pearls of wisdom sharing best practices, anecdotal experiences and clinical challenges in serving homeless youth and ado

1. Peggy Akers (HCH Portland, ME) Isabella Christodoulou (The Drop In Center, New Orleans) Dane� Sergeant (The Drop In Center, New Orleans) Wayne A. Centrone (Outside In, Portland, OR) THANK YOU � it is a real honor to present to this group, as you are all such important parts of the homeless healthcare delivery continuum. A little about why we have all come together to bring you this �round table� workshop � perspectives, differences, lessons, challenges and triumphs OUR GOAL FOR THIS TALK: Help enhance delivery of care to high risk and vulnerable young adults; specific drill down emphasis on �hard to serve� population of homeless young adults Wayne will be �TIME KEEPER� and help to move format in accordance to time allotments.THANK YOU � it is a real honor to present to this group, as you are all such important parts of the homeless healthcare delivery continuum. A little about why we have all come together to bring you this �round table� workshop � perspectives, differences, lessons, challenges and triumphs OUR GOAL FOR THIS TALK: Help enhance delivery of care to high risk and vulnerable young adults; specific drill down emphasis on �hard to serve� population of homeless young adults Wayne will be �TIME KEEPER� and help to move format in accordance to time allotments.

2. It is important to remember that homelessness is an experience and not a destination or a final place in one�s life; our goal is to introduce the audience to a group of young adults and adolescents who are experiencing homelessness and the challenges, needs, frustrations and triumphs of delivering care ands services to them.It is important to remember that homelessness is an experience and not a destination or a final place in one�s life; our goal is to introduce the audience to a group of young adults and adolescents who are experiencing homelessness and the challenges, needs, frustrations and triumphs of delivering care ands services to them.

4. Objectives: (:80 min) Describe the unique cohorts that are HY/A, HYA, and �Hard to Serve� (YIHA) (:10 min didactic) Discuss a model program to reach HYA in New Orleans, LA � with a special emphasis on the mental health needs of HYA (:20 min didactic) Discuss a model program to reach �hard to serve� HY/A and HYA in Portland, ME (:20 min didactic) Invite audience into a moderated discussion and Q&A session about model and unique approaches to serving HY and HYA (:30 min Q&A session) HY/A � Homeless youth and adolescents HYA � Homeless young adults YIHA � Youth identified homeless adults Format � Wayne INTRODUCTION � why here from three agencies; why more emphasis on anecdote then pure scientific discussion of statistics? Wayne start with discussion of epidemiology and social needs of HY and HYA Wayne describe the cohort that is �hard to serve� YIHA and the �Road Warrior Outreach Program� that OI started to reach them and bring care Wayne segue into discussion by Peggy and Bella re: unique programs facing unique challenges and creating unique solutions Bella Description and discussion of your program and why it is unique. Bella � emphasis on the Mental Health needs of HY and HYA Bella video with discussion of �sub cohorts� within HY and HYA � �gutter punks� Peggy � Discussion of uniqueness that is Portland, ME program; why started, what is the scope of services? Peggy � Why is your program project differnet from other HY and HYA programs and projects? Peggy � Does your program have a �philosophy of care?�HY/A � Homeless youth and adolescents HYA � Homeless young adults YIHA � Youth identified homeless adults Format � Wayne INTRODUCTION � why here from three agencies; why more emphasis on anecdote then pure scientific discussion of statistics? Wayne start with discussion of epidemiology and social needs of HY and HYA Wayne describe the cohort that is �hard to serve� YIHA and the �Road Warrior Outreach Program� that OI started to reach them and bring care Wayne segue into discussion by Peggy and Bella re: unique programs facing unique challenges and creating unique solutions Bella Description and discussion of your program and why it is unique. Bella � emphasis on the Mental Health needs of HY and HYA Bella video with discussion of �sub cohorts� within HY and HYA � �gutter punks� Peggy � Discussion of uniqueness that is Portland, ME program; why started, what is the scope of services? Peggy � Why is your program project differnet from other HY and HYA programs and projects? Peggy � Does your program have a �philosophy of care?�

