We propose four resident educational goals and additional specific didactics to guide programs’ development of curricula in homelessness (Table 1). These goals and didactics are compatible with existing educational approaches in public psychiatry, systems-based practice, and structural psychiatry. For programs that do not have the resources or room in their didactic schedules to add a new curriculum on homelessness, we have included suggestions to facilitate implementation of homelessness education into existing didactics (Table 2).
The first goal for resident education is to evaluate patients, including special populations, for housing status and relevant social determinants of health. Understanding the social determinants of health for patients who are homeless will help residents provide sensitive, collaborative, and effective healthcare [29, 36]. Homelessness is a potent social determinant of health. Life expectancy among those experiencing homelessness is greatly reduced, estimated to be 43–47 years of age . People who are homeless are less likely than the general population to get medical care from a primary care doctor ; they may have difficulty keeping appointments and proving insurance status or may have negative experiences with health care . In the face of resource scarcity, people experiencing homelessness make individual-level tradeoffs in favor of necessities like food or shelter over health care services, contributing to downstream delays in preventive care and overutilization of acute care services [40, 41]. Residents may need to develop trust and rapport with these patients before they agree to start psychiatric treatment; they may first need to assist their patients with housing or employment needs.
Some subgroups of patients have unique social determinants that residents should recognize. Children are impacted significantly by housing instability, parental substance use and mental health problems, poverty, and witnessed violence. Many of these experiences are considered adverse childhood experiences (ACEs) and are known to affect health. These children have increased risk of academic problems, mental health problems, developmental delay, cognitive outcomes, and homelessness in the future [42, 43].
Residents should also be aware of the social determinants of health among women who experience homelessness. Domestic violence is the leading cause of homelessness for women , and a study of mothers who were homeless found that 93% had experienced trauma . They may be at continued risk for sexual victimization because they may engage in survival sex for basic needs; they are also at risk for sexually transmitted infections [46,46,48].
Finally, veterans experiencing homelessness have unique social determinants and resources. Veterans are more likely than the general population to be homeless; beyond general risk factors like poverty, they may have also experienced military trauma, traumatic brain injury, and difficulty adjusting to life outside of the military . Conditions such as posttraumatic stress disorder and military sexual trauma may increase the risk of homelessness among veterans [50, 51]. Women veterans experiencing homelessness may be especially vulnerable to a loss of social connections; indeed, women veterans are four times as likely to be homeless than civilian women [50, 52].
Given the high prevalence of trauma during periods of homelessness, individuals experiencing homelessness—especially vulnerable populations such as women, children, and veterans—are at risk for re-traumatization in health care settings. These patients may benefit when residents employ a trauma-informed approach to care . Trauma-informed care refers to a set of principles that guide treatment—such as collaboration, trust, empowerment, and safety—with the goal of avoiding distress and re-traumatization [53, 54]. Residents can offer opportunities for patients to rebuild control, at least during the clinical encounter; ensure environmental and emotional safety; and utilize a strengths-based approach to care.
Table 1 identifies two resident lectures on providing compassionate care to homeless persons. The first provides an overview of the social determinants of health for subgroups of people experiencing homelessness; the second focuses on trauma-informed care, ACEs, and adult victimization. Programs in cities with a high burden of homelessness may consider adding lectures focused on unmet health care needs among people who are homeless and the unique impact of homelessness among veterans. Programs with less flexibility in their curricula can consider including cases on homelessness in existing case conferences. They can also include trauma-informed care in their existing lectures on high-risk populations or on lectures about trauma (Table 2).
The second goal for resident education is to understand and practice appropriate referrals to evidence-based health care models for patients experiencing homelessness. Patients who are homeless benefit from health care that is tailored to their needs. Residents who are educated on these models will understand the core components and benefits of these programs and will be empowered to practice appropriate referrals to programs that are available in their communities. If such programs are not available in their communities, education on evidence-based models may inspire resident advocacy for such programs. One example is the US Health Care for the Homeless Program (HCHP), a delivery model that includes comprehensive primary care, substance use treatment, and supportive services. The HCHP became a national program in 1987, and today 285 HCHPs are located across the country. The Boston Health Care for Homeless Program (BHCHP) serves over 12,000 people who are homeless in Boston, MA. Its team of outreach providers sees patients in shelters and the streets in an attempt to overcome barriers of transport, property, and stigma in the clinic setting .
Another delivery model that is well suited to the care of patients who are homeless is the patient-centered medical home (PCMH), which is a physician-directed care setting that provides coordinated and continuous care . The Veterans’ Administration uses a PCMH model called the Homeless Patient-Aligned Care Team (HPACT), created to provide social services, primary care, and mental health care to veterans who are homeless. HPACT emphasizes using an empathic approach with patients that is cognizant of their barriers to care. For instance, HPACT tries to accommodate walk-ins whenever possible. Six months after implementation of HPACT, emergency department visits decreased by 19% and hospitalizations by 34% .
