John, 42, who has Type 2 diabetes, is being seen in the ED for a foot injury. His bicycle, his only means of transportation, is stolen while he is being treated.

Tim, a homeless 22-year-old with schizophrenia and alcohol abuse, can’t afford his medications and drinks to help ease his symptoms.

Homelessness is increasing in the United States.¹ While homelessness is considered a temporary condition and the number of homeless is difficult to measure, estimates are that 3.5 million people (including 1.35 million children) experience homelessness in a year.^2,3 Half of the homeless people on any given night in this country need minimal assistance to find a home. Their homeless condition is relatively short-lived.¹ Of greater concern are those who are homeless repeatedly and who have complex health care conditions; this half of the homeless population requires multiple coordinated interventions. In this latter group, the homeless mentally ill are the subgroup that will be the focus of this article.

What is homelessness?

In the United States, a person is considered homeless when he or she lacks a permanent nighttime residence; sleeps primarily at a shelter or institution providing temporary quarters; or regularly sleeps in a place not intended for human habitation.² In addition, nurses should be alert for homelessness in someone who has recently been discharged from a treatment facility or jail or who is fleeing domestic violence.⁴ Asking “Where will you sleep tonight?” or “Where did you sleep last night?” will help the nurse to screen for homelessness.

Imagine having no place to call home: no closet for your clothes, no refrigerator for food or medication, no place to bathe, no ready access to drinking water, no place to cook, and never feeling safe. How does one keep track of medications, health care supplies, or personal care items with no place to store them? To what address do others send you mail? What address do you list on a job application? At what phone number might you be reached? Imagine all these circumstances complicated by trouble thinking or feeling normally. Those who have been homeless for a longer time experience depersonalization, or loss of a sense of self, further affecting mental health and the ability to function.⁵ Mental illness can predispose people to homelessness and make dealing with the problems of homelessness much more difficult.

It’s estimated that 20% to 30% of the homeless population have a severe and persistent (chronic) mental illness (while only 5% of the 4 million people with serious mental illness are homeless).^6,7 The prevalence of alcohol abuse is about six to seven times greater in the homeless population than in the general population.⁸ While the numbers are difficult to estimate, a dual diagnosis of serious mental illness and alcohol or substance abuse is not uncommon.⁸

People with severe and persistent mental illnesses (such as schizophrenia, bipolar disorder, or major depression) are more vulnerable to homelessness.^3,8 People with these diagnoses are also more likely to have comorbid health problems, such as diabetes, respiratory infections or asthma, malnutrition, dental caries, sexually transmitted diseases, or thyroid dysfunction.^3,8 Foot problems are common because walking is the primary means of transportation. While mental illness and chronic medical conditions present management challenges for anyone, the conditions of homelessness make management nearly impossible.

Historical context

Historically, those with mental illness symptoms have been stigmatized and marginalized by society.⁹ The problem of homelessness increased with deinstitutionalization in the early 1960s. As formerly institutionalized mentally ill individuals were released into communities, support services were not adequate, and medication alone did not fully alleviate symptoms or prepare people with the skills needed to reintegrate into a community. In the 1980s, homelessness began to increase with cuts in federal programs, and the most vulnerable, such as those with severe mental illnesses, were most affected.⁶ The stigma of mental illness compounded the stigma of homelessness, making it more difficult to access needed services.

Nationally, the McKinney Act of 1987 attempted to address the growing problem of homelessness, particularly for those with severe and persistent mental illness or substance abuse problems. Later revisions to the act incorporated a continuum of care approach and more recently provided for the creation of “safe havens,” supportive housing for more difficult-to-treat clients.⁵ In 2003, the U.S. Department of Health and Human Services released a plan to end homelessness in the next decade.¹⁰ A goal of ending homelessness represents a significant paradigm shift from previous approaches focused on emergency shelters, transitional housing, and sobriety-based programs, primarily run through charitable organizations, to a multisystem approach involving mainstream organizations with an expectation of ending chronic street homelessness.¹¹

The focus of treating mental illness in the community has changed each decade since deinstitutionalization.¹² Initially, in the 1960s, the focus was on preventing problems for high-risk individuals; nursing roles were limited. The 1970s used a biomedical model that emphasized brain dysfunction; nurses became involved in medication management and psychotherapy. The 1980s focused more on developing a comprehensive system of care and coordinated services; nurses became more involved as service coordinators and case managers. Since the 1990s, the approach has become more individual and patient-focused, emphasizing culturally competent care and consumer participation; nurses have an opportunity to use all facets of the nursing role in this setting.¹² These changes over time in service delivery and organization relate directly to care of the homeless mentally ill because most services for this population are community-based.