5. The estimated number of street children and youth in the world ranges from 30 to 170 million United Nations, Department of International Economic and Social Affairs, The Situation of Youth in the 1980s and Prospects and Challenges for the Year 2000. New York: United Nations, 1986. The homeless youth population is estimated to be approximately 300,000 young people each year (Institute for Health Policy Studies, 1995). 40% of Street Youth in Latin America. According to the Research Triangle Institute, an estimated 2.8 million youth living in U.S. households reported a runaway experience during the prior year (U.S. Department of Health and Human Services), 1995 According to the U.S. Conference of Mayors, unaccompanied youth account for 3% of the urban homeless population (U.S. Conference of Mayors, 1998). Hard to really know - street kids - Homeless youth - Runaways Diverse group Large group Human rights issue with roots in poverty and victimization - victimization within the family and further exploited on the streets Estimated 40 million abandon youth and children on the streets of L. America (Hoge, 1983, NY Times) - Talk re: work in PeruThe homeless youth population is estimated to be approximately 300,000 young people each year (Institute for Health Policy Studies, 1995). 40% of Street Youth in Latin America. According to the Research Triangle Institute, an estimated 2.8 million youth living in U.S. households reported a runaway experience during the prior year (U.S. Department of Health and Human Services), 1995 According to the U.S. Conference of Mayors, unaccompanied youth account for 3% of the urban homeless population (U.S. Conference of Mayors, 1998). Hard to really know - street kids - Homeless youth - Runaways Diverse group Large group Human rights issue with roots in poverty and victimization - victimization within the family and further exploited on the streets Estimated 40 million abandon youth and children on the streets of L. America (Hoge, 1983, NY Times) - Talk re: work in Peru

6. Homeless & Abandon Youth 730,000 to 1.3 million nationally 25% Permanently homeless; 50% Runaway secondary to abuse 75% Engaged in illegal activity; 50% Involved with prostitution 50% �Alcoholic�, 80% Street Drugs, 35% Intravenous Drug Use Often engage in �survival sex� which increases the likelihood of STD�s and unintended pregnancies Noell J, et al. Childhood sexual abuse, adolescent sexual coercion and sexually transmitted infection acquisition among homeless female adolescents; Child Abuse and Neglect; 25(1): 137�48, Jan 2001.

7. Why are U.S. Youth �Homeless?� Family conflict and abuse 60-75% report serious sexual and physical abuse Economic problems in the �home� of origin �Aging out� of foster care Gay, lesbian, bisexual, transgender, questioning (GLBTQ) Residential instability School and learning Powers J, Eckerd J, Jaklitsch B. Maltreatment among run away and homeless youth. Child Abuse Negl 1990;14:87-98. Causes of homelessness among youth fall into three inter-related categories: family problems, economic problems, and residential instability. Number of causes and a number of reasons � - Abuse � physical, emotional, sexual � It does not have to be physical Part of longer term pattern Study by Allen, et al. in 2000 in J. of Poverty and Policy � between 20-25,000 youth are emancipated from foster care system each year without being adopted or returning to families Youth exiting juvenile justice systems also are at higher risk of becoming homeless (in a study of 940 youth in a shelter in WA, 28% were currently involved with a juvenile justice system) Repeated contacts w/ Public Social Service Systems - occurs at a very early age Study by Robertson in 1996 - School and learning � a study suggested that interrupted or difficult school histories; 2 studies found that about 25% report participation in special or remedial classes; while hx with school problems is prominent in literature, its contributions to homelessness are unclear; school problems are often hypothesisized to be precipitant of family conflictCauses of homelessness among youth fall into three inter-related categories: family problems, economic problems, and residential instability. Number of causes and a number of reasons � - Abuse � physical, emotional, sexual � It does not have to be physical Part of longer term pattern Study by Allen, et al. in 2000 in J. of Poverty and Policy � between 20-25,000 youth are emancipated from foster care system each year without being adopted or returning to families Youth exiting juvenile justice systems also are at higher risk of becoming homeless (in a study of 940 youth in a shelter in WA, 28% were currently involved with a juvenile justice system) Repeated contacts w/ Public Social Service Systems - occurs at a very early age Study by Robertson in 1996 - School and learning � a study suggested that interrupted or difficult school histories; 2 studies found that about 25% report participation in special or remedial classes; while hx with school problems is prominent in literature, its contributions to homelessness are unclear; school problems are often hypothesisized to be precipitant of family conflict

