Helping and supporting hospitalized youth experiencing homelessness: An American perspective

Similarities

The first similarity is that both countries, despite having a wealth of resources, are unable to provide accurate counts of the homeless youth population. Quintyne and Harpin (2020) note that of the 103,000 young people who sought services, less than 15% were accepted as being homeless and eligible for priority services. In the United States, the Department for Housing and Urban Development conducts point in time counts to determine the number of people experiencing homelessness. These counts occur on a single night, usually in January. Those who are in shelter or staying in areas where people experiencing homelessness are known to reside are easier to count. This method of counting misses those who are “the hidden homeless”—people who are sofa surfing (or couch-surfing, as we say in the United States), “doubled up” (living in housing meant for fewer people to save resources), living in hotels/motels or cars, migrant workers, or those who are temporarily returning to live with family before leaving again. The point-in-time count provides information about the incidence of the homelessness on that night, but not the prevalence. The 2019 point-in-time count reports the number of unaccompanied homeless youth under age 24 in the United States as 35,038 young people (U.S. Department of Housing and Urban Development (HUD), 2019). The report notes that there were 102,968 people under age 18 in families experiencing homelessness and 12,449 people age 18–24 in homeless families (U.S. Department of HUD, 2019). Summing that up, we have 150,455 children and young people under age 25 experiencing homelessness in the United States.

However, in a study estimating the prevalence of youth homelessness, Morton et al. (2018) found that over 660,000 children age 13–17 and 2.4 million youth age 18–24 experienced at least one night of homelessness in the 12 months prior to the study . The data from the National Center for Homeless Education (2020) align with that from Morton’s study documenting that 1.5 million students were experiencing homelessness in the 2017–2018 academic year.

Factors precipitating homelessness are also similar. In the United States, many youth report family conflict, violence, or abuse as reasons for leaving home (Embleton et al., 2016; Gambon et al., 2020). Other contributing factors are pregnancy and identity as lesbian, gay, bisexual, or transgender. Youth experiencing homelessness are also likely to have mental health problems. Many youth experience trauma prior to becoming homeless. Others are traumatized or re-traumatized once homeless. Estimates indicate that the majority of youth who identify as homeless have mental health problems, including but not limited to posttraumatic stress disorder (PTSD), bipolar disorder, major depressive disorder (MDD), oppositional defiant disorder (ODD), and attention deficit hyperactive disorder (ADHD) (Medlow et al., 2014). In addition, adolescents with high levels of depressive symptoms that worsened over time and a history of running away in adolescence were more likely to experience homelessness in adulthood (Williams et al., 2019). Children in foster care are also at higher risk of homelessness in adulthood (U.S. Department of Health and Human Services, Office of the Assistant Secretary of Planning and Evaluation, 2017).

Youth experiencing homelessness often seek care for health problems while homeless. There is some evidence to support that youth may be more likely to accept services and take steps toward exiting homelessness when they seek care (Auerswald & Eyre, 2002). The processes and services available for helping youth link to care are where the United States and the United Kingdom have some significant differences.

Differences

Quintyne and Harpin (2020) describe the Local Authority as a centralized place where youth can access services. While these services are based on borough of residency, there are provisions to access care if the young person is otherwise connected to the borough. In the United States, we do not have something like the Local Authority. Services are separated by type: education, transportation, health care, and are often siloed. For example, a young person may be accessing health care through a free clinic run by a local charity, but not be identified as homeless by their school. The converse is also true. Physicians and health care providers may be caring for a youth in clinic or in the hospital without knowing that they are couch-surfing or otherwise meet the criteria for being homeless (Beharry & Christensen, 2020).

While legislation to help youth experiencing homelessness access services exists, many youth and their families may not know about these services. A key piece of legislation to help youth experiencing homelessness was the McKinney Vento Act. Since it was first approved in 1987, the McKinney Vento Act has helped define homelessness, led to the establishment of what is now known as the US Interagency Council on Homelessness, and led to provisions to help youth access education while homeless (Beharry & Christensen, 2020; U.S. Department of HUD, 2011). As a result of this Act, each state has a State Coordinator who oversees and works with the local liaisons to help youth access educational opportunities including extracurricular activities (National Association for the Education of Homeless Children and Youth, 2020). However, if a young person is not connected to the local liaison, they may not be able to access educational services.

Another striking difference is the ability to access health care. In the United States, health insurance is tied to employment, income level, and age. According to data from the United States Census Bureau (2020) in 2018, 5.5% of children under age 19 did not have health insurance. Among those aged 12–18, 6.3% were uninsured. For children with health insurance, 35.3% received their insurance through government-funded programs such as Medicaid and CHIP (Children’s Health Insurance Program). Transition age youth, those age 19–25, represent the age group with highest rate of being uninsured at 14.3% (Berchick et al., 2019). While a young person may be covered under their parents’ insurance, if they are no longer living with their parent or do not have proof of their identity, they may not be able to use that coverage. Logically, a person who is experiencing homelessness is living in poverty, however, to qualify for government-funded health insurance, an application has to be submitted. If a person is moving from home to home or to different states, or in some cases different areas within the same state, the insurance coverage they have may not be accepted. States may have different laws about which services minors may access independently, which can be a challenge for youth to navigate if they move from state to state. While all youth can access emergency care, receiving outpatient services, such as mental health appointments, is a bit more challenging.

The wait times for an appointment to address mental health concerns can be lengthy. In their study of appointment wait times, Cama and colleagues (2019) posed as parents of a 12-year-old girl with depression and asked for the next available appointment. The researchers found that they could get an appointment with a pediatrician in an average of 12.7 days and with a child psychiatrist in 42.9 days (Cama et al., 2019). If the insurance was reported as Medicaid, they were less likely to get an appointment. Other barriers to care included not having accurate contact information for the practice or the provider not accepting new patients (Cama et al., 2019).

Common solutions

Providers cannot help those who are not identified as needing help. Strategies to identify youth who are currently homeless or at a risk of being homeless include working with all staff, including the clerical team, to note which youth have had frequent changes in address or who report their address as one linked to a homeless shelter and taking a psychosocial assessment to identify risk factors for homelessness and/or financial risk factors that make them at risk of homelessness (Beharry & Christensen, 2020). Psychosocial assessments can be completed by the provider or other appropriately trained team members, such as social workers. Once identified, youth who are experiencing homelessness should be linked to available services if they are willing to accept them. Providers should respect the young person’s wish to accept or refuse services and follow practices of trauma informed care (Society for Adolescent Health and Medicine (SAHM), 2018; Substance Abuse and Mental Health Services Administration, 2020). Partnering with community organizations and key stakeholders can help maintain continuity of care and avoid duplication of services (SAHM, 2018).

When possible, preventing homelessness and avoiding “discharging patients to the streets” should be part of the treatment plan. In the United States, in addition to advocating for services for youth experiencing homelessness, we are also tasked with having to find a way for youth to obtain and maintain health insurance (Council on Community Pediatrics, 2013; National Health care for the Homeless Council, 2019; SAHM, 2018; Harpin et al., 2017). Until we can achieve universal health coverage in the United States, individual states and health plans have advocated for and demonstrated the benefits of providing housing in reducing admissions and readmissions (Sandel & Desmond, 2017).

Conclusion

The similarities and differences in caring for homeless youth in our two countries highlight the need for increased attention to the prevalence of youth homelessness, strategies for providing care, and advocating for the needs of youth and their communities. Increased research on strategies to prevent and intervene in youth homelessness can help inform policy and, ideally, reduce the number of young people and adults experiencing homelessness.