Mental and physical health problems are strongly
connected to homelessness. It is best to see
homeless people not as constituting a separate
category, but as being a group of people who find
themselves at the extreme end of the spectrum of
social exclusion. Some of the most powerful
determinants of health are embedded in conditions of
social inequality (Pickett and Wilson, 2009) and
these are not usually directly affected by health
As with other socially-excluded groups, homeless
people die earlier and have a higher prevalence of
mental and physical illnesses than the general
population (Fazel, 2014, Aldridge 2017). Migration,
a major source of homelessness, is linked to a range
of health problems, including mental health problems
(EPRS, 2016). Like other groups at the bottom end of
the social-economic scale, they likely to be subject
to the “inverse care law” and so less likely to
receive the health care that they need (Tudor Hart,
Psychosis, multiple trauma and addiction are often
causes of homelessness, whereas emotional distress,
anxiety and depression can be responses to
homelessness (Leng, 2007).
Physical health problems can arise directly from the
specific dangers of being homeless, from a lack of
the normally-assumed social framework for health, or
be worsened because of the lack of access to
treatment. For example, if you suffer from diabetes,
tuberculosis or other illnesses, it is hard to take
care of your health in the streets while homeless
You will be more vulnerable to extremes of
temperature, more likely to become wet, and more
likely to be assaulted.
You will generally lack control over life to
establish and maintain the basic routines to
maintain health. These include a healthy diet, clean
clothes, adequate rest, security of possessions and
privacy. This is also likely to affect your ability
to take medication regularly.
You will often not be able to conform to the
arrangements for clinics – many health and social
services have limited contact with this population
and do not design their services to address such
There have been statements from European bodies
concerning healthcare and those who are homeless or
socially excluded. In 2016 the European Parliament
issued a statement regarding the right to health
services for refugees or asylum seekers, with or
In the same year, Mental Health Europe (MHE, 2016)
issued a paper strongly arguing for refugees and
asylum seekers to have full access to appropriate
health services, particularly where issues of trauma
In spite of these assertions, the PROMO study
(Canavan et al., 2012) has demonstrated major issues
with access to health care for homeless people in
Europe. Their summary comments: “Input from
professionally qualified mental health staff was
reported as low, as were levels of active outreach
and case finding. Out-of-hours service provision
appears inadequate and high levels of service
exclusion criteria were evident. Prejudice in the
services towards homeless people, a lack of
co-ordination amongst services, and the difficulties
homeless people face in obtaining health insurance
were identified as major barriers to service
In addition, there is evidence that, within health
services, there can be considerable stigmatisation
of certain groups of patients, including homeless
people (Jeffrey, 1979).
2. Main ideas
Direct access to care and resources is crucial,
especially for undocumented people. Homeless people
tend to experience multiple problems simultaneously,
so they can easily be perceived as difficult to
treat and thereby become “unwanted” by mainstream
services. At the same time, homeless people tend to
find it hard to deal with bureaucratic barriers,
waiting lists and complicated treatment plans. The
more rigid and complex a service is, the more likely
it is that homeless people will be excluded from
that service, or to lose contact with it. Health
services should be aware that:
While general populations have difficulties adhering
to treatment plans, homeless people have added
difficulties in doing this.
Services should not make it difficult to access
their services – access needs to be as easy and
quick as possible (and not just for homeless
Because of myths within services regarding
entitlement to those services, homeless people need
access to and knowledge of their rights regarding
access to healthcare.
Aftercare and follow up after discharge from
hospital presents specific problems. Without a
physical home to go to, or a supportive social
one needs to consider that a homeless person may
well be being discharged to a hostile and
unsupportive environment. It is particularly
important that, for a homeless person, a clear and
robust aftercare plan is made. Without this, any
gains from the hospital admission can easily be
lost. However, this is often not done for homeless
people before their discharge from the hospital.
Attention to Relationships
It may be that, in some contexts and with some
clients, adequate care and treatment can be
delivered without needing to pay attention to the
relationship between the client/patient and the
service provider. This is absolutely not true with
homeless people – it is a central, essential part of
the work. Effective interventions with homeless
people depend on the establishment of a good
relationship with an individual – but can also,
sometimes, be cultivated in a group setting.
