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6. Summary and Recommendations
Pages 136-162

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From page 136...
... 99-129: 1. evaluate whether existing eligibility requirements for health care services actually prevent homeless people from receiving those services; 2.
From page 137...
... The committee also commissioned 10 papers on specific areas of concern, such as the legal aspects of access to health care and the problems of providing health care for homeless people in the rural areas of America. Committee members, assisted by a study staff of two professionals, reviewed what is known about the health of homeless people, as evidenced in the scholarly literature, reports of public and private organizations, and in particular- the ongoing evaluation of work of the 19 Health Care for the Homeless projects funded by the Robert Wood Johnson Foundation and the Pew Memorial Trust.
From page 138...
... The homeless have also been stereotyped as uniformly mentally ill, in part because severe disorders such as schizophrenia are conspicuously overrepresented among homeless individuals on the street. Most studies of mental illness among the homeless reveal that 30 to 40 percent of the adults show evidence of some type of major mental disorder; 15 to 25 percent acknowledge having been hospitalized for psychiatric care in the past.
From page 139...
... 3. Deinstitutionalization The policy of deinstitutionalization, which characterizes the way state mental health systems have been administered since the early 1960s, is clearly a contributing factor; in addition, a policy of noninstitutionalization that is, not admitting people for psychiatric care except for very brief periods of time has further exacerbated the problems of mentally ill homeless adults.
From page 140...
... With regard to financial access, homeless people generally face the same problems as do other poor and near-poor people: eligibility requirements for financial assistance, benefit levels well below the current market price for health care, and a reluctance of health care providers to supply low-cost treatment (especially in specialties like obstetrics, for which malpractice premiums are extremely high)
From page 141...
... Meetings were held with local officials, service providers, volunteers, and advocates for the homeless; numerous reports of other programs were evaluated. Of particular interest were the efforts of the 19 Robert Wood Johnson Foundation-Pew Memorial Trust Health Care for the Homeless projects, because they represented a particular targeted approach to providing health care services to homeless people.
From page 142...
... Although the main issue is housing, for some homeless people, such as the chronically mentally ill, the mentally retarded, the physically disabled, those with histories of alcohol and drug abuse, the very young, and the very old, housing alone may not be sufficient. They need the kind of social support systems and appropriate health care that would
From page 143...
... Although there are some chronically homeless people, many poor people slip in and out of homelessness. Extending health care services to the homeless while continuing to deny them to the domiciled poor is, thus, not only administratively impractical and bureaucratically cumbersome but also ethically difficult for those who provide or finance health care services.
From page 144...
... Coordinated efforts to address housing, income maintenance, and discharge planning are needed to prevent and reduce homelessness. Housing The problem of homelessness will persist and grow in the United States until the diminution and deterioration of housing units for people with low-incomes are reversed and affordable housing is made more widely available.
From page 145...
... 3. Many individuals and families only require a stable place to live, but some, especially the mentally ill, alcohol and drug abusers, the physically handicapped, and those with chronic and debilitating diseases, need housing and an array of professionally supervised supportive services in order to remain in the community—and, in many cases, to enable a transition to independent living.
From page 146...
... Augmented outreach efforts to identify and assist the homeless and those at risk of becoming homeless (especially those about to be discharged from institutions) could reduce and prevent homelessness (see the section Health Care and Related Services in this chapter for a more complete discussion of outreach)
From page 147...
... Discharge Planning Inadequate discharge planning coupled with inadequate communitybased support and housing can cause homelessness. State, local, and private mental hospitals; inpatient substance abuse facilities; facilities for mentally retarded and developmentally disabled people; general hospitals; nursing homes; and correctional facilities all share a common responsibility to help arrange access for their clients or patients to appropriate and affordable postinstitutional living arrangements, including supportive services when necessary.
From page 148...
... The committee recommends that public and private institutions adopt and observe discharge planning processes that ensure in advance of discharge to the extent possible- that clients have suitable living arrangements and necessary supportive services. To help increase the availability of adequate postdischarge arrangements, such institutions must work to improve communications and coordination with organizations that provide postdischarge ambulatory care, home health care services, and other relevant community agencies and organizations (Chapter 54.
From page 149...
... Such health care should include, for example, either by direct provision or by contractual agreement, primary health care services such as pediatric care (including well-baby care and immunizations) , prenatal care, dental care, testing and treatment for sexually transmitted diseases, birth control, screening and treatment for hypertension, podiatric care, and mental health services.
