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Understanding Homelessness

Overview Before we begin...Who do you imagine?Where are they?A broader reality Reflect on your experience Why definitions matter ETHOS Light ETHOS Light - Six Operational Categories Other Definitions of Homelessness Three interacting layers of cause Pathways into Homelessness and Typical Trajectories Typical Trajectories of Homelessness Stages of Homelessness: Attempt at Reintegration, Regression, Resignation Health, Psychological and Social Consequences of Homelessness Myths and Stereotypes Cultural and National Differences in the Perception of Homelessness Approaches to Addressing Homelessness: Staircase Model vs. Housing First Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Core Insight for Integrated Health and Social Care Rethinking Homelessness Through Multiple Lenses Applied assessment Closing reflection

Health Complexity

Overview Before we begin...Overview of Physical Health Conditions Common in Homeless Populations Physical Illness as a Socially Determined Condition Spectrum of Physical Health Problems Emergency Care and System Fragmentation Complexity Rather Than Isolated Illness Chronic and Infectious Diseases in Homeless Populations Infectious Diseases Interaction Between Chronic and Infectious Disease Mental Health and Substance Use: Clinical and Systemic Complexity Mental Health Disorders Substance Use and Health Consequences Trimorbidity and Clinical Complexity: When three crises overlap Multimorbidity and Complexity of Care Needs Social Complexity and Care Burden Barriers to Healthcare Access: Stigma, Administrative, Financial and Logistical Obstacles Consequences of Access Barriers Innovative Healthcare Delivery Models: Street Medicine, Mobile Clinics, Outreach Teams and Telehealth Evaluating Applicability in European Contexts Ethical Dilemmas in Providing Healthcare to Marginalised and Excluded Groups Integrative Synthesis Core Insight for Integrated Health and Social Care When Multimorbidity Meets System Fragmentation Applied assessment Closing reflection

Social Integration

Overview Before we begin...Housing as a Determinant of Health Housing First and Housing-Led Approaches in Europe The Eight European Housing First Principles Evidence Base and Health Outcomes European Implementation Contexts Housing First in Central and Eastern Europe (CEE)Housing-Led Approaches: Conceptual and Structural Differences Structural Preconditions and System Integration Economic Stability and Broader Pathways to Social Integration Employment Support and Vocational Reintegration Broader Forms of Social Integration Interdependence of Housing, Income and Participation Structural Barriers Across European Contexts Legal Protection, Eviction Prevention and Sustaining Tenancy Rights-Based Approaches Preventing Evictions: Early Intervention Matters Sustaining Tenancy: Beyond Preventing Eviction Psychological Dimensions of Tenancy Sustainment Structural Variation Across Europe Community Integration, NGOs and Peer Empowerment Community as Health Infrastructure Role of NGOs in Integration Pathways Municipalities and Local Governance Peer Involvement: Lived Experience as Structural Knowledge Benefits of Peer and Community Involvement Community Integration in Central and Eastern Europe Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Core Insight for Integrated Health and Social Care Applied Practice When Integration Depends on Coordination Applied assessment Closing reflection

Architecture

Overview Before we begin...Principles of Integrated Health and Social Care What Integrated Care Means in Practice Four Core Principles of Integrated Health and Social Care Four Core Principles of Integrated Health and Social Care Principle 1: Whole-Person Integrated Care Principle 1: Whole-Person Integrated Care Practical Example: Whole-Person Care in Action Principle 2: Low-Barrier and Equitable Access Principle 2: Low-Barrier and Equitable Access Practical Illustration: High-Barrier vs. Low-Barrier Systems Principle 3: Trust-Based and Trauma-Informed Practice Principle 3: Trust-Based and Trauma-Informed Practice Practical Illustration: Fragmented vs. Integrated Trust-Based Model Principle 4: Health and Housing as Rights – System Responsibility Principle 4: Health and Housing as Rights – System Responsibility Practical Illustration: Traditional vs. Rights-Based Integrated Model Module 4 – Principles Summary Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Integrative Synthesis Selected International Models of High-Integration Practice Integrative Synthesis Core Insight for Integrative Synthesis When Services Exist but Integration Fails Applied Assessment Task Strategic Reflection & Closing Strategic Reflection Integration Is Not Co-Location Economic and Ethical Imperative Micro-Sparring Closing Closing reflection