A good relationship and a working alliance with the
homeless person is the only way to continuing
contact with services and, where necessary, to
engagement with treatment or other health
Paying attention to interpersonal and relational
aspects is as important as other, more obviously
“technical” concerns. Although these are often
referred to as “soft” skills, they are capable of
being learnt, communicated and measured, so should
be seen as “hard” skills as much as any more
obviously physical and technical skills.
The ability to create and maintain a helping
relationship should be seen as a technical concern
in its own right. Group interventions can also be
effective as they foster a sense of belonging and
enable shared non-hierarchical learning.
The notion of going to meet with potential patients
or clients, sometimes without any invitation, rather
than waiting for them to come and see you.
Given the almost-universal medical tradition of
responding to a health need clearly expressed by an
individual, how can this be justified in ethical
terms? Are we not in danger of offering unwanted
treatment in a paternalistic fashion? The
traditional model of offering medical assistance is
based on two assumptions. One is that the
doctor/nurse is available; the other is that the
potential patient is not impaired by any sort of
intoxication or brain disorder. Both practical
experience and research into homeless populations
show that neither of these assumptions holds true
for much of the time for many homeless people. They
are either unable to access appropriate services for
practical or cultural reasons or are so impaired by
physical or mental illness or intoxication, that
they are unable to access the services to which they
have a right.
So, outreach can be both a strategy for:
Follow up and continuing care (further material
concerning this will be found in the separate
In health, it is an approach that can be applied to
the assessment and treatment of both mental and
physical health problems.
There is a range of outreach styles, from
proactive/assertive approaches to more gradual,
participative and receptive styles. These styles
are influenced by national cultural attitudes,
economic circumstances, specific ideologies of
mental illness and homelessness – and the legal
structures that control some aspects of psychiatric
As a result, there can be no universally-applicable
“prescription” for the practicalities of outreach.
However, there are probably universal principles
that can be applied to most situations - see the
section dedicated to outreach
Structurally, health outreach can involve a range of
professionals and non-professionals, including:
Dedicated clinics in existing health establishments.
Visiting clinics in existing homeless settings such
as hostels, shelters or day facilities.
Consultation settings with non-medical homeless
Visits by individual health workers.
Peer support, peer educators, working 1:1 or in
The intensity and frequency of such interventions
will depend both on the resources available and the
attitude of the staff – see the section on hospital
admission. An assertive outreach approach (Coldwell
& Bender, 2007) has been shown to be an effective
model of care for homeless people with mental health
This is essential because, usually, a homeless
person will face multiple health and social problems
at a single point in time. If only a health problem
is addressed, it is often the case that other active
issues will undermine any gains from an otherwise
effective health intervention. And, in this
population, multi-morbidity should be assumed to be
the norm rather than the exception. This can include
both a range of physical disorders, mental disorders
and drug or alcohol problems, all of which need to
be considered for each homeless person.
So - no single professional, or non-professional
group can, on its own, provide adequate care and
support when they first encounter a homeless person.
Even most multi-disciplinary teams do not have the
full range of resources within their team to address
the full range of possible issues. Clearly, not
every issue needs to be addressed at the same time –
one must be guided by the patient’s priorities and
by what is practical – or bearable – for the
individual patient. But the critical set of skills
and resources may not be available when they are
needed by the patient.
Active networking can go some way towards resolving
this problem by connecting up dispersed resources in
such a way that they can be activated/engaged when
needed. By establishing an active network, a person
or facility working with homeless people with mental
health problems should be able to offer the most
comprehensive service possible.
Facilities such as hostels, shelters, soup kitchens,
day centres and shower facilities, should have the
capacity to be involved in active person-centred
networks, using both formal agreements between
organisations and informal communications between
In terms of continuing, planned work, networking and
collaboration with other professionals and services
are needed to construct a comprehensive (or at least
multi-faceted) service plan involving the provision
of basic needs and a plausible plan for the future.
All professionals and other people working with
homeless persons would benefit from training in how
to create and maintain networks and active
collaborations (see section on Networking).
Phone or email communications are clearly vital –
but personal meetings can engender a sense of
personal trust between services that can make things
work much more smoothly.
