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TB Notes 2, 2000
Update from the Research and Evaluation Branch
Update on the Management of Homeless TB Patients
Homeless TB patients account for about 6% of reported TB cases
in the United States. Some areas have greater concentrations of
homeless TB patients: In Atlanta, Dallas, Miami, and San Francisco,
homeless persons account for 11% of the area TB patients; in Houston,
10%; and in Los Angeles, 8% of TB patients are homeless.1
A few areas have much greater concentrations: In Orlando, homeless
persons comprise 18% of the city's reported TB cases; in Seattle,
they comprise 15%. In terms of numbers, in 1998, Los Angeles reported
106 cases and New York reported 88 TB cases among homeless persons,
levels about twice as high as the remaining urban reporting areas.
Results from the CDC Study of Hospitalization of Tuberculosis Patients,
recently published, 2 demonstrated the link between homelessness
and increased rates of TB hospitalization, longer hospitalization
lengths, and greater inpatient costs. Hospitalization tends to cost
about $2,000 more for a homeless patient than for a nonhomeless
patient. Providing stable housing and needed services may be more
cost-beneficial than hospitalization, 3 thus reducing
inpatient costs while promoting adherence to TB treatment and limiting
the transmission of TB and the development of drug-resistant TB.
The study was conducted at 10 US TB program sites (seven metropolitan
areas: Chicago, IL; Dallas/Ft. Worth, TX; Fulton County, GA; Houston,
TX; Los Angeles, CA; San Diego, CA; San Francisco, CA; a region
surrounding New York City; and two states: Mississippi and South
Carolina); data collection began in 1995 and ended in early 1996.
The participating sites were asked about current policies, procedures,
and funding sources for management of homeless TB patients.
Nine of the 10 sites offer homeless TB patients some form of housing
as an enabler or incentive to TB treatment adherence. The tenth
site only provides referrals of homeless patients to public hospitals
Of the nine sites providing housing, six provide alternatives to
hospitalization when patients are still considered infectious. These
alternatives include motels, apartments, mobile homes, cottages,
and single-room-occupancy (SRO) apartments. The motels and apartments
have single-unit ventilation to prevent sharing of air with other
units in the building. Where and when alternatives are unavailable,
infectious homeless TB patients are hospitalized at county public
hospitals. Three sites located in one state must follow state law
requiring local TB program approval before release of an infectious
TB patient from the hospital to prevent inappropriate discharges.
Nine sites provide housing alternatives for noninfectious homeless
patients until they complete TB treatment. In addition to SROs and
apartments, these alternatives include homeless shelters, boarding
houses, and substance-abuse treatment halfway houses. Directly observed
therapy (DOT) is provided by the TB program or health department
to patients at these locations.
Of the nine sites providing alternative housing, two receive funding
from their county health departments. Five receive funds from either
their state health department or the state TB control program; at
one of the sites receiving state funding, counties must apply to
the state for funding incentives or enablers that may include housing.
TB programs may also access federal or private funding for housing
TB patients. One of the nine sites receives federal funding for
a demonstration project to provide comprehensive room and board
services to homeless TB patients. At another of the nine sites,
funding is received from Health Care for the Homeless, a national
advocacy group, through a grant from the US Department of Housing
and Urban Development (HUD). Two sites receiving state funding are
also provided some funding for housing by local affiliates of the
American Lung Association.
In 1993, Karen Brudney warned that crowded shelters are especially
inappropriate for homeless AIDS patients. Four of the sites access
additional funding for housing homeless HIV-infected TB patients
through HUD's Housing Opportunities for Persons with AIDS (HOPWA)
program, HHS's Ryan White program, or local AIDS service providers.
The TB program sites also mentioned barriers to providing alternatives
to hospitalizing homeless TB patients. Six sites mentioned difficulties
in locating housing vendors, four because of housing costs or availability
and two because of fear and stigma about TB. One rural site mentioned
that the number of homeless TB patients in the area is insufficient
to make permanent arrangements for alternative housing. The staff
of the same site stated that they lack social workers to locate
housing and resolve patient needs, relying instead on nurses, who
have other responsibilities. One site mentioned concerns about the
ability to follow up and manage patients in various alternative
housing arrangements and also discussed jurisdictional boundaries
as obstacles to finding solutions for highly mobile populations.
Two sites listed patients' substance abuse, behavioral problems,
or unwillingness to leave the area as barriers to finding and keeping
alternative housing arrangements.
Two sites defray basic living expenses (rent, utilities, food)
to ensure that patients who otherwise would become homeless due
to their illness do not lose existing housing.
This article gives readers a snapshot of how some TB programs manage
their homeless TB patients. To reduce inpatient costs, all programs
should consider providing alternatives to hospitalizing infectious,
as well as noninfectious, homeless TB patients. However, they must
first overcome barriers to locating and then funding these housing
alternatives. Rural areas, with limited and thinly-stretched resources,
face additional challenges. TB providers and health departments
may not be aware of existing funding sources for housing, such as
Veterans Administration programs or HUD's Shelter Plus Care and
HOPWA programs. They can find out about funded housing arrangements
in their geographic areas by calling HUD's Community Connections
at (800) 998-9999, or they can access HUD's Website at
www.hud.gov then click on "homeless" under "topics,"
or go directly to www.hud.gov/hmless.html.
They should also ask HUD about options for applying for new funding
and local persons to contact to discuss potential collaboration.
Some TB Controllers have been able to work with partners such as
local affiliates of the American Lung Association or agencies for
the homeless to identify additional alternatives for housing homeless
TB patients. TB remains a problem, for a variety of reasons, among
the homeless. Providers can help eliminate TB among the homeless
by assessing homelessness among TB patients and linking the homeless
to existing housing and other resources. When local resources do
not exist, providers should work with DTBE consultants to find solutions
and prevent future TB outbreaks among the homeless.
—Submitted by Suzanne Marks, MPH, MA
Division of TB Elimination
- Moore, M. CDC Division of TB Elimination Surveillance and Epidemiology
Branch, personal communication. November 1999.
- a. Marks S, Taylor Z, Ríos Burrows N, Qayad M, Miller B. Hospitalization
of homeless persons with tuberculosis. American Journal of Public
b. Taylor Z, Marks S, Ríos Burrows NM, Weis SE, Miller Bess, Stricoff
Rachael L. Causes and costs of hospitalization of tuberculosis
patients. The International Journal of TB and Lung Disease. In
- Marks S and Taylor Z. Net benefits of providing housing to hospitalized
homeless TB patients. The International Journal of Tuberculosis
& Lung Disease. 1998;2(9)(Supplement):S155. Abstract.
- Brudney K. Homelessness and TB: a study in failure. J Law Med