. #ospital and Community +sychiatry <81245* 2424-242=. .%r$h, C., Smi$h, :. A S"i$,nagel, :. 1233G5. Hi%lence an# $he H%meless* An :"i#emi%l%gic S$u#y %& Hic$imi,a$i%n an# Aggressi%n. 2ournal of /raumatic Stress 3125* 3E-224. .yama$hi, A. 1233B5. C%m"ara$ive S$u#y %& 8ac$%rs Rela$ing $% H6H Ris Level %& Blac H%meless W%men. 2ournal of )cHuired !mmune Aeficiency Syndromes 9* BBB-BB7. .yama$hi, A. 1233F5. Sense %& C%herence in Min%ri$y W%men A$ Ris &%r H6H 6n&ec$i%n. +ublic #ealth 'ursing ,51F5* 2E2-2E7. ;-C%nnell, J. J. A Gr%$h, J. 1:#s.5 123325. /he &anual of Common Communicable Aiseases in Shelters. B%s$%n* B%s$%n HCH Pr%gram. ;-C%nnell, J. J., L%,ier, J. A Gingles, D. 123395. !ncreased Aemand and Aecreased Capacity. Challenges to the &cKinney )ct;s #ealth Care for the #omeless +rogram. .ashville, !.* .a$i%nal HCH C%uncil, July. ;-C%nnell, J. J., Summer&iel#, J. A Dell%gg, R. 123345 !he H%meless :l#erly. 6n Bric ner, P.W. e$ al., 1:#s.5 1nder the Safety 'et. /he #ealth and Social Welfare of the #omeless in the 1. S. .e( L%r * W.W. .%r$%n. ;IC%nnell, J. A Leb%( J. 1233B5. A6DS an# $he H%meless %& B%s$%n. 'ew Fngland 2ournal of +ublic +olicy -* EG2-EE=. ;l&s%n, M. 123345. Asser$ive C%mmuni$y !rea$men$* An :valua$i%n %& $he :'"erimen$al :vi#ence. #ospital and Community +sychiatry <,* =FE-=G2. Pabl%s-Men#e,, A., Dnirsch, C. A., Barr, R. G., Lerner, B. H. A 8rie#en, !. R. 123395. .%na#herence in !ubercul%sis !rea$men$* Pre#ic$%rs an# C%nse)uences in .e( L%r Ci$y. )merican 2ournal of &edicine, ,5:1B5* 2=G-294.

Pa#ge$$, D. A S$ruening, :. 1233B5. Hic$imi,a$i%n an# !rauma$ic 6n0uries Am%ng $he H%meless* Ass%cia$i%ns Wi$h Alc%h%l, Drug an# Men$al Pr%blems. )merican 2ournal of %rthopsychiatry =:1G5* EBE-EFG. Pa$ers%n, C. M. A R%#eric , P. 123345. ;bs$e$ric ;u$c%me in H%meless W%men. 4ritish &edical 2ournal. 85,* B=F-B==. Pe$ers%n, J., Pil%$e, L., K%l%"a, A. A M%ss, A. 1233F5. 6nsigh$s 8r%m $he S$ree$* Peer Heal$h A#vis%rs an# Me#ical Care in $he H%meless. 6n$erna$i%nal C%n&erence %n A6DS 3*7=3 1abs$rac$ n%. P;-D2=-F3435. Pian$eri, ;., Hicic, W., Byr#, R., Brammer, S. A Michael, M. 123345. Hy"er$ensi%n Screening an# !rea$men$ in $he H%meless. 6n Bric ner, P.W. e$ al., 1:#s.5 1nder the Safety 'et. /he #ealth and Social Welfare of the #omeless in the 1 S. .e( L%r * W.W. .%r$%n. Pil%$e, L., !uls y, J. P., K%l%"a, A. R., Hahn, J. A., Schec$er, G. 8. A M%ss A. R. 1233=5. !ubercul%sis Pr%"hyla'is in $he H%meless. A !rial $% 6m"r%ve A#herence $% Re&erral. )rchives of !nternal &edicine, 9=* 2=2-E, Jan. BB. P%"li, S., Davir#as, J. !., .eubauer, B., H%chenberry, B. Han%, J. :. A 6ng, !. S. 1237=5. !rans#ermal Cl%ni#ine in Mil# Hy"er$ensi%n. )rchives of !nternal &edicine ,<=* B2G4-GG. Primm, A. B. 1233=5. Asser$ive C%mmuni$y !rea$men$. 