Many homeless people have had poor experiences with
health systems – in common with many other
marginalised groups – or may be disabled by mental
illness, illiteracy or dependence problems. Advocacy
and emotional support through interactions with
various health and social systems, therefore, have
an important part to play in services for homeless
people. It can also play a part in establishing and
reinforcing a therapeutic relationship, with an
individual worker or with a team.
Emergency services (such as Accident and Emergency
departments/Emergency rooms)- are
crucial points of entry into the health system for
homeless people. However, if a homeless person does
try to use a hospital emergency department, he or
she can be looked upon with suspicion, as if they
are only looking for a meal or bed (Jeffery, 1979).
This prejudice can lead hospital staff to overlook
the very real health needs of that homeless person.
On the other hand, a homeless person can arrive at
the emergency room after a long period of
involvement with community services and outreach
teams, who have worked hard to make this attendance
happen. Staff working in emergency services need to
know that these services exist, and should
prioritise communications with them.
They also need to be aware of the services network
that can be activated and enlisted to help these
clients — having the involvement of a social worker
or social nurse right from the start can facilitate
the recruitment of
these community services.
Good recording of social and clinical information is
clearly necessary for sustained and coherent
clinical activity, and professional accountability.
However, it is also vital in terms of being able to
describe and evaluate the service that is being
The usual professional standards apply to work with
homeless people, so all activities and
socio-demographic data should be carefully recorded.
If interactions and interventions are restricted by
the environment, then this should be documented. It
is clear that the situations in which one can meet
many homeless people are not ideal, and that one can
often not do as much as would be possible in a
Attention should be given to how information is
shared between different parts of the system – e.g.
between hospital wards, outpatient services and
community services. Again, the same confidentiality
standards apply to homeless people as do to anyone
It may be helpful to have a “tagging” or “alerting”
system of some sort to ensure that everybody who
needs to know is alerted when a homeless person
comes into the hospital.
Most work with homeless people is best accomplished
by working collaboratively in the community.
However, hospitalisation can be needed when an
Has health needs that cannot be met with
Has lost the capacity to make informed decisions
about their health care and is neglecting their
self-care or attention to safety.
(rarely) poses an immediate risk to themselves
In certain circumstances, an involuntary/compulsory
admission to hospital may be needed.
It may be helpful to have a standard protocol for
admission, agreed between the in-patient wards,
community services and local homeless services.
To be effective, in-patient treatment must fully
take into account the conditions a homeless person
is likely to face if they return to the street if it
is to discharge the person in a way that allows them
to continue their recovery. Discharge to the streets
should never happen.
To achieve this, community services and
professionals in homeless services, who have been
involved with the individual, must take the
initiative in communicating with and sharing
information with, in-patient staff. This can be
In such a context, discharge from hospital can
happen without joint working with the community
services, resulting in inappropriate treatment, lack
of treatment or inappropriate discharge from the
hospital. A meeting between in-patient and community
staff should always happen before a homeless
patient is discharged from the hospital.
Homeless services need to “inreach” to in-patient
staff while one of their clients is in hospital.
To optimise a hospital admission:
Keep an “accumulative history” for the patient,
that will allow the Ward staff to quickly grasp
the essentials of your clients’ predicament.
Use an “admission plan” protocol to succinctly
set out the reasons for admission, what has and
has not worked in the past, and what the
anticipated outcome for the admission would be.
Have regular joint meetings between the homeless
team and mainstream teams.
Maintain the intensity of your input during
See your client on the Ward within 24 hours of
admission. This can be reassuring for them, but
can also help you to ensure that the ward staff
understand the case.
View the admission as not just as an opportunity
for safeguarding and treatment, but also as an
opportunity for change.
Be very clear about your clients’ capacity to
make important decisions – like whether to stay
in hospital or not or to consent to or refuse
medication. Wrongly-assumed capacity can be used
as a reason to discharge the patient
inappropriately, or not to provide treatment.
Easy access to such services is essential. Good
examples are the “Open psychotherapeutic group” and
“Open consultation” models that work regularly,
every week without an appointment.
Coordination / joint work with social services
Collaboration with social services is essential.
Even if the system is over-loaded, homeless people
have the same rights of access to it as anyone
else. Social services need, and appreciate,
collaborative work to help to deal with their most
difficult cases with mental health problems. On the
other hand, mental health services need to
collaborate with social services to create
appropriate arrangements after hospital discharge.
