1. 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

2. 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

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

4. 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)

5. 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

6. 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

7. Increased Odds of Unsheltered Status
Shelter Status
Increased Odds of Unsheltered Status

8. Decreased Odds of Unsheltered Status
Shelter Status
Decreased Odds of Unsheltered Status

9. 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)

10. Premature Mortality Risk
Decreased Odds of Mortality Risk
Increased Odds of Mortality Risk

11. 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 ) 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

12. 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

13. 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 Homes Campaign. Public Health Reports, 131(6), 765–772.
doi: /

14. References
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Leopold J, Ho H. (2015). Evaluation of the 100,000 Homes Campaign. Washington, DC: Urban Institute.