Frequently Asked Questions
- What is the official definition of homelessness?
- Are there different types of homelessness?
- When and how was the Health Care for the Homeless Program created? What does it do?
- What is the relationship between health, housing, and homelessness?
- How many people does the Health Care for the Homeless Program serve each year?
- Where can individuals experiencing homelessness go to obtain health care services?
- My organization is interested in becoming a health care for the homeless site; where can I find more information?
- Are health care services available for homeless youth?
- What types of housing and health services are available to veterans?
- Where can I obtain more information about homelessness and the Health Care for the Homeless Program?
- Where can I find information about health care reform, patient-centered medical home (PCMH), and meaningful use (MU)?
There is more than one “official” definition of homelessness. Health centers funded by the U.S. Department of Health and Human Services (HHS) use the following:
A homeless individual is defined in section 330(h)(4)(A) as "an individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility (e.g., shelters) that provides temporary living accommodations, and an individual who is a resident in transitional housing." A homeless person is an individual without permanent housing who may live on the streets; stay in a shelter, mission, single room occupancy facilities, abandoned building or vehicle; or in any other unstable or non-permanent situation. [Section 330 of the Public Health Service Act (42 U.S.C., 254b)]
An individual may be considered to be homeless if that person is "doubled up," a term that refers to a situation where individuals are unable to maintain their housing situation and are forced to stay with a series of friends and/or extended family members. In addition, previously homeless individuals who are to be released from a prison or a hospital may be considered homeless if they do not have a stable housing situation to which they can return. A recognition of the instability of an individual's living arrangements is critical to the definition of homelessness. (HRSA/Bureau of Primary Health Care, Program Assistance Letter 99-12, Health Care for the Homeless Principles of Practice)
Programs funded by the U.S. Department of Housing and Urban Development (HUD) use a different, more limited definition of homelessness [found in the Homeless Emergency Assistance and Rapid Transition to Housing Act of 2009 (P.L. 111-22, Section 1003)].
- An individual who lacks a fixed, regular, and adequate nighttime residence;
- An individual who has a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping ground;
- An individual or family living in a supervised publicly or privately operated shelter designated to provide temporary living arrangements (including hotels and motels paid for by Federal, State or local government programs for low-income individuals or by charitable organizations, congregate shelters, and transitional housing);
- An individual who resided in a shelter or place not meant for human habitation and who is exiting an institution where he or she temporarily resided;
- An individual or family who will imminently lose their housing [as evidenced by a court order resulting from an eviction action that notifies the individual or family that they must leave within 14 days, having a primary nighttime residence that is a room in a hotel or motel and where they lack the resources necessary to reside there for more than 14 days, or credible evidence indicating that the owner or renter of the housing will not allow the individual or family to stay for more than 14 days, and any oral statement from an individual or family seeking homeless assistance that is found to be credible shall be considered credible evidence for purposes of this clause]; has no subsequent residence identified; and lacks the resources or support networks needed to obtain other permanent housing; and
- Unaccompanied youth and homeless families with children and youth defined as homeless under other Federal statutes who have experienced a long-term period without living independently in permanent housing, have experienced persistent instability as measured by frequent moves over such period, and can be expected to continue in such status for an extended period of time because of chronic disabilities, chronic physical health or mental health conditions, substance addiction, histories of domestic violence or childhood abuse, the presence of a child or youth with a disability, or multiple barriers to employment.
Hence different agencies use different definitions of homelessness, which affect how various programs determine eligibility for individuals and families at the state and local level. Health centers use the HHS definition in providing services.
Yes, there are groups of people who experience homelessness in different ways, but all homelessness is characterized by extreme poverty coupled with a lack of stable housing. Children on their own or with their families, single adults, seniors, and veterans compose various demographic groups that may use different types of programs or services or have differing factors that contribute to their homelessness. There are also those who experience homelessness for various lengths of time (short-term, long-term, or “chronic”) or who experience multiple episodes of homelessness (moving between housing and homelessness). Those who are “doubled up” or “couch surfing” are also considered homeless if their housing arrangement is for economic reasons and is unstable (a disagreement or other scenario could result in being asked to leave). Accessible and affordable housing is the key underlying need for all these situations regardless of other demographic factors.
The Health Care for the Homeless (HCH) Program started in 1985 through 19 demonstration projects funded by the Robert Wood Johnson Foundation and the Pew Memorial Trust. The intention of these initial projects was to determine if a specialized model of delivering services could improve the health of individuals experiencing homelessness. Federal funding for more projects began in 1987 through the Stewart B. McKinney Homeless Assistance Act. In 1996, HCH projects were consolidated with community health centers and other primary care projects administered by HRSA’s Bureau of Primary Health Care. By law, HCH projects receive 8.7% of appropriated health center funds. There are now 208 HCH projects nationally—at least one in every state, the District of Columbia, and Puerto Rico.
