In June, the CSBJ published Part I of an article about the characteristics of our local, chronically homeless population with research conducted by Homeward Pikes Peak and the UCCS Economic Forum. The article shared some underlying and rather stark themes related to the childhoods of our region’s chronically homeless population. The data showed a high prevalence of alcohol, drug and/or mental and/or physical abuse by a parent or caregiver — a tragic but not necessarily surprising finding. What was most striking in that data is the high prevalence of all the childhood traumas: a parent or caregiver abusing alcohol, and drugs, and being mentally and physically abused. The percentage of clients who experienced all of the above ranged from 25-60 percent. Another pattern discussed in the first article centered on the high occurrence of inflicted violence at any point in the client’s history (ranging by program from 57-91 percent) as well as the infliction of violence on others (reaching as high as 45 percent). Not surprisingly, incarceration rates were also high (between 8-83 percent).
In this article, a few other traits are examined, such as educational attainment, clients’ marital and parental status, mental and physical health status, whether clients are accessing any kind of mental health service, the prevalence of substance abuse at client intake, and the incidence of hospitalizations and emergency room visits.
Graph 1 shows that HPP clients in 2018 had an average of 11.9 years of educational attainment. The mothers from Bloom House had the lowest attainment level at 10.8 years. This undoubtedly ties to the adverse home environment the majority of HPP clients experienced as children, as discussed in the first article. The presence of substance and other types of abuse creates a survival environment obviously not conducive to academic support within the home. These low education levels are another critical barrier in overcoming homelessness, above and beyond the aforementioned childhood traumas, and the lack of academic achievement nearly guarantees a future of financial instability.
The HPP programs varied in terms of marital status and parental status. As Graph 2 shows, a relatively low percentage of HPP’s clients were married or had a partner at intake (ranging up to 18 percent), but a relatively high percentage of the chronically homeless have children. In all five programs, the percentage of clients who had children ranged from 46-67 percent. This data adds another dimension to the ongoing challenge of homelessness. Surely the children of our region’s chronically homeless have the odds stacked against them much as the homeless individual did in the adverse environments in which they were raised.
Across HPP programs, a high proportion of clients state at intake that they have chronic health problems and/or mental health problems (Graph 3). On average, 46 percent of clients state they have chronic health problems and the highest percentage is for the Housing First Veterans program (86 percent). Likewise, an average of 70 percent of clients state across programs that they have mental health problems, with the highest proportion again belonging to the veteran program (86 percent). The proportion of clients who state at intake that they are receiving mental health treatment varied more widely (25-100 percent). The highest proportion for this metric also belonged to the veteran program, suggesting that the military health safety net program is being accessed.
Many of our region’s chronically homeless are self-treating their physical or mental health problems with drugs or alcohol. The percentage of HPP clients who report having a drug or alcohol problem ranges from 22 percent (alcohol problems for Harbor House Clinic) to 100 percent (Bloom Recovery House). It is important to note that Harbor House Clinic patients are at HPP because of a referral for substance abuse treatment, but clearly not all clients acknowledge their abuse. Likewise, Bloom House has parental and substance abuse criteria.
The prevalence of physical and mental health challenges most likely explains the relatively high incidence of emergency department visits and inpatient stays for HPP’s two largest programs. In 2018, 13 percent of Harbor House Clinic’s clients reported hospitalization within the past 90 days. This year’s figure: 19 percent. Similarly, 22 percent of Harbor House Residential clients had a 2018 hospitalization in the past 90 days and 36 percent has an ED visit in the past 90 days this year (Graph 4). The other, smaller programs did not collect this data. Different studies cite different amounts, but the average cost of an ER visit across the U.S. seems to hover around $2,000, and about $3,000 per inpatient day in Colorado (Kaiser Family Foundation). Our chronically homeless are heavily utilizing acute care services and it is costly.
There are many takeaways from the descriptive data gathered by HPP and analyzed by the UCCS Economic Forum. The recurring themes of childhood trauma and persistent violence discussed in the first article certainly increases the probability of mental illness and alcohol or drug abuse. These traumas are occurring during key formative years: According to the National Institutes of Health, 90 percent of the adult human brain is formed by age 6. These past and current challenges call for intensive mental health counseling, and highlight the inherent crisis presented by the shortage of mental health providers across the country.
Tragically, the adverse history of our chronically homeless and their low educational attainment may very well extend beyond the homeless HPP client. All the HPP programs had some clients who were parents in 2018. It is well documented that childhood traumas are often repeated. There is also a strong correlation between a parent’s educational attainment level and a child’s.
One bright spot in this analysis is the high percentage of clients who have health insurance coverage (from 94-100 percent). It is noteworthy that most clients in all HPP programs do have or quickly obtain insurance when they present at HPP and receive help from their trained staff. This could potentially offer some pathways for improvement for this population, particularly around mental health. Each sober living program at HPP requires the client to enter intensive outpatient treatment with a local provider.
The results of this evaluation portray a seemingly hopeless situation. Yet the information may provide some tactics specific to those who are chronically homeless within our city.
First, it is important to note that HPP clients are typically chronically homeless individuals and are quite different from an individual who unexpectedly experiences unemployment or bankruptcy. The latter group usually can transition out of homelessness, especially in communities where there is access to temporary support services. There is a “churn” inherent in this population, meaning that any region will likely have some number of transitioning homeless. This analysis presents the challenges of those who typically have more deep-seated, chronic issues that are harder to overcome. Although difficult, helping even some portion of this population may help alleviate the enduring and perpetual problem of homelessness within a given region.
Second, the themes of childhood trauma suggest treatment therapies centering on post-traumatic stress disorder. This clearly needs more investigation by expert clinicians who are now equipped with this local data around the childhood experiences of this population.
Third, the high proportion of chronically homeless who are parents suggests that active outreach to the children of our local homeless population, with parental consent, may provide a mechanism to interrupt the cycle of traumas.
Fourth, our region may want to pursue simple public health awareness campaigns that highlight the critical importance of those first six, highly formative years. And finally, preventing the high use of very costly hospital facilities implies that there may be cost savings in actively engaging and managing the health of our region’s chronically homeless. Homelessness experts typically advocate for increasing access to medical detox centers, short-term residential crisis stabilization for severe mental illness, and more permanent supportive housing for those with mental illness and addictions.
It is unfortunately not possible to turn back the clock and erase childhood traumas and violence, but it is possible to understand the context of our local, chronically homeless. An understanding can drive a concerted effort to provide targeted and coordinated services that at least have a chance of effecting change for some portion of those who have most acutely lost their way.
Author’s note: Thank you to Beth Roalstad for her commitment to our region’s chronically homeless and to rigorous evaluation. Thank you to the Colorado Springs Health Foundation for its commitment to improving our region’s well-being.
Dr. Tatiana Bailey is the director of UCCS Economic Forum. She can be reached at firstname.lastname@example.org.