6n Brea ey, W.R. 1:#.5 !ntegrated &ental #ealth Services. &odern Community +sychiatry. .e( L%r * ;'&%r# >niversi$y Press. Pr%chas a, J. ;., DiClemen$e, C. C. A .%rcr%ss, J. C. 1233B5. 6n Search %& H%( Pe%"le Change* A""lica$i%ns $% A##ic$ive Behavi%rs. )merican +sychologist <3135* 224B-222B. Ran#%l"h, 8., Blasins y, M., Legins i, W., Par er, L. B., G%l#man, H. H. 123395. Crea$ing 6n$egra$e# Service Sys$ems &%r H%meless Pers%ns (i$h Men$al 6llness* !he ACC:SS Pr%gram. +sychiatric Services <-1F5* F=3-F9F. Reuler, J., Ba', M. A Sam"s%n, J. 1237=5. Physician H%use Call Services &%r Me#ically .ee#y, 6nner-Ci$y Resi#en$s. )merican 2ournal of +ublic #ealth 3=* 22F2-22FG. Re( L. 1233=5. Heal$h Ris s %& H%meless A#%lescen$s* 6m"lica$i%ns &%r H%lis$ic .ursing. 2ournal of #olistic 'ursing, ,<1G5* FG7-FE3, December. Ring(al$, C. L., Greene, J. M., R%ber$s%n, M. A McPhee$ers, M. 123375. !he Prevalence %& H%melessness Am%ng A#%lescen$s in $he >ni$e# S$a$es. )merican 2ournal of +ublic #ealth, --135* 2FBE-2FB3. R%ber$s%n, M. A C%usineau, M. 1237=5. Heal$h S$a$us an# Access $% Heal$h Services Am%ng $he >rban H%meless. )merican 2ournal of +ublic #ealth 3=* E=2-E=F.

R%ber$s%n, M. J. 1233=5. #omeless ?outh on /heir %wn. Ber eley, Cali&%rnia* Alc%h%l Research Gr%u". R%ber$s%n, M., R%"ers, R. A B%yer, R. 1237E5. /he #omeless of >os )ngeles County. )n Fmpirical Fvaluation. L%s Angeles* >CLA Sch%%l %& Public Heal$h/L%s Angeles Basic Shel$er Research Pr%0ec$. R%ber$s%n, M., Kl%$nic , C. A Wes$er&el$, A. 123395. Drug >se Dis%r#ers an# !rea$men$ C%n$ac$ Am%ng H%meless A#ul$s in Alame#a C%un$y, Cali&%rnia. )merican 2ournal of +ublic #ealth -3* BB2-BB7. R%senhec , R., M%rrissey, J., Lam, J., Call%(ay, M., J%hnsen, M., G%l#man, G., Calsyn, R., !eague, G., Ran#%l"h, 8., Blasins y, M., A 8%n$ana, A. 123375. Service Sys$em 6n$egra$i%n, Access $% Services an# H%using ;u$c%mes in a Pr%gram &%r H%meless Pe%"le (i$h Men$al 6llness. )merican 2ournal of +ublic #ealth --1225* 2=24-2=2E. R%$h, D. A Bean, G. 1237=5. .e( Pers"ec$ives %n H%melessness* 8in#ings &r%m a S$a$e(i#e :"i#emi%l%gical S$u#y. #ospital 7 Community +sychiatry 83*92B-923. Sac s, J., Philli"s, J. A Ca""elle$$y, G. 123795. Charac$eris$ics %& $he H%meless Men$ally Dis%r#ere# P%"ula$i%n in 8resn% C%un$y. Community &ental #ealth 2ournal :8* 22G-223. Sa ai, J., Dim. M., Sh%re, J. A He"&er, M. 123375. !he Ris %& Puri&ie# Pr%$ein Deriva$ive P%si$ivi$y in H%meless Men Wi$h Psych%$ic Sym"$%ms. Southern &edical 2ournal D,* FGE-FG7. Sali$, S. A., Duhn, :. M., Har$,, A. J., Hu, J. M. A M%ss%, A. L. 123375. H%s"i$ali,a$i%n C%s$s Ass%cia$e# Wi$h H%melessness in .e( L%r Ci$y. 