8. Why are U.S. Adults Homeless? Lack of affordable housing Low paying jobs Substance abuse and lack of needed services Mental illness and lack of needed services Domestic violence Unemployment Poverty Prison release U.S. Conference of Mayors. A Status Report on Hunger and Homelessness in America�s Cities: a 27-city survey. December 2001.

9. The total street youth population is estimated at 1,500-2,000 youth. 1,065 unduplicated homeless youth were served by O/I during fiscal year 1995-1996 As previously stated � HY suffer from a disproportionately higher rate of problems and medical Dx Research has shown that all children and youth need basic social, emotional and cognitive supports in order to become productive, contributing members of society.� These supports should begin at birth and continue throughout the child�s life.� Their impact is cumulative.� Most parents try to provide their children with these supports.� But even in the most stable and supportive of families, research is now indicating that familial support to enable a child to enter adulthood often continues well beyond the age of 18.� However, for the over 500,000 children in the foster care system in the U.S., this is not always the case.� Many children in foster care go through their childhood without the consistent, fundamental supports that any child needs to succeed.�Children in the foster care system face even more difficult hurdles as they transition out of the system into adulthood and independent living.� Because of the conditions that led to their placement in foster care, and the possible lack of support that comes from not having a stable foster home placement, they often need additional, specific supports in order to navigate this difficult period in their lives.� The total street youth population is estimated at 1,500-2,000 youth. 1,065 unduplicated homeless youth were served by O/I during fiscal year 1995-1996 As previously stated � HY suffer from a disproportionately higher rate of problems and medical Dx Research has shown that all children and youth need basic social, emotional and cognitive supports in order to become productive, contributing members of society.� These supports should begin at birth and continue throughout the child�s life.� Their impact is cumulative.� Most parents try to provide their children with these supports.� But even in the most stable and supportive of families, research is now indicating that familial support to enable a child to enter adulthood often continues well beyond the age of 18.� However, for the over 500,000 children in the foster care system in the U.S., this is not always the case.� Many children in foster care go through their childhood without the consistent, fundamental supports that any child needs to succeed.�

10. Background Data Persons experiencing homeless have disproportionate rates of chronic illness and death (O�Connell, 2005) Higher morbidity burden in AEH (Richardson, 2003) Young adults experiencing homelessness are less likely to engage �conventional� care environments (Auerswald and Eyre, 2004) The provision of healthcare services to young adults experiencing homelessness must be specialized and targeted (Barry, 2002) There is a growing population of �youth identified� YAEH who require specialized and targeted care delivery (Theory) YAEH � Young adults experiencing homelessness AEH � Adults experiencing homelessness I KNOW THAT OUR FOCUS FOR TODAY IS ON homeless youth � but bear with me for a second; this data is compelling (and � we do not have a great deal of data on HY)YAEH � Young adults experiencing homelessness AEH � Adults experiencing homelessness I KNOW THAT OUR FOCUS FOR TODAY IS ON homeless youth � but bear with me for a second; this data is compelling (and � we do not have a great deal of data on HY)

13. Housing Unsuitable for Habitation

14. Homeless adolescents often suffer from severe anxiety and depression, poor health and nutrition, and low self-esteem. In one study, the rates of major depression, conduct disorder, and post-traumatic stress syndrome were found to be 3 times as high among runaway youth as among youth who have not run away (Robertson, 1989).Homeless adolescents often suffer from severe anxiety and depression, poor health and nutrition, and low self-esteem. In one study, the rates of major depression, conduct disorder, and post-traumatic stress syndrome were found to be 3 times as high among runaway youth as among youth who have not run away (Robertson, 1989).