From page 150...
... Furthermore, ways should be found to expand the VA's outreach effort to include homeless veterans who are not chronically mentally ill. · Because the VA has already shown itself to be willing to assist in preventing homelessness by serving those "at serious risk" of becoming homeless, the VA should consider expanding its efforts to include outreach to such institutional settings as mental hospitals, acute-care hospitals, and prisons so that assessment and placement can be arranged before people are released from such facilities.
From page 151...
... 99-319) , which currently applies only to mentally ill people in residential settings, should be amended to support protection and advocacy
From page 152...
... Because many homeless women are pregnant and a growing number of homeless people are children, it is especially important that the WIC Program be strengthened in order to address comprehensively the nutritional needs of pregnant women and young children. Mental Health, Alcoholism, and Drug Abuse Alcohol-related problems and mental disorders are the two most prevalent health problems among homeless adult individuals, and drug abuse appears to be on the increase.
From page 153...
... and because there are certain basic similarities in efforts to provide treatment, those recommendations that address elements common to programs that treat individuals with all three diagnoses are identified before those recommendations relating to individuals with a specific diagnosis. In seeking to resolve the very complicated interrelationships among homelessness and mental illness, alcoholism, and drug abuse, the following services should be included: · targeted outreach services directed at homeless individuals suffering from mental illness, alcoholism, or drug abuse; ~ supportive living environments encompassing programs ranging from the most structured to the least structured; this is necessary so that as the individual improves, progress can be made through several stages of decreasing support and on to independent living, when possible (some will need various support services throughout their lifetimes)
From page 154...
... The committee recommends that the first priority in addressing the problems of the mentally ill homeless must be to ensure the adequate availability of clinical services (including professionally supervised supportive housing arrangements) at all levels.
From page 155...
... In addition, Congress should consider extending the provisions of the Stewart B McKinney Homeless Assistance Act of 1987 that currently deal with mental illness and the treatment of alcoholism and drug abuse in individual adults to cover homeless parents, children, and adolescents as well.
From page 156...
... 100-77 give high priority to its review of all programs that might be of assistance in helping subpopulations among the homeless, irrespective of whether such programs are specifically directed toward helping homeless people. The council should: · conduct an extensive review of such support programs, primarily to identify programs that are providing or that could provide help to subpopulations among the homeless; · review joint federal-state efforts, such as state veterans homes with partial federal funding, that, although not targeted directly to the homeless, might help many homeless people; · publicize successful efforts to help the homeless as a means of encouraging other groups to develop similar programs in their communities; and · consider ways and means of extending or enhancing the funding for programs that are deemed effective in relieving or preventing homelessness until the current prevalence of homelessness is substantially reduced.
From page 157...
... Because the homeless are an especially vulnerable subpopulation of poor people, the committee believes that such programs would be of similar benefit to this group. It recognizes that because the population of homeless families includes some of the most hopeless and alienated among the poor—and because they are more likely to move from place to place there may be obstacles to participation in such programs; therefore, the committee recommends the following: · Federal support for enriched day care and Head Start programs should be expanded and coupled with the development of outreach efforts to encourage homeless parents to take advantage of enrichment programs for themselves, their infants, and their young children.
From page 158...
... · Once a model code is developed and after a reasonable amount of time has passed for compliance to be obtained, the federal government should adopt the standards as a condition for receipt of Emergency Assistance payments or other federal assistance, including Federal Emergency Management Agency funds. However, Federal Emergency Management Agency funds should be made available to assist existing shelters to achieve compliance with the standards.
From page 159...
... This is especially critical in regard to malpractice and liability insurance because it is already difficult to recruit volunteers and to create university affiliations for training in the settings in which homeless people are served; these programs can ill afford to bear the additional burden of excessive insurance premiums or the potential loss of coverage. Research Many questions about the health of the homeless remain unanswered.
From page 160...
... The National Institute of Mental Health and the Robert Wood Johnson Foundation are to be especially commended for the initiatives that they have taken in encouraging and supporting research in the financing, organization, and delivery of services to the severely mentally ill. Public and private research funding organizations should encourage research into the dynamics of homelessness, the health problems of homeless people, and effective service provision strategies.
From page 161...
... 1987. Progress Report on the Veterans Administration Program for Homeless Chronically Mentally Ill Veterans.


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