This excellent paper was written to fulfill an assignment for the class I teach on cultural diversity at CSUDH.

Homeless in our Hometown
The Hidden Community

by Cammi Schwarze-Beem
School of Nursing, CSUDH

In today’s society a person’s worth is determined by their material possessions, the size of their home, what kind of car they drive and how well they dress. How are you viewed by society if you have nothing and live on the streets? What kind of treatment do you receive if you chose to live this way? Is homelessness a choice you make or simply the result of circumstances beyond your control? I had these and many other questions regarding this issue and in researching this topic I discovered a complete community of people living within our city. The statistics are staggering and the stories break your heart, but the most upsetting part is we don’t have a long term plan to fix the problem. Because healthcare costs are increasing at an alarming rate our hospitals are no longer able to provide services to those unable to pay. We now need to find different ways to provide the care for our community within the constraints of a budget, in order to sustain our resources. The first thing we can do is educate ourselves on what is already available in our area and provide written handouts to each social worker, case manager and nursing unit. Since the homeless arrive in the Emergency Room needing medical attention, if we had a system to provide the care in an alternative location it would free up hospital beds and prove more cost effective. In the event that they need to be admitted, we must provide culturally sensitive care and allow visitation by patient’s augmented family members. I feel we should change the way we look at these people and treat them with the respect and dignity they deserve. It is true that some choose this life, but others are only trying to get back on their feet and making the best of what has happened to them.

I interviewed several homeless people in various places and found different situations and stories that lead to their current situation. I meet two individuals sitting outside the HOPE medical van waiting to be seen by physician, a young couple hanging out at the park, and a pregnant woman outside Costco holding a sign asking for money to feed her children. I also spoke with medical providers of the HOPE van, the director of People of Progress services and several social workers and case managers at my hospital facility in order to get their feelings about homeless situation.

Resources for the Homeless
When faced with caring for the homeless, bedside nurses are unfamiliar with the resources available in our community for assistance. Due to recent change in hospital policy our social workers are now spending more time arranging patient transfers to skilled nursing facilities making them unavailable to assist with social concerns. The case managers are also too busy documenting appropriate level of care according to Interqual criteria to be of much help. The case managers and social workers are also required to flex down according to the census, so the staff are never assured they will have someone available when needed. That leaves the bedside nurse to know how to help and understand what resources are available. When I started my research I had no idea what was already in place to benefit not only the homeless, but also low income individuals in our area. I’ve gathered several handouts regarding services and will be combining, copying and distributing throughout my hospital and educating the staff. I believe knowledge is power and this information must get out to those who will benefit.

ICU Visitation Policy
Many of the homeless I spoke with have no biological family around and rely of their augmented family members for support. This is in conflict with the policy of our ICU, which only allows direct family (spouse, parents, siblings & children) to visit within the locked unit. This policy is not followed by all staff members, making it difficult for families to understand the rules. I’m sure the policy was implemented for patient safety, but the nurses who enforce it just don’t want to be bothered by family/friends, which requires increased attention and questions. There are many evidence based studies showing patients recover faster with strong family support, which can be presented at the staff meetings to try and change the current visitation policy. I also feel the staff needs to be educated to understand how important friends are to this population of patients, as they are considered family members. I don’t think we should be keeping patient’s support system away just because they don’t fit the “usual family unit”. I understand it’s easier to manage a patient for 12 hours without having to explain things to family, but that isn’t what we should be doing. These patients sometimes require long term wound care, who better to be taught but the family/friends they have available. In order to change this policy I will plan to attend monthly staff meetings to educate nurses on the family unit and special needs of the homeless patients. I don’t foresee a financial impact to the hospital, since I will be attending meetings during my usual work hours.

Hospital/ER Bed Utilization
In order to provide the necessary care of these patients without using hospital resources, I think we need to develop an alternative location. The cost of caring for one homeless patient in our Emergency room is $2,400.00/visit just for the bed, let alone any charges for medications, tests or the physician time. In the event the patient has to be admitted the cost starts at $2,650.00/day for the bed and goes up to over $3,000.00/day depending on level of care needed. Since many of these patients have no insurance or other means to pay for services, if we had a more cost effective place to provide care it would benefit the patient as well as the hospital. Many of the unfunded or underfunded patients are served by our community health clinic, but that is only open Monday-Friday, 8:00 am to 5:00 pm. Our hospital helps to support the HOPE (Health Outreach for People Everywhere) van, which provides medical and dental services in various places for the homeless around the area. This is a wonderful service for patients that lack transportation to clinics, as the mobile van visits local parks to see patients. The best option would be to develop an after hours clinic or transitional care unit to manage these patients who may need more attention. I know from trying to discharge homeless patients needing IV antibiotics for a week or two to treat wound infections, we have a real need. If we can’t get outpatient medications and home care arranged to visit in homeless shelter, than the patient stays in hospital. This drives up the costs and occupies a hospital bed, which could be better utilized by a paying customer. I tried to talk with administration regarding the needs of this population and how our facility could provide a valuable service, but was met with talk of financial deficits instead. I understand our hospital helps support many community programs already, but we need to do more for the homeless.

