Shelter Status and Risk for Mortality Dennis Culhane, PhD Director of Research, National Center on Homelessness Among Veterans Dana and Andrew Stone Professor of Social Policy, School of Social Policy and Practice, University of Pennsylvania

Unsheltered Homelessness Relative to their sheltered counterparts, people living in unsheltered situations are disproportionally burdened by poor health Physical symptoms and chronic health conditions1-4 Cognitive and mental health conditions2,3,5,6 Substance use disorders3,6-8 Co-occurring mental health and substance use disorders7 Increased risk of premature death9 Previous studies of unsheltered populations have used small samples, often limited to service users or certain geographic areas 100,000 Homes Campaign identified sheltered and unsheltered persons in participating communities and assessed their housing and health using standardized instruments10

Study Objectives To identify correlates of unsheltered status To assess the relationship between unsheltered status and increased risk of mortality

Methods Potential Correlates Sample & Analysis Climate Demographics Duration of homelessness Institutional history Income Mental health Substance use Sample: 25,489 respondents to 100,000 Homes Campaign Sheltered Unsheltered Analysis: mixed effects logistic regressions with community entered as random effect Potential Correlates Climate (avg. state temp. in Jan.) Demographics (sex, age, race/ ethnicity, education, Veteran status) Duration of homelessness Institutional history (incarceration, foster care) Income (employment, entitlements, informal) Mental health (history of mental health treatment, involuntary commitment) Substance use (alcoholism; history of drug/alcohol abuse, IV drug use, treatment)

Respondents’ Characteristics Sheltered (n=11,728) Unsheltered (n=13,761) p Living in cold climate 69.1 48.7 <.001 Male 70.2 75.6 Non-Hispanic white 32.9 36.7 Education <High school 29.3 34.9 High school/GED 41.8 41.0 Postsecondary 28.9 24.1 Veteran 15.2 16.4 .006 Years spent homeless <1 31.1 18.6 >1 year 69.0 81.4

Respondents’ Characteristics Sheltered (n=11,728) Unsheltered (n=13,761) p History of incarceration 73.8 82.0 <.001 History of foster care 14.5 17.3 Employment income 24.6 21.7 Entitlement income 66.7 61.6 Informal income 10.4 27.7 Involuntary psychiatric hospitalization 19.2 24.0 Alcoholism 10.2 23.0 History of drug/alcohol abuse 61.9 68.6 History of IV drug use 15.8 21.2 History of substance abuse treatment 45.1 47.2 .001 Increased mortality risk 56.1 59.3

Increased Odds of Unsheltered Status Shelter Status Increased Odds of Unsheltered Status

Decreased Odds of Unsheltered Status Shelter Status Decreased Odds of Unsheltered Status

Premature Mortality Risk Sleeping in unsheltered situation for ≥6 months and ≥1 high risk condition(s): Trimorbidity of substance use, severe mental illness, chronic medical illness Intensive health care service use >60 years of age HIV/AIDS Liver or kidney disease History of frost bite, hypothermia, immersion foot Trimorbidity of substance use (past or present), severe mental illness (past involuntary psychiatric hospitalization), chronic medical illness (past or present heart disease, diabetes, asthma, emphysema, cancer, hep C, TB) Intensive health care service use (hospitalization in past year or ≥3 ED visits in past 3 months)

Premature Mortality Risk Decreased Odds of Mortality Risk Increased Odds of Mortality Risk

Shelter Status & Mortality Risk Non-Hispanic white ▪ No high school diploma ▪ Veteran status ▪ Incarceration ▪ Informal income ▪ Longer duration of homelessness ▪ Increased odds of unsheltered status and mortality risk Decreased odds of unsheltered status AOR for transgender as correlate of increased mortality risk (1.48, 95% CI .97-2.27) is not quite stat. sig. (p=.069), presumably due to small sample size (N=102) Female sex Transgender Postsecondary education Entitlement income Increased odds of mortality risk

Conclusions Interventions to prevent unsheltered status—including assisting individuals in their transitions from incarceration or military service—may decrease risk of premature mortality Both women and transgender individuals appear to be at increased risk for premature mortality, which may be related to greater exposure to trauma, calling for a trauma-informed approach to the provision of care for this population

For more information Montgomery, A. E., Szymkowiak, D., Marcus, J., Howard, P. & Culhane, D. (2016). Homelessness, Unsheltered Status, and Risk Factors for Mortality: Findings from the 100 000 Homes Campaign. Public Health Reports, 131(6), 765–772. doi:10.1177/0033354916667501 http://journals.sagepub.com/doi/abs/10.1177/0033354916667501

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