Coordination with Health Authorities - compulsory
Compulsory treatment is always (or should be) a
complex and difficult process. Pro-active
collaboration with health authorities can make this
process more effectively, and more helpfully for the
individual concerned. Once mainstream health
services understand the benefits and effectiveness
of treating homeless patients, they are likely to be
much more positive about working with homeless
Research, training and case discussion
These need to be incorporated into the regular life
of any team, not just as occasional events. They
not only enable homeless services to demonstrate
what they are doing but are also be
fulfilling and motivating for team members.
“Hard to engage”
Homeless people can be seen by mainstream services
as difficult to engage – but this will usually have
much to do with access to basic rights, social
security and language barriers.
Overlap of physical, mental health and drug/alcohol
Mainstream services often have separate and strictly
demarcated services for mental illness and
alcohol/substance issues. Many homeless people will
often have problems in both these areas – but then
this is increasingly the case in the domiciled
population as well.
A street assessment can clearly be sub-optimal in
terms of confidentiality, comfort and quietness, and
the time available. However, it is absolutely
justifiable when the alternative is no access to
services at all.
There are difficulties inherent in conducting a
health assessment on the street:
Lack of privacy.
Lack of control of the environment.
Difficulty in persuading the person to stay.
Lack of recognition by other agencies (e.g.
police) of the individual’s mental health needs.
Communication difficulties in a noisy
Sometimes, sheer physical discomfort!
So, it is particularly important that experienced
health professionals, able to evaluate these complex
situations, should be carrying out such street
Mental assessment for compulsory admission is a
difficult and complex process. Professionals working
within the health system, and those outside it, can
often have very different and contradictory
perspectives. For example, there can be a great
concern in the community about the health situation
of a homeless person – but, at the same time, this
person can be seen in the emergency room (or on an
in-patient ward) as having no significant mental
A person can be disabled by their symptoms, yet not
obviously unwell. If the focus of an assessment is
purely directed towards symptoms, the person's
impairments may be overlooked. It is, therefore,
advisable to perform a formal assessment of a
person’s capacity (Pathway, 2016) to make important
decisions for themselves. This will often be clearly
impaired, even when symptoms of mental illness are
not disclosed to the interviewer.
A focus only on health or only on social needs tends
to foster a lack of communication between
professionals, statutory services and charity/NGO
services. If doctors only talk to doctors, or social
workers only to social workers, misunderstandings,
lack of necessary information, duplication of effort
and poor results will follow. The same applies to
the medical domain to in-patient and community
Many homeless people are immigrants or refugees,
from different parts of the world. Different
cultural expectations, ways of behaving, and
thinking can complicate mental health assessments,
behaviour, treatment and symptoms.
Multiple – or so-called “revolving door” admissions
are not necessarily a problem as they can be part of
the relationship-building process. The crucial
element is that lessons should be learnt from each
admission so that the persons care and treatment can
be enriched and become more effective.
4. Good practices
Outreach work is fundamental to working with people
who have often avoided health and services or people
who have experienced such services as inaccessible
and unhelpful. It must address social, mental and
physical health needs.
Access to mainstream services
At the same time, mainstream services should
increase access for homeless people. Open door
services without an appointment or waiting lists are
good ways to achieve this.
There should be clear, well-established and agreed
on protocols for compulsory admissions, which
Sending assessment and reports of the person
prior to admission
Actively and negotiating a bed to be used, not
just relying on the emergency department.
The homeless team should maintain regular
contact with hospital staff during the
Pre-discharge meetings should be arranged
towards the end of any hospital admission
(mental or medical). These will involve the
hospital team and the homeless team (with a
social worker) to plan future accommodation, and
organise a discharge / follow up plan.
Staff should be trained in cultural aspects of
mental health, particularly how non-European
people may view mental health issues and how
they might be dealt with.
Work with our professional colleagues
Advocacy, good information and marketing about
homeless people and issues are vital to helping
other professionals become less
suspicious/pessimistic about homeless people, and
thus more likely to make their services accessible
to homeless people.
We need not to meet our colleagues as though we are
asking for favours from them – we honestly see this
(from both sides) as a way of improving everybody’s
life and, most importantly, the life of the patient
– a win-win scenario.