Assertive Community Treatment (ACT) programs also serve people with severe mental illness and have demonstrated improvements in symptoms and housing status among homeless populations . These programs conduct longitudinal outreach services to people who are homeless and provide intensive case management and social work in addition to mental health treatment. ACT is well studied and associated with lower rates of psychiatric hospitalization and increased housing stability .
Table 1 includes two didactic sessions to help residency programs fulfill this educational goal. The didactics we suggest are an overview of community resources and local delivery models and an overview of ACT programs. These sessions can be led by experienced psychiatrists, social workers, or administrators within these care settings. A relevant clinical experience could consist simply of practicing appropriate referrals under the guidance of a knowledgeable clinician, or even of a rotation at a specialized care model or ACT program if this is possible. Programs with less flexibility in their curricula can focus on encouraging appropriate referrals from the inpatient unit or ED (Table 2).
The third goal for resident education is to analyze structures that impact housing and to advocate to improve the health of people who are homeless. More broadly, it is helpful for psychiatry residents to understand existing structures that impact homelessness, which can include economic policies, historic practices such as redlining, and current issues such as lack of rent stabilization or other tenant protections, immigration policies and patterns, racism, stigma, and the criminal justice system. Psychiatrists have the opportunity to advocate on behalf of patients experiencing homelessness. In some systems, psychiatrists have specific gatekeeper functions and can help patients secure treatment services, for example, with finances (such as disability benefits) and diversion from incarceration, both of which can relate to homelessness prevention. Psychiatrists can also conduct housing evaluations, which are essential components of patients’ applications (e.g., HRA 2010e) for permanent supportive housing, such as in New York City’s NY/NY III housing system . At UCLA’s psychiatry residency, a core curriculum class was developed on homelessness policies (Measures H and HHH) and roles for psychiatrists within local initiatives . The class is taught by a local policymaker.
Cities are starting to implement novel policies to prevent and end homelessness. Measure H in Los Angeles County appropriates $40 million to such assistance; funds can be used to cover rent or moving expenses for people who may otherwise become homeless . Residents should be aware of low-income housing, Housing First , and rapid re-housing programs  in their regions such as Section 8 housing vouchers , Housing Opportunities for Persons with AIDS (HOPWA) , Public Housing, the Low-Income Housing Tax Credit program , and other housing available for special populations such as seniors or persons with disabilities.
For veterans in particular, a cornerstone of the effort to end veteran homelessness is a partnership between the US Department of Housing and Urban Development and VA Supportive Housing (HUD-VASH) . This program is a component of the Section 8 Housing Choice Voucher (HCV) program for civilians. Like all HCV vouchers, HUD-VASH vouchers are exchanged for private rentals. They are allocated specifically for veterans, and the program includes additional funding to the VA for case management services . In 2018, in addition to renewing existing housing vouchers, the government appropriated $40 million specifically to new vouchers for the HUD-VASH program . Typically, veterans can be assessed for homelessness at VA facilities and then referred to housing agencies for vouchers.
Residents can learn how to refer and advocate for their patients through collaborations with local medical-legal partnerships, in which legal experts work together with health care providers to aid patients who are homeless or with local legal aid organizations specializing in housing and eviction defense . Through this cross-sector collaboration, residents can learn to counsel patients to seek legal assistance in the case of an eviction.
Given the complexity of this topic, we suggest three didactic sessions to cover this material: (1) an overview of low-income housing and rapid re-housing; (2) a discussion of the structural causes and consequences of homelessness, as well as strategies for advocating for structural change; and (3) an overview of medical-legal partnerships (Table 1). Programs with less flexibility in their curricula can consider incorporating these topics into systems-based practice education, such as into existing case conferences or during clinical supervision (Table 2).
The fourth goal for resident education is to exhibit humanism when interacting with patients experiencing homelessness. As illustrated in the aforementioned case study by Braslow and Messac , residents may develop cynical attitudes and stigma toward patients experiencing homelessness that can contribute to barriers to care. Patients who are homeless may not establish care in outpatient clinics due to staff who are hostile or dismissive on the basis of a patient’s appearance . Some training sites have developed educational initiatives designed to improve provider empathy toward patients who are homeless. One interprofessional clinical curriculum incorporated narrative work and reflective practices, which led to improvements in trainee empathy and helper behavior toward patients who were homeless .
The Homeless Aligned Patient Care Team (HPACT) of the Veteran Affairs Greater Los Angeles Healthcare System developed and utilizes the “Humanism Pocket Tool” (HPT) to foster humanism and reduce stigma. This tool includes use of “vivid vignettes” to communicate a patient’s aspirations and barriers to achieving those aspirations . The HPT encourages residents and team members to use humanistic language to discuss mutual patients. More research is needed to understand resident attitudes and what drives a hesitancy to treat individuals experiencing homelessness–including possible concerns about available resources, lack of understanding, or lack of support. We suggest one didactic on humanistic clinical interactions with patients experiencing homelessness that would include how to obtain a narrative history and how to investigate personal subjective reactions to patients such as bias and cynicism.