Barriers and facilitators to resolving older adult homelessness through stays with family: qualitative findings from the HOPE HOME study

ABSTRACT

Living with family and friends is a common strategy to prevent or exit homelessness, but little is known about structural barriers that impede family and friends’ ability to provide temporary or permanent housing for older homeless adults. We conducted semi-structured interviews with 46 homeless participants from the HOPE HOME study, a cohort of 350 community-recruited homeless adults age 50 or older in Oakland, CA, who reported staying with housed family/friends for 1 or more nights in the prior 6 months. We conducted semi-structured interviews with 19 hosts of homeless participants and 11 stakeholders in housing and homelessness. We found that homeless older adults and hosts perceived these stays as a form of temporary housing rather than as a permanent exit to homelessness. Structural barriers to family and friends providing housing for temporary stays or permanent exits from homelessness included housing regulations restricting visitors and changing rent obligations; decreased eligibility and priority for shelter and permanent housing; geographic and transportation challenges; and environments inconducive to older adults. We suggest four areas for policy reform: providing subsidies to hosts and homeless individuals, removing disincentives for homeless older adults to stay with family, changing lease regulations, and expanding the supply of affordable housing.

KEYWORDS:

• Homelessness
• family
• friends
• policy
• social ecological model

Acknowledgements

The authors would like to thank the participants who chose to tell their stories and our Community Advisory Board for their leadership and assistance. The authors would also like to thank Erin Hartman and Cheyenne Garcia for their review of this manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the UCSF School of Medicine under a summer research grant awarded to the first author, Christopher Cai; National Institute on Aging at National Institute of Health under Grants 5R01AG050630, 5R01AG041860, 2K24AG046372 awarded to Dr. Kushel. The NIH had no role in the data collection, analysis or writing of the manuscript. The contents and views in this manuscript are those of the authors and should not be construed to represent the views of the National Institutes of Health.

Notes on contributors

Christopher Cai

Christopher Cai is a fourth-year medical student at the University of California San Francisco (UCSF). His work on Medicare for All financing has been published in PLoS Medicine, featured on ABC news and shared by members of Congress. During medical school, he interned with U.S. Representative Pramila Jayapal (D-WA) and was a board member of Students for a National Health Program (SNaHP). He hopes to pursue a career at the intersection of politics and clinical medicine.

Kelly R. Knight

Kelly Ray Knight, PhD is a medical anthropologist and Associate Professor & Vice-Chair in the Department of Anthropology, History and Social Medicine at University of California San Francisco (UCSF). Her work centers on the experiences of poverty and addiction in clinical and policy contexts, racism and health disparities, and health conditions produced or exacerbated by structural violence. Dr. Knight’s NIH-funded research explores the health, social and policy implications of homelessness in California and the clinical and social consequences of the UC opioid overdose crisis. She has spear-headed efforts in medical education reform at the UCSF School of Medicine, and nationally, related to addiction medicine and structural competency.

Pamela Olsen

Pamela Olsen is a Research Project Manager at University of California, San Francisco’s Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center. Before joining UCSF, she worked for 20 years with vulnerable populations as a criminal and legal investigator in California and Nevada, including on post-conviction mitigation for those sentenced to death. She has a master’s degree in Gerontology and has worked with Dr. Kushel on her longitudinal research of older people experiencing homelessness in Oakland, California (HOPE HOME). She also manages an NIH-funded research project on Advance Care Planning for older, vulnerable populations who have experienced homelessness. Her work centers on issues of homelessness, poverty and other structural inequities that contribute to vulnerabilities.

John Weeks

John Weeks has been with UCSF for 11 years. His most recent research project involved the study of homelessness among people age 50 and older in Oakland, CA. Prior to that, John had worked as a Project Coordinator for the Bruthas Project, which was a CAPS intervention study focusing on HIV prevention among MSM populations in San Francisco and Oakland. John joined Dr. Kushel's HOPE HOME Study in August 2015 as a Clinical Research Coordinator.

Margaret A. Handley

Margaret A. Handley is a public heath trained epidemiologist in the Departments of Epidemiology and Biostatistics and at the Center for Vulnerable Populations, at the University of California San Francisco. Her research focuses on implementation science and bridging the fields of primary care, public health, and health communication. Dr. Handley co-directs the UCSF Program in Implementation Sciences. She has methodological expertise in practice-based research, community-engaged research, quasi-experimental designs, implementation science, and mixed methods.

Margot B. Kushel

Margot B. Kushel, MD is a Professor of Medicine at University of California San Francisco, and Division Chief and Director of the UCSF Center for Vulnerable Populations, and Director of the UCSF Benioff Homelessness and Housing Initiative. She is a practicing general internist at Zuckerberg San Francisco General Hospital. Margot's research focuses on the causes and consequences of homelessness and housing instability, with the goal of preventing and ending homelessness and ameliorating the effects of homelessness on health. She speaks at a local, state and national level about issues of homelessness, and provides testimony to legislative bodies. She received her AB from Harvard College, her MD from Yale and completed residency, chief residency and fellowship in internal medicine at UCSF.