Nursing care

Nurses caring for the homeless mentally ill client face many challenges. The needs of the client are multifaceted and complex; care is rarely as simple as following existing standards. First, nurses need to increase their knowledge of this special and diverse population. Second, as with all nursing interactions, thorough assessment is needed. Third, the nurse-client relationship needs to be developed. Even though contacts may be short and intermittent, trust is essential to collecting accurate information and setting mutual goals. Fourth, immediate needs, as perceived by the client, must be addressed as much as possible. Fifth, nurses need to become familiar with and establish links to community resources.

Increase knowledge: Even the most seasoned nurse needs to become knowledgeable about the special needs of the homeless mentally ill population. Standard protocols will look different when applied to this population. Nurses need to understand the context of their homeless lifestyle and determine what support systems are available to the person. By raising awareness and educating others about the needs of this population, nurses will begin to dispel misconceptions and myths.

However, nurses may sense that the community resource system is unresponsive or lacking. The apparent futility of the situation may feel overwhelming, leading the nurse to rationalize that spending time with the client is useless. By understanding the face of homelessness, the quality of care the nurse provides to those who are members of this population will improve.

Perform an assessment: Physical condition — People who are mentally ill and homeless are at increased risk for multiple and complex health problems such as those mentioned previously. One tool available immediately to any nurse is careful observation: noting skin color and hydration, lesions, respirations, gait, and level of personal care.

Mental status: Noting the level of orientation (to person, place, time) and of speech characteristics (speed, content, clarity) can give information about cognitive functioning and emotional state. Being alert for signs of hallucinations, delusions, and paranoia will help determine mental status. The nurse also should make an attempt to assess any potential for violence that may arise from psychotic thought processes. Hopelessness, helplessness, shame, and despair are feelings that evolve in homelessness as one feels less and less control over life. The stressors of a homeless lifestyle may result in behavior that looks like a mental illness. By asking clients how long they have been homeless and in what context, the nurse can begin to determine the variables that affect their mental status.

Spirituality. Exploring what gives meaning to an individual’s life can elicit strengths as well as spiritual concerns. Such a discussion may include spiritual faith as well as beliefs, attitudes, and values. Identifying client strengths — ways the person has dealt with adversity in the past, spiritual or other sources of meaning and purpose, personal characteristics that have helped him or her persevere — can empower and restore hope.

Substance use and abuse. The risk for substance abuse among people who are homeless and mentally ill leads the prudent nurse to screen for alcohol and substance use. Ask about alcohol and street drug use/history and observe for signs and symptoms of possible alcohol and substance intoxication or withdrawal. Symptoms of alcohol withdrawal, such as tremors or confusion, may need to be differentiated from those that also might be caused by mental illness or the prescriptions used to treat mental illness. The National Health Care for the Homeless Council has developed a tool that nurses will find useful to help the health care team evaluate clients and plan a reasonable level of care.¹³ (See www.nhchc.org and look under “Triage Levels.”)

Develop relationships and trust through communication: Because trust may be low, time is needed to establish a relationship. Listen carefully to what the person says and does not say. Try to understand the individual’s perspective: what he or she perceives to be the problem as well as the possible solution. This may be different from the perspective of the health care provider. However, it is vital to address the perception of the individual, both to establish a relationship and to find a point of agreement for any intervention. A client’s making eye contact with you may indicate growing trust. However, clients may fail to make eye contact because of cultural differences, lethargy, low self-esteem, shame, or suspiciousness.