Having said this, there can still be a stigma
regarding both homeless people and specialist
homeless services which may need to be addressed.
Offering trainees training opportunities in homeless
services, whether medical, addictions, housing or
social support. Most medical, nursing or social work
students find such placements extremely rewarding
and are likely to become more sensitive to the needs
of homeless people – and to become more skilled in
Support for staff
Not all stories end happily – so burnout is always a
possibility in homeless services. Staff welfare and
effectiveness cannot be taken for granted. Planned
supervision and staff care are needed for good
practice to be maintained. (See section on staff
Prevention is generally described in three ways
(WHO). The involvement of health services in
preventing homelessness can be:
“improving the overall health of the population”
Most of the primary drivers of homelessness fall
outside the remit of health or social services –
although it can be argued that work to improve the
treatment of and follow up of, mental disorders by
such services could reduce homelessness.
“Improving detection of disorders”
In the UK, the recent Prevention of Homelessness Act
(2017) has placed an obligation on both social and
health services to take preventative action if a
person in contact with their service is in danger of
becoming homeless. For some reason, this does not
apply to out-patient or community services, but it
certainly encourages a more assertive approach to
maintaining accommodation for vulnerable people.
Prior to this, some local council housing services
had formal liaison arrangements with local mental
health services, which would allow extra input to
people who were in danger of losing their
“Improving treatment and recovery”
The provision of specialist mental health services
for homeless people can be seen as a way of reducing
the impact of health problems that have
precipitated, or continue to perpetuate,
homelessness, thereby leading to a resolution of the
This is a more contentious area - tertiary
prevention can be taken to represent a continuing
service to minimise the impact of a condition – or
homelessness – on a person’s well-being, while not
aiming at any final resolution of the problem. Are
we really happy to view our services as merely
helping our clients/patients to survive
homelessness, rather than as being part of a way for
them to escape homelessness?
5. Case profile
Case Profile: Rita
A 54th-year-old Finnish woman who left
Finland in 2017, after the death of close family
members, and came to Barcelona on her own. Her
father, her half-sister, her son and her daughter
lived in Helsinki, but she stopped contacting them a
year before coming to Barcelona.
She said that she had been a nursing assistant and
worked in France and Sweden, but had not worked for
a long time. She said she could speak eight
languages and enjoyed travelling, reading and music.
Mental health problems:
Paranoid schizophrenia /schizoaffective disorder
with multiple psychiatric admissions in several EU
countries over the last 15 years due to her
Mental and behavioural disorder due to Alcohol,
IV heroin from ages 17-27, with periods in
detoxification units and programs with methadone and
of IV cocaine from ages 15 to 27, occasional
Consumption of LSD and amphetamines in youth.
Currently a heavy smoker
Other health problem:
Cor pulmonale, asthma, diabetes, HBV and positive
seizures in the context of brain neoplasia years
ago, and a diagnosis of narcolepsy.
She was referred to our team from a shelter with
ideas of self-harm but, before our first visit, she
had to be referred to the A&E department due to an
opiate overdose. From intensive care, she was
discharged again to the shelter (she wasn’t admitted
to a psychiatric ward).
From the shelter, she was admitted to a respiratory
medicine ward and again referred back to the shelter
where we continued to follow her up.
From the shelter, she was referred to a medium stay
psychiatric unit without our knowledge, due to plans
made during her admission for her chronic
obstructive pulmonary disease. She was again
discharged, without any plans for her accommodation.
She had lost her place at the medium stay unit and
the shelter, so an emergency hostel had to be
organised with the help of a social worker after an
urgent referral by our team.
In hostel (although an inadequate placement for her
Admitted to a medium stay psychiatric unit where she
overdosed with heroin, possibly wishing to harm
herself. She was admitted to an intensive care unit
and then to a psychiatric ward.
Discharged and placed in the same shelter as before
(no other placement would accept her). Our team then
started to work to return her to Finland, her
country of origin.
Another admission to a respiratory medicine ward.
On discharge, we managed to place her in a
convalescent unit where her pulmonary condition
could stabilise for her return trip to Helsinki.
Returns to Helsinki, a trip organised by our team.
