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A Downward Spiral: A Case Study in Homelessness

National Health Care for the Homeless Council

Terri LaCoursiere Zucchero, PhD, RN, FNP-BC, and Pooja Bhalla, MSN, RN


Stopping a Downward Spiral - A Case Study in Homelessness
 Learning Objectives: At the end of this activity, you will be able to:

  • Analyze at least three issues contributing to homelessness.
  • Describe barriers to health care for individuals who are homeless.
  • Identify key characteristics of quality health care for the homeless.
Description: Thirty-six-year-old John may not fit the stereotype of a homeless person. Not long ago, he was living what many would consider a healthy life with his family. But when he lost his job, he found himself in a downward spiral, and his situation dramatically changed.

John’s story is a fictional composite of real patients treated by Health Care for the Homeless. It illustrates the challenges homeless people face in accessing health care and the characteristics of high-quality care that can improve their lives. 

Case: Married with two young children, John and his wife rented a two-bedroom apartment in a safe neighborhood with good schools. John liked his job as a delivery driver for a large food service distributor, where he had worked for more than four years. His goal was to become a supervisor in the next year. John’s wife was a stay-at-home mom.

John had always been healthy. Although he had health insurance through his job, he rarely needed to use it. He smoked half a pack of cigarettes each day and drank socially a couple times a month.

One afternoon, John’s company notified him that it was laying him off along with more than a hundred other employees. Though he was devastated about losing his job, John was grateful that he and his wife had some savings that they could use for rent and other bills, in addition to the unemployment checks he would receive for a few months.

John searched aggressively for jobs in the newspaper and online, but nothing worked out. He began to have feelings of anger and worry that led to panic. His self-esteem fell, and he became depressed. When John’s wife was hired to work part-time at the grocery store, the couple felt better about finances. But demoralized by the loss of his job, John started to drink more often.

Two beers a night steadily increased to a six-pack. John and his wife started to argue more often. Then, about six months after losing his job, John stopped receiving unemployment checks. That week, he went on a drinking binge that ended in an argument with his wife. In the heat of the fight, he shoved her. The next day, John’s wife took the children and moved in with her parents. No longer able to pay the rent, John was evicted from the apartment.

John tried to reconcile with his wife, but she said she’d had enough. Over the next few months, John “couch surfed” with various family members and friends. At one point, he developed a cold, and when it worsened over a few weeks, he sought care at the emergency department. Hospital staff told him that he would be billed because he didn’t have insurance. John agreed, and a doctor diagnosed him with a sinus infection and prescribed antibiotics. With no money to spare, John could not get the prescription filled.

John continued to live with family and friends, but his heavy drinking and anger only got worse, and his hosts always asked him to leave. He went from place to place. Finally, when John ran out of people to call, he found himself without a place to stay for the night and started sleeping at the park.

One night when John was drunk, he fell and got a cut on his shin. The injury became red and filled with pus. John was embarrassed about his poor hygiene and didn’t want a health care provider to see him. But when he developed a fever and pain, he decided to walk to the nearest emergency department. He saw a provider who diagnosed him with cellulitis, a common but potentially serious bacterial skin infection, and gave him a copy of the patient instructions that read “discharge to home” and a prescription for antibiotics. John could not afford the entire prescription when he went to pick up the antibiotics, but he was able to purchase half the tablets.

Winter arrived, and it was too cold for John to sleep outside, so he began staying at a shelter run by the church. Each morning, he had to leave the shelter by 6 AM. He walked the streets all day and panhandled for money to buy alcohol.

One evening, some teenage boys jumped John in park, stealing his backpack and kicking him repeatedly. An onlooker called 911, and John was taken to the emergency department. Later that evening, the hospital discharged John. He returned many times to the emergency department for his health care, seeking treatment for frequent colds, skin infections, and injuries. Providers never screen him for homelessness and always discharge him back to “home.” 

One day at the park, an outreach team from the local Health Care for the Homeless (HCH), one of about 250 such non-profit organizations in the United States, approached John. The team, including a doctor, nurse, and case worker, introduced themselves and asked John, “Are you OK?” John didn’t engage. They offered him a sandwich and a warm blanket. John took the food without making eye contact. The team visited John for the next several days. John started making eye contact and telling the team about his shortness of breath and the cut on his arm. The team began seeing John frequently, and he began to trust them. 

A couple weeks later, John agreed to go the HCH clinic. It was the first time in years that John went to a health clinic. Upon his arrival, the staff at the clinic registered him and signed him up for health insurance through Medicaid and food benefits. John felt comfortable in clinic, and he saw some of the people who also stayed at the shelter and spent their days in the park. They were happy to see him and told John about how the clinic staff care and would be able to help.

John began going to the HCH clinic on a regular basis. He saw a primary care provider, Maggie, a nurse practitioner. In John’s words, she treated him like a real person. In addition to primary care, the clinic offered behavioral health services. Both scheduled appointments and walk-in care was available. John connected with a therapist and began working on his depression and substance abuse. 

A year later, John’s health has improved. He rarely needs to go to the emergency room. He is sober and working with a case manager on finding housing.

Terri Zucchero is the Family Team Director at Boston Health Care for the Homeless Program and an Assistant Professor at the Graduate School of Nursing, University of Massachusetts Worcester. Pooja Bhalla is the Chief Operating Officer at Boston Health Care for the Homeless Program.​ For more information on health care for the homeless, please visit the National Health Care for the Homeless Council and Boston Health Care for the Homeless Program.

Discussion Questions:

  1. What events in John’s life created a “downward spiral” into homelessness? Which events related to social needs, and which could health care have addressed?
  2. What were some of the barriers John faced in accessing health care?
  3. Why do you think the emergency department was the first place John thought to go for care? How might the emergency department improve care for patients like John?
  4. Why do you think John wouldn’t make eye contact with the HCH team at first? How would you build a trusting relationship with a person like John?
  5. What aspects of the HCH care do you think represent high-quality care for the homeless? How do you think Maggie made John feel like he was a “real person?”
  6. In your own experience, have you encountered a homeless individual? What was that like? Do you recall what you were thinking?
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