The plan of care needs to be a cooperative activity involving both the client and the nurse who is oriented to the person’s perceived need. The plan itself must include an understanding that the client may not have everything needed to follow the plan of care (e.g., transportation to appointments, refrigeration for medications, storage space for health care supplies). This will require the nurse to address practical concerns that often aren’t an issue with other populations.

Address immediate needs: Begin the assessment by first addressing and acting upon the expressed need of the client whether physical, emotional, social, or spiritual.¹⁴ Be open to hearing about needs that are clearly based on survival such as need for food, shelter, and access to medications. Because of a probable long history of recurrent homelessness as well as severe mental illness, patients may have untreated symptoms that may make it difficult for them to meet basic survival needs. A person who is homeless is in a survival mode. The focus is on the present, more than the past or the future. The next meal, a place to sleep tonight, or alleviation of symptoms may be the major concern. It is difficult to remember the past or envision a future when you are only trying to survive. Nurses can help by understanding the homeless person’s perspective and need to deal with the here and now. Help the individual with immediate needs, then move to longer-term goals. For instance, a person with alcoholism could be referred to “safe haven” housing, which does not require abstinence from alcohol although substance use is not allowed on the premises. Because of previous experiences that were not always positive with health care providers, the client may be guarded in responses and may refuse a thorough assessment. By keeping the initial screening and assessment short and unobtrusive, a more complete assessment may be possible later.¹⁵

Establish links and advocate: Individually focused interventions are critical, but the nurse should consider a community-systems approach when planning care with the client. Individually focused interventions address the client’s individual needs such as medical treatment for an infection. In contrast, a community-systems approach is a process through which agencies and individuals involved in the delivery of services to the targeted population work together to address the range of needs and services for a whole population (e.g., the mentally ill homeless population). This may include such things as access to services, transportation, communication between service providers from different agencies, continuity of care, or payment for service.

Chronically homeless individuals who are mentally ill likely have had previous contacts within the health care system and may continue the contact, even when homeless.⁹ Those with mental health or substance abuse problems are also likely to have some type of health care coverage or be eligible for public assistance.¹⁰ The nurse can identify and link the client with the resources to continuity of care.

Discharge planning is a key element to reducing homelessness among people with mental illness. Regardless of the site (e.g., acute care, jail, long-term care facility), the discharge plan should be developed by a team made up of the discharge planner, housing professionals, health care staff, mental health professionals, outreach workers, and other community partners as well as clients themselves. Evidence-based programs know that stabilizing housing is a prerequisite to success of other services.¹⁵ Intensive case management is necessary to coordinate and access services. Whenever a client presents for services, access to both housing and case management services is essential.¹⁵ Realizing this, the nurse can point a homeless mentally ill client toward those services and encourage a team approach.

Effective case management facilitates follow-up and reduces fragmentation of services, which often is a problem because health care for the homeless mentally ill person is usually crisis-oriented and intermittent.¹⁶ Clear identification of case manager responsibilities (both who is responsible and what he or she is responsible for) and agreement that follow-up will occur are essential for homeless mentally ill individuals, who experience multiple barriers to care. Team members need to state what their responsibility and action will be with the individual client; this approach will initially take time, but will be clear and save time in the long term. Documentation of the agreement, with a copy to each member, will enhance accountability. A comprehensive plan such as this requires an integrated, coordinated, and positive working relationship among care providers as well as system administrators.¹⁷

Systems strategies

Homeless mentally ill people need a broad range of services and specialized assistance from several community health and social services agencies. Unfortunately, most community-based service systems are fragmented and can be a serious obstacle to care.¹⁸

At a community level, linkages among agencies and individuals to stop homelessness can include interagency coalitions, co-location of services (“one-stop shopping”), interagency management information systems, uniform applications, eligibility criteria and intake assessments, and interagency service delivery teams. No single strategy will lead to improved delivery of service and continuity of care, but each of these has been shown to reinforce service delivery.¹⁸

Nurses can become active in the community by working with organizations, agencies, government officials, and policy-makers to end homelessness through a comprehensive and integrated system that includes outreach and intensive case management. And nurses can have an impact on each homeless person they encounter by remembering that stable housing and quality case management are top priorities.