The Aging of the Homeless Population: Fourteen-year Trends in San Francisco Judy Hahn, Margot Kushel, David Bangsberg, Elise Riley, Andrew Moss

Background Changes in homelessness in the US 1930’s –Young transient men in search of work 1950’s to 1970’s: –“Skid row”, single older low income white men, unstable housing (flophouses, SROs, missions) 1980’s onward: –Loss of SRO hotels and affordable housing in urban centers –Shelter capacities nationwide increased –More families and minorities, younger –Poorer living conditions compared to Skid row Rossi, American Psychologist 1990

Background In San Francisco, Continued decline in the number of low cost housing and SRO units in the 1990s –Units lost due to earthquakes, fires and gentrification The response to homelessness –Establishment of emergency shelters and soup kitchens and large shelters with services (1980s) –Policing programs (mid 1990s) –Supportive housing (some late 1990s, most starting 2004), leveraging Federal $ Ilene Lelchuk, San Francisco Chronicle September 7, 2003.

Objectives We have studied HIV and TB in the homeless and marginally housed in San Francisco from 1990 to In this analysis, we sought to examine changes in the homeless population over time in: –Demographics – age, race, sex –Housing –Health status –Health service utilization –Drug use

Methods Wave 2: Wave 1: Wave 3: Wave 4: 2003 Four cross sectional studies (“waves”) conducted at shelters and free meal programs Over the entire study period we conducted sampling at a total of 13 shelters and 8 free meal programs

Methods Inclusion criterion: Age 18 and older 45 minute interviewer-administered survey HIV antibody testing and counseling, TB testing (waves 1 and 2) $10-$20 remuneration for participating Anonymous

Analysis We included in this analysis: Shelters and meal programs that were sampled in at least ¾ of the “waves” –4 shelters and 2 free meal programs (78% of those sampled) Study participants who were “literally homeless” in the prior year –87% of those sampled

RESULTS Demographics (n=3534) Male77% Race African American52% Caucasian33% Other, or mixed race15% Veterans (of the men)33%

Substance use and mental illness Psychiatric hospitalization, ever23% Crack use, ever63% Injection drug use, ever38% Heavy alcohol use, prior 30 days35% At least one of the above80% Two or more of the above49%

Age trends

Age trends by group 1% overall >= age 65

Demographics

Housing

Self-reported health

Hospital utilization

Drug/alcohol use

Aging in 6 cities

Conclusions and Implications The homeless population is getting older. This aging indicates that the homeless population is static and not regenerating itself in time. –A dynamic population would have as many new young people joining the population as old people leaving the population and would have a constant age over time. Good news: resources spent on housing the homeless now may be finite.

Conclusions and Implications Of concern: the homeless will increasingly need health care services -- either to control their chronic disease or to treat the more serious outcomes of unmanaged chronic disease. Control of chronic disease will be very difficult to deliver to persons not in housing.

Recommendations Provide supportive housing with onsite medical services for those age 50 and older in order to intervene in the course of chronic disease early Base on the model of San Francisco Department of Public Health’s Direct Access to Housing –Houses 1000 people in 12 buildings –3 buildings dedicated to seniors –Psychiatrists, nurses, physicians assistants –Case worker : resident ratio: 1:20 –80% stay at least 1 year

Acknowledgments REACH field staff and study participants Grants: NIH 5R01DA004363, 1R01MH054907, R01DA010164, and K08HS Contact info: Judy Hahn, Ph.D. Assistant Professor EPI-Center, Department of Medicine University of California, San Francisco San Francisco, CA

Bonus data! Younger vs. older homeless 2003 data wave Age<50 (n=384) Age  50 (n=140) Median age (IQR)40 (33-45)53 (51-58) Sex=Female*25%15% Race/ethnicity* African American Caucasian Mixed/other 43% 34% 23% 55% 28% 17% *p<0.05

Younger vs. older homeless Housing Age<50 (n=384) Age  50 (n=140) Median total months homeless (IQR)* 36 (9-76)48 (18-108) Median years since first homeless (IQR)* 6 ( )7 (3-16) Lived on streets/outdoors, prior year51%50% Lived in shelter, prior year82%87% Lived in SRO, prior year40%46% Lived in own apt, prior year*23%10% *p<0.05

Younger vs. older homeless Health Health issue, prior yearAge<50 (n=384) Age  50 (n=140) Visited ED49%44% Admitted to hospital29%26% Mental health admission8%5% Any days ill (prior 30)35%36% Chronic health problem Heart disease*3%10% Hypertension*14%34% Diabetes6% Emphysema*3%9% Asthma13%15% *p<0.05

Younger vs. older homeless Substance use 30 day useAge<50 (n=384) Age  50 (n=140) Heavy drinking28%23% Injected drugs*18%9% Drugs used: Crack cocaine32%29% Powder cocaine7%4% Heroin13%8% Methamphetamine*18%8% *p<0.05

Summary of bonus data Many older homeless persons are using drugs or drinking heavy amounts of alcohol, though somewhat fewer than younger homeless persons Older homeless persons have the same rate of ED visits and inpatient hospitalizations though higher rates of chronic disease