'ew Fngland 2ournal of &edicine 88-1BG5, June 22. Scanlan, B. C. A Bric ner, P. W. 123345. Clinical C%ncerns in $he Care %& H%meless Pers%ns. 6n Bric ner, P.W. e$ al., 1:#s.5 1nder the Safety 'et. /he #ealth and Social Welfare of the #omeless in the 1. S. .e( L%r * W.W. .%r$%n. Schu$$, R. D A Garre$$, G. R. 1233B5. *esponding to the #omeless. +olicy and +ractice. .e( L%r * Plenum Press. Segal, S. P., G%m%ry, !. A Silverman, C. J. 123375. Heal$h S$a$us %& H%meless an# Marginally H%use# >sers %& Men$al Heal$h Sel&-Hel" Agencies. #ealth 7 Social Work :8125* GE-EB, 8ebruary. Sherman, D.J. 1233B5. !he .eglec$e# Heal$h Care .ee#s %& S$ree$ L%u$h. +ublic #ealth *eport 53* GFF-G4, July-Aug. Shern, D. L., 8el$%n, C. J., H%ugh, R. L., Lehman, A. 8., G%l#&inger, S., Halencia, :., Dennis, D., S$ra(, R., A W%%#, P. A. 123395. H%using ;u$c%mes &%r H%meless A#ul$s (i$h

Men$al 6llness* Resul$s &r%m $he Sec%n#-R%un# Mc inney Pr%gram. +sychiatric Services, <-* BF3-BG2. Shuler, P. A. 123325. #omeless WomenCs #olistic and Family +lanning 'eeds. )n Fxposition and /est of the 'urse +ractitioner &odel EAissertationB. L%s Angeles* >niversi$y %& Cali&%rnia, L%s Angeles. Shuler, P. A., Gelberg, L. A Davis, J. :. 1233E5. Charac$eris$ics Ass%cia$e# Wi$h $he Ris %& >nin$en#e# Pregnancy Am%ng >rban H%meless W%men. 2ournal of the )merican )cademy of 'urse +ractitioners 3* 2F-FB. Slavney, P. 123375. +sychiatric Aimensions of &edical +ractice. Bal$im%re* J%hns H%" ins >niversi$y Press. Smerec , G. A. A H%c man, :. M. 123375. Prevalence %& H6H 6n&ec$i%n an# H6H Ris Behavi%rs Ass%cia$e# (i$h Living Place* ;n-!he-S$ree$ H%meless Drug >sers as a S"ecial !arge$ P%"ula$i%n &%r Public Heal$h 6n$erven$i%n. )merican 2ournal of Arug and )lcohol )buse, :<1B5* B33-F23, May. Smi$h, :. M., .%r$h, C. S. A S"i$,nagel, :. L. 1233B5. A Sys$ema$ic S$u#y %& Men$al 6llness, Subs$ance Abuse an# !rea$men$ in =44 H%meless Men. )nnals of Clinical +sychiatry <* 222-2B4. Smi$h, :. M., .%r$h, C. S. A S"i$,nagel, :. L. 1233F5. Alc%h%l, Drugs an# Psychia$ric C%m%rbi#i$y Am%ng H%meless W%men* An :"i#emi%l%gical S$u#y. 2ournal of Clinical +sychiatry 9<* 7B-79. S%mlai, A. M., Delly, J. A., Wags$a&&, D. A. A Whi$s%n, D. P. 123375. Pa$$erns, Pre#ic$%rs, an# Si$ua$i%nal C%n$e'$s %& H6H Ris Behavi%rs Am%ng H%meless Men an# W%men. Soc Work <8125* 9-B4, January. S$ahler, G.J. 1233E5. !he :&&ec$iveness %& S%cial 6n$erven$i%ns &%r H%meless Subs$ance Abusers. 