The homeless I spoke with expressed feelings of being abandoned by society and left wanting America to do more to end the epidemic. I heard from more than one that our government should be spending more money to feed and care for those here in our country, instead of supporting a war that we have no business being involved in. Fortunately there are many services available to assist people, but they have to want to change things for themselves. Many of the services require mountains of paperwork and follow through in order to get the help, which sometimes doesn’t get completed. When your main concern is where you will sleep that night and what food you can find to eat, filling out papers doesn’t seem so important. Another issue facing this group of people is substance abuse, which often times is the reason they are in the situation. I was amazed at the willingness of these people to share their stories with me and how open and honest they spoke about their choices. Another common theme among the homeless is the desire to live free of society’s restrictions, without anyone controlling them, even if that meant life on the street and the unknown.

I believe homelessness leads to development of separate culture in order to survive life on the streets. What you grew up learning and believing is forever changed by the struggles faced on a daily basis. Gone are the secure feelings of a solid roof over your head and warm place to sleep. The values of money, privacy, independence, freedom, health, fitness and physical appearance (Galanti, 2004) are suddenly modified in order to make it through another day. It appears from my interviews that this group have developed their own set of values, some very different than those in general society. For some people that live on the streets they are no longer concerned with physical appearance, privacy or modesty. The luxury of clean clothes and warm showers are a rare occurrence, leading to a lack of interest in the outward appearance that others see. That same feeling is not shared by everyone I met; in fact the young woman I spoke with had a different approach. I found Kelly outside the HOPE van waiting to see the physician regarding her antidepressant medications. She has been homeless since June 18, 2007 as a result of domestic violence at the hands of her husband. Because of what she has been through she feels it’s important to put on makeup and get dressed so others don’t know she is homeless. She verbalized feeling ashamed of her situation and tries to hide it, in order to not be looked down on and treated differently. I found Kelly wasn’t alone in her feelings of shame and not wanting to be judged by society.

I discovered everyone I spoke with possessed strong feelings regarding freedom and value that above all other things. It didn’t matter if they live in tents, cars, homeless shelters or the streets; they believe they are in control of their lives and that is what is important. Every human wants to feel like they belong and are valued and loved no matter what. I found some “outsiders” have chosen a life of homelessness in order to have a group that accepts them as they are. I’ve never been around such non-judgmental people, it seems to come naturally. Everyone is willing to listen to one another, not pushing any beliefs or religions and genuinely appears to get along. It doesn’t matter if you believe in God or some other deity; no one feels they are above anyone else. What a different world this would be if everyone had the same acceptance of other’s beliefs. When considering the worldview of homeless, that varies as much as it does for any cultural group. I did find many have a strong faith in God and believe he will provide when the time is right. They seem to have very positive outlooks and believe God provides when you need it most, which may not be when you feel help is needed. When discussing Kelly’s situation, she said “I try to believe everything happens for a reason, I just don’t understand why God would take away my baby like he did.” I sat quietly and held her hand, allowing her to share her feelings of loss and sadness. Even after all she’s been through Kelly remains hopeful that she will get into an apartment soon and regain custody of her three children. I also discovered a strong Christian faith as backbone of the homeless shelter and many transitional housing programs. I think by adhering to a common faith that also provides a sense of belonging and more of a community within the group. I think people need to have something beyond them to rely on for strength and that is what having faith provides.

In conclusion, I was deeply touched and profoundly moved by this project. I had no idea that within our city was a community of homeless people of all ages and situations. We take our lives for granted and never give a thought to what might happen if we lost our job and had no way to pay the bills. What would you do if the sole support of your household left you without money? The main reasons for becoming homeless are loss of job or income, although domestic violence, substance abuse and divorce are also leading causes (Shasta Homeless Continuum of Care, 2007). The numbers are frightening, especially since they continue to rise each year. The most difficult statistics are the homeless children living in shelters or transitional housing/hotels, which has increased from 660 in 2005 to 1,092 in 2007 (Shasta COC, 2007). The total number of homeless in our area has increased from 2090 in 2005 to 3316 in 2007 (Shasta COC, 2007). I think what I learned was the homeless are just people like everyone else; sometimes enduring terrible abuse and then trying to put their lives back together. I had the image of dirty, panhandling homeless person, which was not what I found when I started my research for this paper. I feel that I must now become an advocate for these people and work to change the policies within my facility. By working to educate the staff on resources available, family units and common causes of homelessness, I believe we can change attitudes and improve the way we care for these patients. I will also continue to work on policy change and further research available locations to provide necessary medical attention. I understand we must utilize our resources wisely, but we also need to care for our community members, no matter the cost.

References

Galanti, G. (2004). Caring for patients from different cultures (3rd ed.) Philadelphia: University of Pennsylvania Press.

Shasta Homeless Continuum of Care. Key Facts from the Shasta County Homeless Year-long Survey-2006Retried on February 12, 2008 http://www.shastacoc.org/www/Main%20Files/2006SurveyNotes.htm