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MEDICAL
CARE Jessica is a 19 year old female who was living with her mother in the Bronx until age 16, when she left because she and her mother were unable to get along. She went to a shelter in Manhattan and lived there for several weeks. While living there, Jessica met her 30 year-old boyfriend. She left the shelter to live with him, and endured physical abuse throughout their three year relationship. Three days prior to her presenting for medical services, Jessica’s boyfriend told her that he wanted her to perform sex work to support their household. She refused, and he brutally beat her to the point that she developed blurred vision in her left eye, probably as a result of a dislocated lens. Jessica left the apartment and went back to the youth shelter, but her boyfriend found her in the neighborhood around the shelter the day she sought medical care and detained her at knifepoint, threatening to kill her unless she returned to him. During the interaction, a police car passed by and Jessica took the opportunity to run. She presented herself to an emergency medical clinic to evaluate her blurred vision in her left eye, and reported that she didn’t know where to go because she knew that her boyfriend would find her if she stayed at the youth shelter in Manhattan.
During her visit with the clinic’s outreach program, Jessica gave her medical and social history, received a focused physical examination, supportive counseling and referrals to a domestic violence shelter and emergency room in Brooklyn where she would be safe.
STATEMENT OF THE ISSUE Adolescence marks a time of great physical, developmental and emotional change. Navigating through this tumultuous period can be difficult even for those coming from the most stable of circumstances. Childhood environments characterized by significant instability, chaos and loss often deny them the proper tools to negotiate a path to a healthy and productive adulthood. Sadly, the lives of most homeless youth are scarred by histories of abuse (60% - 75%)1 and involvement with the foster care system (65% - 80%)2,3. A toxic combination of poor life skills, inadequate education, and low self-esteem often makes it difficult for homeless young people to reach their potential. Arriving on the streets puts them into contact with an underworld economy that rapidly becomes their only means of survival. Ironically these survival behaviors are also the same activities that place their physical and mental health at greatest risk. Numerous studies have demonstrated worse health outcomes for those youth that are on the street compared to those who are sheltered. Prostitution and other forms of survival sex (sex for food, a place to stay, drugs or companionship), robbery, panhandling and drug selling are common practices in the street economy. Alcoholism, drug addiction, street gang involvement and sexual promiscuity are risk-taking behaviors that characterize street culture. Thus, the prevalence of sexually transmitted and other communicable diseases, unintended injury, unwanted pregnancies, depression and suicide are significantly higher than in domiciled adolescent populations. There is a serious gap in accessible comprehensive primary care services for homeless/street youth in NYC at the present time. The American Academy of Pediatrics considers its gold standard of primary care the Medical Home whose essential role is to provide comprehensive primary care services in a stable, trusting community-based environment in tune with the constituents it serves. The following list is the components of a medical home that homeless youth are NOT receiving:
Outside of the major issue of lack of health insurance other factors contributing to inadequate care specific to these adolescents are:
These barriers are potent forces in keeping youth away from traditional health care centers. Studies on the pattern of accessing health care by homeless persons consistently demonstrate improved continuity of care and compliance with treatment regimens when attending nontraditional clinics located at sites where they are receiving other services (e.g., drop-in centers, needle exchanges, shelters, food pantries). Furthermore, arcane procedures for Medicaid enrollment and strict eligibility rules become system-based barriers to care. Lack of insurance severely limits access to a wider range of services and pharmaceutical products. Consequently, the burden of cost for providing health care for these uninsured youth falls onto the programs that serve them. This in turn becomes a built in constraint; preventing both expansion of services by those providing care and a disincentive to those considering developing new programs.
CURRENT ISSUE Homelessness has a significant impact on health outcomes and takes an immense psychological toll. The combination of past and present trauma, the stress of daily living and feelings of hopelessness all undermine the teen’s ability to prioritize health concerns.. Not surprisingly, there is limited data on the specific prevalence of health conditions in this population. What has been shown is that youth who (1) live on the streets as compared to shelters and (2) have no contact with any homeless-youth services compared to those who do have worse health outcomes. We can infer that any health statistic underestimates the true gravity of the problem, as they do not document those youth not interacting with the system. Unintended injury, sexually transmitted diseases (including HIV), unwanted pregnancies, substance abuse, depression and suicide are common medical problems seen in adolescence. However, compared to a domiciled population the prevalence of these problems in the homeless is considerably higher. Chronic exposure to the elements also results in a higher incidence of upper respiratory tract infections, dermatological conditions (including sunburn) and trauma. Tuberculosis is more frequently seen as the result of living in congregate care facilities (group homes, shelters and prisons). Survival sex and needle use, common practices among homeless adolescents have the added risk of HIV, syphilis and hepatitis A, B, and C.
EXISTING SERVICES Currently, homeless adolescents can receive free, comprehensive health care from several organizations that focus specifically on their unique needs. Mobile medical services are currently provided by three adolescent health clinics in New York City. Mobile medical services to street youth are primarily provided by three mobile medical vans in New York City. Some homeless youth programs either provide on-sight health services or have adolescent health care or hospital referral linkages in their immediate vicinity.
1. Geographic: The programs mentioned above cover a small geographic area. Given the success of mobile medical services in engaging hard-to-reach youth it is reasonable to conclude that more extensive outreach would engage more youth. 2. Health Insurance: The majority of homeless youth lack insurance even though they are eligible through Medicaid, Child Health Plus and Family Health Plus due to the cumbersome application process. Barriers include the need to go to multiple appointments and possess proof of identity. For undocumented immigrant youth over the age of 18 years, it is virtually impossible to get insurance. 3. Expanded Services & Specialty Care: While access to comprehensive primary care are available through programs mentioned above; expanded medical and specialty services are much harder if not impossible to obtain without insurance. This includes medical subspecialty care, dental care, pharmaceuticals, durable medical equipment, radiology and other diagnostic services. Mental health and substance use care for youth (especially uninsured) are virtually non-existent. 4. Subset Populations: There exist subsets of the homeless youth community that require yet more specialized care that is often limited or wholly unavailable. Examples of this include transgender-identified, heroin injecting and immigrant youth. 5. Homeless Adolescent Oriented Care: More health care professionals that are trained in the unique bio-psychosocial needs of homeless youth are needed.
RECOMMENDATIONS · Expand Health Insurance Coverage to all youth under the age of 21 years old, irrespective of immigration status. · Simplify the Application and Documentation process for health insurance. This should include (a) enrollment-site expansion (e.g., drop-in centers, shelters and mobile medical units) and (b) place homeless youth in fee-for-service, rather than managed care, plans to permit wider access of services. This is especially important considering their transient nature and difficulty utilizing a sole primary care provider. · Develop a Dept. of Health Task Force to focus on the health problems of homeless youth. This body must work in close collaboration with existing homeless youth health care providers and coalitions. · Improve Awareness to the Medical Community of specific health care issues of homeless populations by incorporating such expanded topics into the curriculums of medical school, residency training programs and medical associations. · Increase Funding to programs that provide medical care to homeless youth, with a focus on expanding mobile medical services. Models that incorporate both shelter and drop-in centers combined with medical care have proven most effective and should be replicated.
REFERENCES: 1 Homeless and Runaway Youth Health & Needs: A Position of Paper of the Society of Adolescent Medicine, Journal of Adolescent Health: 1992; 13:717 – 726. 2 The New York City Task Force on Homeless Youth Fact Sheet- 2001. 3 NY Times “Youth Leaving Foster Care System with Few Skills or Resources,” 3/28/00.
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