2ournal of )ddictive Aiseases ,<* G. S$ar , L. 1233B5. Barriers $% Heal$h Care &%r H%meless Pe%"le. 6n Jahiel, R. 1:#.5 #omelessness. ) +revention %riented )pproach. Bal$im%re* !he J%hns H%" ins >niversi$y Press. S$%ner, M. 1237F5. !he Pligh$ %& H%meless W%men. Social Service *eview 93* E=E-E72, December. S$ric%&, R. L., Denne#y, J. !., .a$$ell, !. C., Weis&use, 6. B., A .%vic , L. 8. 123325. H6H Ser%"revalence in a 8acili$y &%r Runa(ay an# H%meless A#%lescen$s. )merican 2ournal of +ublic #ealth, -,1su""lemen$5* E4-EF.

Susser, :., C%n%ver, S. A S$ruening, :. 123735. Pr%blems %& :"i#emi%l%gical Me$h%# in Assessing $he !y"e an# :'$en$ %& Men$al 6llness Am%ng H%meless A#ul$s. #ospital and Community +sychiatry <5* B=2-B=E. Susser, :., S$ruening, :. A C%n%ver, S. 123735. Psychia$ric Pr%blems in H%meless Men. )rchives of @eneral +sychiatry <=* 7GE-7E4. Susser, :., Halencia, :. A G%l#&inger, S.M. 1233B5. Clinical Care %& H%meless Men$ally 6ll 6n#ivi#uals* S$ra$egies an# A#a"$a$i%ns. 6n Lamb, H.R., Bachrach, L.L. A Dass, 8.6.1:#s.5* /reating the #omeless &entally !ll. Washing$%n, D.C.* American Psychia$ric Ass%cia$i%n. Susser, :., Halencia, :., an# C%n%ver, S. 1233F5. Prevalence %& H6H 6n&ec$i%n Am%ng Psychia$ric Pa$ien$s in a .e( L%r Ci$y MenIs Shel$er. )merican 2ournal of +ublic #ealth -81G5* E=7-E94. Susser, :., Halencia, :., C%n%ver, S., 8eli', A., !sai, W., A Wya$$, R.J. 123395. Preven$ing Recurren$ H%melessness Am%ng Men$ally 6ll Men* A ?Cri$ical !ime@ 6n$erven$i%n A&$er Discharge 8r%m A Shel$er. )merican 2ournal of +ublic #ealth -31B5* BE=-B=B. S(ay,e, 8. H. 1233B5. Clinical Case Managemen$ (i$h $he H%meless Men$ally 6ll. 6n Lamb, H. R., Bachrach, L.L. A Dass, 8.6.1:#s.5, /reating the #omeless &entally !ll. Washing$%n, DC* American Psychia$ric Ass%cia$i%n. !essler, R. A Dennis, D. 123735. ) Synthesis of '!&# Funded *esearch Concerning +ersons Who are #omeless and &entally !ll. Washing$%n, DC* >. S. De"ar$men$ %& Heal$h an# Human Services. !h%m"s%n, J. W. A Brea ey, W. R. 123395. !he Presen$ an# 8u$ure %& 6nn%va$ive Pr%grams &%r $he H%meless Men$ally 6ll. 6n Brea ey, W.R. A !h%m"s%n, J.W. 1e#s.5 &entally !ll and #omeless. Special +rograms for Special 'eeds. Ams$er#am* Har(%%# Aca#emic Publishers. !%r%, P. A., Bellavia, C., Daeschler, C., ;(ens, B., Wall, D. D., Passer%, J. M., A !h%mas, D. M. 1233E5. Dis$inguishing H%melessness 8r%m P%ver$y* A C%m"ara$ive S$u#y. 2ournal of Consulting and Clinical +sychology, =8* B74-B73. !%rres, R. A., Mani, S., Al$h%l,, J. A Bric ner, P. W. 123345. Human 6mmun%#e&iciency Hirus 6n&ec$i%n Am%ng H%meless Men in a .e( L%r Ci$y Shel$er. )rchives of !nternal &edicine ,95* B4F4-B4F=. !semberis, S. 1233=5. 8r%m ;u$cas$s $% C%mmuni$y* A Su""%r$ Gr%u" &%r H%meless Men. 6n An#r%nic%, M.P. 1:#.B &en in @roups. Washing$%n, DC* American Psych%l%gical Ass%cia$i%n.

