Staff (S) and PEH described a variety of different unmet and common health needs of adults experiencing homelessness. Four primary themes of health needs were identified across the two groups: (1) untreated mental illness, (2) untreated substance use disorder, (3) food and nutrition insecurity, and (4) physical injury and disability. However, staff participants more frequently discussed clinical diagnoses and treatments while PEH described their personal experiences.
Twenty-nine of the 34 participants (9 staff and 20 PEH) expressed concerns about a lack of available and accessible mental health and psychiatry services for unhoused people. Staff and PEH described a high prevalence of exposure to trauma both prior to becoming homeless and while experiencing homelessness. Staff participants described mental health needs using clinical language for untreated mental illnesses, such as psychotic disorders and mood disorders. As one noted:
“I would say that there is a lot of those individuals, that present depressive and anxiety symptoms. I would say that they should somehow get some help so that they improve those symptoms. ” (S10).
PEH grounded their mental health concerns in their living conditions and negative experiences of homelessness. One explained the unique and enduring stress of being homeless:
“It makes me crazy being outside […] The stress of being homeless makes people crazy. They need a therapist or psychiatrist. ” (PEH03).
Both staff and PEH identified a lack of available mental health providers for PEH. Reasons for this included that many local mental health care providers were not accepting new patients (ie had full panels), did not accept public health insurance, or were unable to provide care for individuals without insurance. Some staff participants expressed a desire for increased mental health services and support groups that are culturally and linguistically appropriate for the diverse population of unhoused patients, especially patients who are Spanish-speaking.
Untreated substance use disorder was described as an unmet or common health need by most staff participants and some PEH. Both staff and PEH posited a relationship between mental illness or trauma and substance use disorder among homeless patients. One staff member highlighted the lack of available substance use disorder treatment services at clinics for PEH:
“I think most clinics, you know, don’t have access to robust substance abuse treatment services.” (S10).
Another staff member described their understanding of substance use disorder as a mediator between chronic stress and insomnia:
“I’ve heard many homeless people tell me that’s why they use substances. Because they need sleep. They know they need sleep and they’re just so terrified of being attacked when they’re sleeping on the street that it’s the only way they can zone out enough to actually get a night’s sleep. ” (S05).
While staff generally acknowledged substance use disorder as an unmet health issue, PEH elaborated on specific challenges to changing their behavior after long-term use of substances such as marijuana, methamphetamines, heroin, and cocaine:
“I do use – I smoke a fair amount of pot, I do edibles, I just prefer smoking it, I’m not really sure why. It’s gross and it’s bad for you but for some reason. I do, I do use methamphetamine. ” (PEH21).
In addition to behavioral health needs, staff and PEH described chronic physical health needs. Many of these needs were similar to the most common health needs of the general, housed US population, such as obesity, diabetes, hypertension, and heart failure. However, staff and PEH frequently reported three physical health needs that were more specific to PEH: (1) food and nutrition insecurity, (2) physical injury, and (3) disability. PEH described having difficulty accessing healthy food, such as a lack of transportation to reach services that provide food. Staff and PEH agreed on the lack of nutritious food available to unhoused people. One homeless participant said:
“Nutrition is a big thing that I really worry about. Keeping an ice chest and stuff like that to keep everything at the proper temperature is really hard. ” (PEH21).
Physical injury and disability were commonly attributed to street violence or accidents. Staff participants described how disabilities can be health needs and barriers to accessing health care:
“Many of these people start out with cognitive or intellectual disabilities and then if they have deafness or blindness on top of that, you can just imagine how that complicates their ability to survive, much less access services.” (S05).
PEH often connected their injuries or disabilities to terrifying stories of fist fights, stabbings, and motor vehicle accidents they had experienced in the community. One said:
“I got stabbed by some white kids last year. I am very scared walking around. ” (PEH19).
Barriers to accessing health care
Staff and PEH identified three main themes of barriers to accessing medical and behavioral health care: (1) negative emotions and experiences with health care of PEH, (2) competing priorities of PEH, and (3) health care provider turnover.
Both groups spoke about the emotions of shame, stigma, fear, and a lack of trust or belief in clinical staff or the health care system among PEH. Stigma was linked to receiving behavioral health care, as one staff participant explained:
“There is that stigma that wanting to get mental health, is somehow, you don’t see it much because with primary care, you can see a wound or you can see anything that is happening with the health care of the person. But, with mental health, you can’t see. ” (S10).