Like other health centers, HCH projects are community-based and patient-directed organizations that serve low-income populations with limited access to health care. Each is located in a medically underserved community, is a nonprofit organization or public entity governed by a community board, and provides comprehensive primary care as well as supportive services (education, translation, transportation, etc.) that promote access to health care. All services are provided on a sliding scale with fees adjusted based on income and the ability to pay, and no patient may be turned away due to inability to pay. Unlike other health centers, HCH projects are required to provide substance abuse treatment services.
Poor health (illness, injury and/or disability) can cause homelessness when people have insufficient income to afford housing. This may be the result of being unable to work or becoming bankrupted by medical bills.
Living on the street or in homeless shelters exacerbates existing health problems and causes new ones. Chronic diseases, such as hypertension, asthma, diabetes, mental health problems and other ongoing conditions, are difficult to manage under stressful circumstances and may worsen. Acute problems such as infections, injuries, and pneumonia are difficult to heal when there is no place to rest and recuperate.
Living on the street or in shelters also brings the risk of communicable disease (such as STDs or TB) and violence (physical, sexual, and mental) because of crowded living conditions and the lack of privacy or security. Medications to manage health conditions are often stolen, lost, or compromised due to rain, heat, or other factors.
When people have stable housing, they no longer need to prioritize finding a place to sleep each night and can spend more time managing their health, making time for doctors’ appointments, and adhering to medical advice and directions. Housing also decreases the risk associated with further disease and violence. In many ways, housing itself can be considered a form of health care because it prevents new conditions from developing and existing conditions from worsening.
In 2009, there were 1,018,084 patients who were homeless served at all health centers with the vast majority (81%) seen at HCH projects. Of those seen at HCH projects, nearly all (91%) patients are under 100% of the federal poverty level (FPL) and about two-thirds (66%) are uninsured. Most of the patients at HCHs are adults age 20 to 64 (80%), but 17% were children/youth under age 19 and 3% were older adults age 65 and over.
Low-income individuals can obtain health services at any health center in their community. HRSA hosts a search tool to find a health center near you here.
My organization is interested in becoming a health care for the homeless site; where can I find more information?
HRSA is currently expanding the health center program as part of meeting national goals associated with the Affordable Care Act. Over the next five years, funding will become available to create new HCH and other health center projects, sites, and services.
If your organization is interested in learning more about health center requirements, please click here. This site will explain the requirements and the process for applying for grant funds to become an HCH grantee.
Technical assistance with the application process is available from the National Health Care for the Homeless Council via email at email@example.com or (615) 226-2292.
Yes, health care for the homeless projects (and health centers in general) provide a wide range of primary care and other services to children experiencing homelessness. While youth of any age can be served at HCH clinics, laws vary state-by-state about the types of services that youth can receive without parental consent. For minors who are not together with their family, parental consent can be a challenge to obtain. In these circumstances, providers will do everything they can to find the appropriate parent who will consent to care.
Returning veterans who are experiencing homelessness can be connected to the Health Care for Homeless Veterans Program, a separate program administered by the Department of Veterans Affairs (VA). There is a coordinator for this program at each VA medical center who can assist veterans in accessing housing and supportive services. More information on these services is available here.
Veterans can also access health services at any health center. In fact, nearly 203,000 veterans received care at health centers in 2009, and about 10% of these veterans were seen at HCH projects.
Where can I obtain more information about homelessness and the Health Care for the Homeless Program?
The National Health Care for the Homeless Council has a robust website with a library of materials focused on homelessness and health care at www.nhchc.org.
HRSA has more information about HCH projects here.
Where can I find information about health care reform, patient-centered medical home (PCMH), and meaningful use (MU)?
Our website has a clearinghouse page of PCMH and MU resources available from the National Health Care for the Homeless Council here.
You can learn more about the National HCH Council's policy and advocacy work related to health care reform, see a full list of health care reform materials produced by the Council, and review selected materials from other sources on health care reform and special populations here.
If you are looking for technical assistance with preparation for PCMH recognition, know that the National HCH Council offers no-cost assistance to HCH grantees on this and other topics related to health care reform and Medicaid expansion as well as HRSA program requirements. You can request technical assistance through our online form or contact our technical assistance coordinator, Juli Hishida.