reprinted from Issue 21, Fall 2015 of Frontiers of Medicine (PDF)
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When Margot Kushel, MD, was a medical resident in the late 1990s, half the patients she admitted to San Francisco General Hospital and Trauma Center (SFGH) were homeless.
"We'd patch them up for a couple of days, discharge them to the street, and a few days later, they'd be back," said Kushel. "I thought, ‘There's got to be a better way.' Homelessness is ethically intolerable, but it's also a really bad business decision. People who are homeless use the most expensive parts of the health care system."
Kushel has devoted her career to solving this problem. She used her early research on homeless patients' high health care utilization to advocate for a significant expansion of the City and County of San Francisco's medical respite program – which provides a safe place for homeless patients to heal – and served as the program's founding director. She also helped evaluate the effectiveness of permanent supportive housing, which provides subsidized housing with onsite supportive services like counseling and medical care for chronically homeless people.
Now she and her colleagues are studying homeless adults aged 50 and older, who make up a growing segment of the homeless population. The median age of homeless adults not in homeless families is 50. Living on the street also contributes to premature aging; many homeless people in their 50s have physical and cognitive disabilities more commonly seen in people in their 70s or 80s.
With funding from the National Institute on Aging (NIA), Kushel is leading the Health Outcomes for People Experiencing Homelessness in Older Middle Age (HOPE-HOME) study.
Her team enrolled 350 homeless people in Oakland who are age 50 and older, recruiting participants from homeless shelters, free food programs, recycling centers and homeless encampments.
St. Mary's Center (stmaryscenter.org), a nonprofit that serves at-risk seniors in Oakland, is a key research partner and provides space for Kushel's project. The initial interview lasted three to four hours, and included questions about participants' life experiences from childhood to the present, how they became homeless, current health conditions, substance use, mental health problems, health care utilization, experience of violence, and social support. Participants also receive neuropsychiatric testing to assess cognitive function, mobility and strength. Every six months, they return for an hour-long follow-up interview and testing. Kushel plans to track participants for at least three years.
Getting to Know You
The HOPE-HOME study has a follow-up rate of 83 percent for each study visit, which is remarkable given that many participants lack phones and mailing addresses and also struggle with substance use disorders and mental health problems. The key, said Kushel, is building relationships.
"The people in our study are research participants, not subjects," said Kushel. "They are doing us a favor, and we treat them with enormous respect and gratitude for what they're teaching us. Many also appreciate the opportunity to tell their story and participate in something larger than themselves.
"We also build relationships with their contacts, whether it's their family members, pastor, bartender or parole officer, and enlist them in helping us get the participant to return for interviews," she said. She hires research team members who have relevant experience working with vulnerable populations. "My study staff have a certain amount of fearlessness – they are savvy, and if it's safe, they'll walk into an abandoned building if they think one of our participants is there," she said.
As a token of appreciation, participants receive pharmacy or supermarket gift cards after completing each interview, as well as smaller gift cards monthly for updating their contact information by phone or in person.
One of the study's early findings is that 43 percent of participants were never homeless until their 50s. "These are people who worked their whole lives doing physical labor," said Kushel.
"Often, people’s health makes it hard to keep doing such demanding jobs, and when they lose their jobs, they find that they can’t maintain their housing in this expensive housing market."
Many participants have experienced childhood adversity, including physical or sexual abuse, neglect, head trauma, or loss of a parent to death or incarceration. "Our participants have had incredible amounts of adverse childhood experiences," said Kushel. "They’ve also had very poor access to health care and food, and often have a history of substance use, which some initiated as a way to help them cope with tremendous trauma."
Kushel recently received another NIA grant to study whether participants might be able to secure stable housing through family members. She also plans to submit proposals to test whether advance care planning tools could help participants ensure that their wishes around end-of-life issues are followed, and develop new ways to connect homeless seniors with primary care.
"Everything we learn in medical school is irrelevant if someone leaves your office and heads back to sleep on the street," said Kushel. "My big goal is to figure out how prevent people from becoming homeless, or at the very least, how to get them housed again very quickly."