PEH commonly recounted stories of prior negative experiences with health care, such as poor treatment from providers and staff at community-based health care clinics and at hospitals in San Francisco. One homeless participant expressed frustration about their previous experiences with providers:
“The way health care providers treat me is horrible. It prevents me from going back. They shame me because I am homeless but I choose to be out here […] I’m not an idiot. I don’t feel like I can get quality care. ” (PEH23).
Similarly, staff and PEH cited competing priorities as major barriers for PEH when scheduling and attending regular health care appointments. Examples included employment, food, and substance use. Time spent seeking work or income was the most commonly discussed competing priority. Both staff and PEH said that non-medical priorities prevented patients from attending appointments. One PEH commented:
“Well, sometimes it’s hard to keep up with appointments, if your like main goal is to survive. [ …] before going to an appointment, you had to feed yourself and then like you need transportation to get from one place to another. And if you like – if you don’t get a […] way to get to your appointment, you’re gonna be late or you won’t go. ” (PEH14).
PEH also noted that the lack of transportation was an additional barrier to accessing care.
Both groups noted provider turnover as a barrier to continuing to access health care, highlighting the importance of a primary care provider who is familiar with each patient’s history and life circumstances. One homeless participant spoke of this challenge in detail:
“Somebody like a doctor or a nurse that gets to know you and you have a rapport with her so she can evaluate if you’re doing worse or if you’ve progressed. See if you have a different one every time, she only goes to the question, goes and [writes it down]. You know, so many-there’s so many homeless people and so many-that we become this, you know, as long as they keep us alive, that’s the thing. ” (PEH20).
Staff participants focused on the implications of provider turnover on the behaviors and health outcomes of homeless patients, such as turnover leading to decreased medication adherence and unhealthy eating habits:
“So when we had different doctors like every other three months, then patients tend to fall into the cracks and they eventually stop coming or they don’t, I don’t know, they stop taking their medications and stuff like that and also they ‘re not eating healthy because they don’t have money to do so.’ (S07).
Recommendations for clinic improvement
Staff and PEH had many shared recommendations for community-based homeless health care services to reach an increased patient population, improve the quality of care, or expand available services. The four main themes of recommendations were: (1) building more trust and rapport with patients, (2) expanding clinical outreach, (3) providing health education, and (4) expanding drop-in services to address basic needs.
Both staff and PEH spoke of the need for staff to build more trust with their homeless patients through practicing empathy and respect. One PEH, with the assistance of a staff translator, said:
“More patience with clients. More respect. Staff needs to give more respect to clients. ” (PEH03).
Staff participants identified a lack of patience and respect for homeless patients among some staff members:
“But yeah, I understand that patients or clients can be difficult, but given where we work, we kind of have to take-we have to kind of to understand them and understand where they’re coming from and maybe they’re having a really, really rough day […] I think what’s preventing patients from coming back or new patients feel uncomfortable […] would be receiving downstairs and upstairs, the way patients are treated. ” (S07).
Both staff and PEH identified increased clinical outreach as a method for increasing patient numbers and improving community health. PEH reported a need for clinic staff to go out onto the sidewalk and street in the neighborhood and disseminate more information about the services offered at the clinic to other PEH. They also said more frequent outreach would help people who are homeless recognize clinic staff and enhance their willingness to seek services. In contrast, staff participants recommended methods of outreach such as dispensing flyers or flu shots outside the clinic walls:
“You can make flyers and then, you know, send people out on the street […] you do a little advertising and then you draw people into the clinic with those, with those things. And then you can use that as an opportunity for other things like screenings. ” (S09).
Staff and PEH talked about the need for more health education (eg, mental health education, the dangers of substance use, and understanding medications) for PEH in the community. Both also spoke of the need for health care education tailored to each patient’s cultural, linguistic, health literacy, and cognitive ability status. Staff participants noted that even well-intentioned health education from a provider can be insufficient due to cultural or linguistic limitations:
“Conditions are not explained in a culturally sensitive manner. Patients do not understand why they need to take their medications. Providers and staff need to meet the patient where they are at. ” (S06).
Staff and PEH frequently praised the availability of drop-in services for basic needs at the community-based homeless health care clinic, such as showers, laundry, food, hygiene products, and phone charging stations. PEH reported satisfaction with existing drop-in services and a desire for their continuation and expansion. Staff participants agreed and additionally noted that services addressing basic needs provide an important function for the clinic by drawing homeless community members into the building:
“So, I would say the drop-in center is a good way to attract clients over here, especially homeless clients, because they need some type of place to come to, you know, to well spend the day usually they are because on the streets. So, it’s a good way to attract clients to come over here and, little by little, they learn that they can get services from the clinic they can get or case management, too. ” (S10).