According to The State of Homelessness in America, a September 2019 White House report from the Council of Economic Advisers, “Over half a million people go homeless on a single night in the United States,”1 The report estimates that approximately 65% live in homeless shelters; the other 35% are found unsheltered on streets, in parks, and in abandoned buildings.

What about homeless people who are not counted, such as those in rural areas? In an NPR article entitled Unsheltered and Uncounted: Rural America’s Hidden Homeless, Mary Meehan talks about the “scattered and hidden nature of homeless in rural places [which] makes it an especially hard problem to measure and address.”2

Over the years, I have encountered many patients who are homeless and simultaneously living with cancer. Some were living in shelters; however, due to issues such as safety concerns, lack of identification, lack of available space, medical barriers (such as the inability to accommodate needed medical equipment), and risk of infection, many patients have opted to remain out of the shelter system.

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Homelessness Varies

The definition of homeless often doesn’t take into account subpopulations such as those with no physical address of their own but who have an address for mail and correspondence, which is often recorded in electronic health records (EHRs). At times, their nightly struggle to figure out where they will sleep is revealed only through ongoing assessment. Some homeless persons are fortunate to have family or friends who offer temporary shelter, but this often means frequently moving from place to place; and some are living in spaces without the knowledge of anyone in the surrounding area. I would venture to say that even the best estimates underestimate the actual number of homeless people in the United States. As the United States prepares for the 2020 Census, numerous articles point to a homeless population that has grown exponentially in cities and communities across the country.

An oncology social worker (OSW) is usually among the first team members to get a call when homelessness is revealed or discovered for a person living with cancer. Often the consult is to address the problem; however, homelessness is complex. It is a problem that usually cannot be “fixed” in a short window of time, such as by the start of treatment. Each situation is unique, given that “homelessness” doesn’t look the same nor do the contributing factors align from person to person. In addition, treatment barriers vary depending on whether treatment will occur at the hospital/cancer center or at home. For example, home infusion nurses need to meet a patient at a physical address — and not a shelter — to disconnect the infusion pump.

Addressing Barriers

With so many barriers, where does one start? With so many unmet needs at the base of Maslow’s Hierarchy of Needs, a healthcare provider can feel overwhelmed by a patient with newly diagnosed advanced cancer who needs to start treatment immediately but has no home, as well as possibly missing other fundamental needs such as income, food, insurance, and support. Here are some pointers to keep in mind as you proceed.

Don’t panic If you have an oncology social worker or psychosocial coordinator on your team, make a referral as soon as possible. In the meantime, collect details and pertinent information even if you don’t know the next steps to take. If you don’t have an OSW on your team, who is the person that would normally assist patients with psychosocial needs and concerns? Refer your patient to this person.

Assess, assess, assess When I receive a referral in the setting of homelessness, I begin by asking the referral source basic questions to determine what is known; however, a frequent response is, “I wondered about that but I didn’t know how [didn’t want] to ask.” Remember, assessment is essential for all patients, even those who don’t have a place to live.

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Choosing not to ask for pertinent information can sometimes point to our own level of discomfort, bias or our own assumptions. Asking a question doesn’t always mean we will get an answer, but we should always ask.

It’s okay to say, “I don’t know” As a seasoned oncology social worker, I’ve become comfortable with not knowing.How can we know it all? The healthcare industry thrives on what we know and how what we know now differs from what we knew then, especially as it relates to advances in treating cancer. After all, the process of getting from then to now involves an element of not knowing. When we don’t have an answer to a patient’s question(s), perhaps another member of the multi-disciplinary team does. Referring patients to the appropriate personhelps patients to better understand how their cancer care team works together.

Be aware of nonverbal behavior A patient expressed to me once that although everyone on her team treated her well, she didn’t like the looks of pity on their faces. She went on to express that sometimes it made her feel even worse about her situation. What we think is a look of empathy may not be perceived that way. I’m not suggesting that we should be expressionless; however, our overt lip or eyebrow frowns are not always appreciated. Audible sighing when unable to obtain needed information may communicate frustration or other unintended messages; rather, we must proceed with the understanding that there are many factors that influence presenting behaviors. Beware of issues related to transference and countertransference; reach out for supervision or professional support as needed.