>. S. De"ar$men$ %& Heal$h an# Human Services. 1233=5. /he Working @roup on #omeless #ealth %utcomes. &eeting +roceedings. Washing$%n, DC* HRSA/BPHC/DPSP/HCH Branch, June. >. S. De"ar$men$ %& Heal$h an# Human Services. 12337b5. #ealth Care for the #omeless %utcome &easures. ) Chronicle of /wenty +ilot Studies. Washing$%n, DC* HRSA/BPHC/DPSP/HCH Branch. >. S. De"ar$men$ %& Heal$h an# Human Services. 12337a5. #ealth Care for the #omeless Airectory. Washing$%n, DC* HRSA/BPHC/DPSP/HCH Branch. >sa$ine, R. P., Gelberg, L., Smi$h, M. H. A Lesser, J. 1233G5. Heal$h Care &%r $he H%meless* A 8amily Me#icine Pers"ec$ive. )merican Family +hysician <D* 2F3-2G=. Han !%sh, L., 8in le, M., Har$man, B., Le(is, C., Plumlee, L.A., A Sus %, M.A. 1233F5. Working for a Change. Fmployment of Consumers$Survivors in the Aesign and +rovision of Services for +ersons Who )re #omeless and &entally Aisabled. R%c ville, MD* Cen$er &%r Men$al Heal$h Services. Hicic, W. A Weber, C. 1233B5. #ypertension in +ersons Who )re #omeless. .e( L%r , .L* S$. Hincen$-s H%s"i$al, De"ar$men$ %& C%mmuni$y Me#icine. Wang, :. :., Ding, S., G%l#berg, :., B%c , B., Milner, R. A Rea#, S. 123325. He"a$i$is B an# Human 6mmun%#e&iciency Hirus 6n&ec$i%n in S$ree$ L%u$hs in !%r%n$%, Cana#a. +ediatric !nfectious Aisease 2ournal ,51B5* 2F4-2FF. Weinreb, L. 1233B5. Preven$ive Me#ical Care &%r H%meless Men an# W%men. 6n W%%#, D. 1:#.5 Aelivering #ealth Care to #omeless +ersons. /he Aiagnosis and &anagement of &edical and &ental #ealth Conditions. .e( L%r * S"ringer Publishing. Wei$,man, B. C. 123735. Pregnancy an# Chil#bir$h* Ris 8ac$%rs &%r H%melessness< Family +lanning +ersonnel :,1G5*29E-297, 2373. Whi$&iel#, C. L., !h%m"s%n, G., Lamb, A., S"encer, H., P&ei&er, M. A Br%(ning-8erran#%, M. 123975. De$%'i&ica$i%n %& 2,4BG Alc%h%lic Pa$ien$s Wi$h%u$ Psych%ac$ive Drugs. 2ournal of the )merican &edical )ssociation :8D12G5* 2G43-2G24. Wilhi$e, J. 1233B5. Public P%licy an# $he H%meless Alc%h%lic* Re$hin ing ;ur Pri%ri$ies &%r !rea$men$ Pr%grams. 6n R%ber$s%n, M. J. A Greenbla$$, M. 1e#s.5 #omelessness. ) 'ational +erspective. .e( L%r * Plenum Press. Williams, L. 1233B5. )ddiction on the Streets. Substance )buse and #omelessness in )merica. Washing$%n, DC* .a$i%nal C%ali$i%n &%r $he H%meless.