We can see from the case a person with serious
physical and mental health conditions who was
willing to accept help but whose support was
interrupted several times by her medical and
psychiatric situation. This required urgent action,
but also a long-term plan for her recovery and it
wasn’t always possible.
The effort by staff
to provide a long term follow-up independent of her
placement meant that her care and support could
continue in spite of changes in her accommodation.
On the other hand
difficulties and inefficiency in the coordination
between different professionals was constant despite
many emails, phone calls and meetings.
- Which strengths
and risk factors do you identify in this client?
- Which were the
critical moments in the process?
- Which professional
interventions would you like to underline as
positive and which as negative and which were
Case profile: Alan
A 38-year-old English man who had lived for several
years in a large night-shelter for homeless men in
South London. He had been allocated a bed but chose,
instead, to sleep on a wide window-ledge in a large
dormitory on the first floor, using rags that he
gathered from the street rather than blankets
offered by the shelter staff. He had a national
insurance number and so was eligible for benefits.
His shelter fees were paid automatically from his
benefits, but he never claimed his other financial
He never spoke and avoided contact with both staff
and residents. When he was not asleep on the window
ledge, he went out early in the morning, returning
late at night. He was dressed in scavenged clothes
which he never washed. He would never shower, and
the skin of his face and hands were covered in
ingrained dirt. He never ate in the shelter, and it
was unclear where he found his food. As the years
wore on, the staff had become increasingly concerned
over his extreme social isolation, apparent
self-neglect and loss of weight. They, therefore,
referred him to the START team, a mental health
outreach team for homeless people.
We first approached him early one morning – his
response was to get up and leave the shelter,
without talking to us at all. We noticed that, under
the dirt, he looked extremely pale and that his
bedding was infested with lice. We tried three more
times, and each time he just got up and left the
Given his extreme self-neglect and weight loss, it
seemed likely that he was suffering from some sort
of mental disorder, probably a psychosis. We,
therefore, arranged for him to be assessed under the
Mental Health Act and he was admitted to a
psychiatric ward. In initial physical examination
showed that he was both covered in insect bites,
presumably from lice, and that his haemoglobin level
was 3g/dl (compared to a normal of 13-17 g/dl). This
meant that he was in danger of becoming blind
through his extreme anaemia. He had a blood
transfusion and was subsequently treated for
psychotic illness, eventually being able to live in
Points to highlight:
This man never asked for help – and, in fact,
actively avoided it.
His severe mental illness had never been identified,
over many years.
Although he was extremely socially isolated, his
predicament was well-known to the NGO/voluntary
sector staff who ran the night shelter.
While never being an immediate danger to himself or
others, his self-neglect gradually created a
significant danger to his physical health - and his
infestation created a problem for other residents of
Although he was entitled to his benefits, his mental
state meant that he was unable to use them.
The outreach team made several attempts to engage
with him before arranging the compulsory assessment.
The mental health team worked closely with the
people who knew Alan best – the staff of the night
The action of outreaching to this man meant that he
received a service which he had not had over the
Direct access to care and resources.
Essential due to the multiple health and social
(See outreach chapter)
Advocacy and emotional support through various
health and social systems have an important
Paying attention to interpersonal and relational
Community services and professionals must take
the initiative in communicating with and sharing
information with in-patient staff.
Succinctly setting out the reasons for
admission, what has worked in the past and what
the anticipated outcome for the admission could
Assessments carried out in the street
Carrying out an assessment to evaluate a
possible compulsory admission to hospital
“Hard to engage.”
Homeless people can be seen by mainstream
services as difficult to engage, but
this will usually have much to do with access to
basic rights, social security
and language barriers
Multiple admissions to hospital
Open door services
Mainstream services should increase access for
homeless people, therefore without an
appointment or waiting lists are good ways to
the hospital team and the homeless team (with a
social worker) to plan future accommodation, and
organise a discharge / follow up plan.
overall health of the population.
Improving the detection of disorders.
Improving treatment and recovery.
The public health dimension of the European
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(2016). Causes of homelessness prevalence-The
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and clinical and policy recommendations.
Aldridge et al. (2018) Morbidity and mortality
in homeless individuals, prisoners, sex workers,
and individuals with substance use disorders in
high-income countries: a systematic review and
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