Clinical Practice

Overview Before we begin...Operationalising Integrated Care in Complex Mental and Physical Health Situations Trauma, Chronic Stress and Neurobiological Dysregulation 2. Chronic Stress as a Biological Condition 3. Neurobiological Dysregulation 4. Complex Trauma and Emotional Regulation 5. Trauma and Substance Use 6. Trauma and Physical Health Interaction 7. Clinical Implication: Reframing Behaviour 8. Intersectional Vulnerability Key Clinical Insight Multimorbidity and Dual Diagnosis 2. Dual Diagnosis and Psychiatric Comorbidity 3. The Interaction Between Mental Illness and Physical Health 4. Medication Adherence and Executive Function 5. Emergency Department Cycling 6. Matching Support Intensity: ICM vs ACT 7. Parenting and Multimorbidity 8. Minority Stress and Access to Care 9. Clinical Interpretation Shift Key Clinical Insight Evidence-Based Tools as Instruments of Integrated Care 2. Harm Reduction 3. Motivational Interviewing (MI)4. De-escalation and Conflict Management 5. Integrating Physical Health into These Tools 6. Tool-to-Principle Mapping Key Clinical Insight Integrated Case Lab Integrated Case Lab: Clinical Scenarios Cross-Case Reflection Sparring Section – Integration Under Constraint Ethical Tensions in Complex Mental and Physical Health Care Ethical Reflection Questions Closing reflection

Implementation

Overview Before we begin...Policy, System Readiness and Professional Action Introduction Why System Readiness Matters From Fragmentation to Coordination Variation Across Contexts The Role of Professionals The Aim of This Module European and National Frameworks for Integrated Care National Variation in Implementation The Economic Case for Integrated Care Legislative and Regulatory Dimensions Policy as Enabler — or Constraint Key Insight Institutional and Structural Barriers to Implementation 2. Financial Silos and Misaligned Incentives 3. Legislative and Regulatory Constraints 4. Organisational Culture and Professional Identity 5. Workforce Capacity and Burnout 6. Data, Monitoring and Evaluation Gaps 7. The Economic and Political Dimension Key Insight Advocacy and Leadership in Practice 2. Professional Leadership Without Formal Authority 3. Evidence as a Tool for Change 4. Linking Practice to Policy 5. Realistic Scope of Influence 6. The Ethical Dimension of Leadership Key Insight The SCIROCCO Maturity Model The SCIROCCO Dimensions Reflective Application Key Insight Your Role in Implementation Cross-Profile Insight Capstone Exercise Returning to Alex, Jana, and Peter Final Reflection Integrated Health and Social Care

M2 · Health Complexity

M2

Slide 14

CONTENT

Multimorbidity and Complexity of Care Needs

One of the defining characteristics of health among people experiencing homelessness is not the presence of a single disease, but the coexistence of multiple interacting conditions. This pattern is known as multimorbidity — the presence of two or more chronic conditions in one individual.

Among homeless populations, multimorbidity often includes:

Chronic physical illness

Severe mental health disorders

Substance use disorders

Social instability

In many cases, this combination evolves into trimorbidity, where physical illness, mental illness, and addiction coexist simultaneously.

Early Onset and Accelerated Ageing

In the general population, multimorbidity is typically associated with older age. In homeless populations, however:

Multimorbidity appears decades earlier.

Individuals in their 40s may present with disease profiles typical of housed individuals in their 70s.

Chronic stress and deprivation accelerate biological ageing.

Repeated exposure to trauma, environmental hardship, malnutrition, and poor access to preventive care contribute to this accelerated disease burden.

Interaction Between Conditions

Multimorbidity in homelessness is not simply additive — conditions interact. For example:

DIABETES

increases infection risk and slows wound healing.

DEPRESSION

reduces treatment adherence for chronic illness.

ALCOHOL

use worsens liver disease and cardiovascular risk.

RESPIRATORY DISEASE

is exacerbated by smoking and environmental exposure.

These interactions increase complication rates and hospital admissions.

Care plans must therefore consider the interdependence of conditions.

Fragmentation and Care Discontinuity

Traditional healthcare systems are often organised around single-disease specialisation.

WHAT PEOPLE EXPERIENCING HOMELESSNESS COMMONLYENCOUNTER

Attend multiple emergency departments

Have inconsistent primary care access

Miss follow-up appointments

Lack stable contact information

Interrupt medication regimens

WHAT FRAGMENTED SYSTEMS COMMONLYDELIVER

Treatment plans are rarely coordinated.

Medication interactions may be overlooked.

Preventive care is delayed.

Clinical information is not shared effectively.

The system treats diseases separately, while the patient experiences them simultaneously.