16. Who is a Road Warrior? Anecdotal Definition <25 year old (actuality 24-30 y/o) Homeless > 30 days out of past year Not otherwise engaged in services (such as housing, case management, etc) Hard to reach/serve � persistent mental illness Drug/alcohol dependent (much higher than housed-matched cohort and adult PEH) Socially isolated (chronically) Marginalized � economically, academically, socially, and developmentally

17. Who is a Road Warrior? Psycho-Social Information Physical Trauma/abuse Frequent physical/mental/sexual abuse and trauma Chronic Homelessness 81/144 (56%) reported being homeless >12 months Mental Illness High rates of depression, suicide* Drug and Alcohol Use/Abuse >40% report using injection drugs* 44% reported needs for alcohol/drug treatment* >80% w/ self reported daily Etoh �use� * Extracted from case manager reports, 2003

18. Kept late hours � tended to be seeking engagement after most programs were closed Drug/Alcohol � affected and dependent Isolated � Rough Sleepers Disconnected from other street youth �Counter-culture� (distinctive) Disliked �requirements for engagement� Clinic too institutional Barriers to Accessing Services

19. Creating Bridges for Care Delivery Get the story � don�t be afraid to inquire about housing status; vulnerability index (Kuhn, Culhane) Encourage ANY positive change (Hudson) Promote flexibility and creativity (Pires) Communicate with case managers and social workers (Kushel) Advocate � make the �hand off� help to connect patient to a primary care relationship (Salit, Petterson) Promote professionalism and respect in every patient care interaction (Hwang) Recognize the continuum � cohorts of risk w/in HY/A

21. Literature Cited Abdalian SE. Street Youth Mortality: Leaning With Intent to Fall. JAMA. 2004; 292: 624-626. Barkin SL,�Balkrishnan R,�Manuel J,�Andersen RM, Gelberg L. Health care utilization among homeless adolescents and young adults. J of Adoles Health. 2003 April;32(4): 253-256. Dahl RE. Adolescent brain development: A period of vulnerabilities and opportunities: Keynote address. Annals of the New York Academy of Sciences.�2004;1021:1-22. Haldenby, et al. Homelessness and Health in Adolescents. Qual Health Res. 2007;17: 1232-1244. Hwang SW. Is homelessness hazardous to your health? Obstacles to the demonstration of a causal relationship. Can J Public Health. 2002 Nov-Dec;93(6): 407-10. Lam JA, Rosenheck R. Street Outreach for Homeless Persons with Serious Mental Illness Is It Effective? Medical Care. 1999;37(9): 894-907. Neaigus A, Friedman SR, Sufian M, Stepherson B, Goldsmith D, Des Jarlais DC, Mota P. Peer culture and risk reduction among street IV drug users. Int Conf AIDS. 1990 Jun 20-23;6: 226. Noell J, et al. Childhood sexual abuse, adolescent sexual coercion and sexually transmitted infection acquisition among homeless female adolescents; Child Abuse and Neglect; 25(1): 137�48, Jan 2001. O'Connell JJ. Dying in the shadows: the challenge of providing health care for homeless people. Can Med Assoc J. 2004 April;170(8): 1251-1252. O�Connell JJ, Swain S. Rough Sleepers: A Five Year Prospective Study in Boston, 1999-2003. Presentation, MHSA 10th Annual Ending Homelessness Conference, Waltham, MA, 2005. Pires SA, Silber JT. On Their Own-Runaway and Homeless Youth and Programs that Serve Them. Children and Youth at Risk Project. Georgetown University, 1991.