Winars i, J. !. A Dubus, P. 1233=5. )n )nalysis of ,= Federally Funded +rograms for #omeless !ndividuals with Co occurring &ental #ealth and Substance 1se Aisorders. .e($%n Cen$er, Mass.* !he Be$$er H%mes 8un#. Wi$$man, 8. D. A Ma##en, P. 123775. )lcohol *ecovery +rograms for #omeless +eople. ) Survey of Current +rograms in the 1. S. Washing$%n, DC* .6AAA, 8ebruary. W%%#, D. 1:#.5 1233B5. Aelivering #ealth Care to #omeless +ersons. /he Aiagnosis and &anagement of &edical and &ental #ealth Conditions. .e( L%r * S"ringer Publishing. W%%#, D., Hal#e,, R., Hayashi, !. A Shen, A. 123345. Heal$h %& H%meless Chil#ren an# H%use#, P%%r Chil#ren. +ediatrics -=1=5* 7E7-7==. Wrenn, D. 123345. 8%%$ Pr%blems in H%meless Pers%ns. )nnals of !nternal &edicine ,,8* E=E-E=9. Wrigh$, J. D. 123345. !he Heal$h %& H%meless Pe%"le* :vi#ence 8r%m !he .a$i%nal Heal$h Care &%r !he H%meless Pr%gram. 6n Bric ner, P.W. e$ al. 1:#s. 5 1nder the Safety 'et. /he #ealth and Social Welfare of the #omeless in the 1nited States. .e( L%r * W.W. .%r$%n. Wrigh$, J. D., A Weber, :. 123795. #omelessness and #ealth. .e( L%r * McGra(-Hill. Wrigh$, J., R%ssi, P., Dnigh$, J., Weber-Bur#in, :., !essler, R., S$e(ar$, C., Ger%nim%, M. A Lam, J. 1237E5. Heal$h an# H%melessness in .e( L%r Ci$y. R%ber$ W%%# J%hns%n 8%un#a$i%n. Wunsch, D. 12337a5. Can Manage# Care W%r &%r H%meless Pe%"le< Gui#ance &%r S$a$e Me#icai# Pr%grams. .e( L%r * Care &%r $he H%meless an# .a$i%nal HCH C%uncil, ;c$%ber. Wunsch, D. 12337b5. Searching &%r $he Righ$ 8i$* H%melessness an# Me#icai# Manage# Care. .e( L%r * Care &%r $he H%meless an# .a$i%nal HCH C%uncil, ;c$%ber. K%l%"a, A., Hahn, J., G%r$er, R., Miran#a, J., Wl%#arc,y , D., Pe$ers%n, J., Pil%$e, L. A M%ss, A. 1233G5. H6H an# !ubercul%sis 6n&ec$i%n in San 8rancisc%Is H%meless A#ul$s. 2ournal of the )merican &edical )ssociation :3:1=5* GEE-G=2. Re$urn $% $he !able %& C%n$en$s, ASP: H%me Page, %r HHS H%me Page.