**1. Introduction**

The United States, the population is aging, and increasingly more adults are aging into poverty. At the same time, housing is becoming more unaffordable and the costs of health care are rising, leaving older adults at risk of poverty and homelessness [1]. Healthcare access for older adults is an important public health issue to be addressed globally. In the United States, approximately 10,000 people turn age 65 daily, and as the population ages in general, the prevalence of homeless among older adults remain constant [2]. Based on recent demographic trends, the more than 44,000 older adult population accounted for in 2010 will more than double by the year 2050, to nearly 93,000 [3].

Much is written in the health promotion literature about the social determinants of health for older adults, generally and more specifically, as it relates to disease and health promotion [4]. Moreover, it is well documented that a range of personal, social, economic, and environmental factors contribute to individual and population health [5, 6]. Specifically, people with better education, more stable employment, stable housing and living arrangements, and access to preventive health services tend to be healthier across the life course [7, 8]. Conversely, poor health care outcomes are often made worse by a lack of access and opportunities to engage in health social and physical environments [9, 10].

Worth noting is a surveys of patients' experiences with health care services that revealed how well a country's health system can be observed as meeting the needs of its population. Using data from a 2016 survey conducted in 11 countries— Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—research found that adults living in the United States (U.S.) reported poor health and well-being and were the most likely to experience accessibility hardships. Furthermore, the U.S. lagged behind other countries in making health care affordable and ranked poorly on providing timely access to medical care. Deficits in patient engagement and chronic care management were reported, in all countries, and at least one in five adults experienced a care coordination issue or problem. In particular, often, such challenges had high levels of acuity for low-income adults. In the Netherlands, performance at the top of the 11-country range on most measures of access, engagement, and coordination was noteworthy as models of best practices [8].

From a psychological and legal perspective, researchers in the United States have argued that access to mental healthcare for diverse public health populations need improvement, if progress is to be made in the areas of addiction and recovery [11]. Sixty percent of people with mental illness do not get the mental healthcare that they need, and up to 90% of those with a substance abuse disorder do not receive services [12]. Some of the hindrances to those who need to receive mental healthcare include the negative stigma surrounding mental illness, cost of care, limited access in rural areas, and lack of transition between services, among other things. These obstacles have an even greater impact on those in the population without insurance, or lacking sufficient mental health coverage, and those who cannot afford to pay out of pocket for these services. Individuals within some minority groups often do not have the same health resources as the majority [13]. Adding these facts to the number of mentally ill people within the homeless population, it appears that those who need the services the most may be unable to obtain it.

The history of homelessness, from a policy standpoint indicates certain patterns of viewing the issue of homelessness, and paints a picture of why the public perception is focused on the individual person and not the structure of our society. Current policies intended to address homelessness can be improved with the incorporation of social work frameworks and perspectives on creating more equitable, social and distributive justice treatments and interventions [14], as well as, affordable healthcare, public and political opinions span the necessary action or inaction of dealing with the social problems at the patient, provider, and policy levels, especially mental health services. Unfortunately, many fail to recognize the need for healthcare for the aging population. According to the World Health Organization [6], 15% of adults aged 60 and over suffer from a mental disorder. There are several mental disorders that older adults may be diagnosed with; including dementia, depression, anxiety disorder, or substance use problems. According to the American Psychiatric Association [15], one in four older adults experience some type of mental disorder. This number is expected to rise over the next several years due to the overall increase among the aging population.

**155**

*Exploring Mental Health Treatment and Prevention among Homeless Older Adults*

homeless individuals with substance use disorders (SUD).

tion is in keeping with the Code for the profession of social work.

of negative thought and patterns of maladaptive behavior.

From a Social Work perspective, what is understood about the standard of practice is the importance of looking for resources and strategies for assisting marginalized, disenfranchised, poor and underserved individuals, families, groups, communities, and a host of others. The Social Work Code of Ethics [19] speaks to the value of social justice, as well as, social and political action. To advocate for health care reform and especially, for the most effective intervention approaches, so that people can have greater access to mental health and substance abuse interven-

Older adults, consistent with the reports on younger and middle-aged adults are impacted by substance use and addiction in ways that are shaped by biological, psychological, and social factors [11]. The social learning theory (SLT) suggests that homelessness, as well as, addiction recovery models are rooted the very opinions and beliefs that are perpetuated and learn from years of social conditioning and exclusion of specific racial and ethnic minority cultural preferences, norms and attitudes toward healthcare. Treatments based on this theory can disrupt patterns

Racial disparities in treating mental health disorders are widely discussed in the healthcare literature [16, 20–23]. Yet, differences in use of recommended strategies to prevent homelessness as a mental health intervention, by race/ethnicity, have not been widely examined. Racial disparity in homelessness among older adults to growing national concern and questions about barriers to service provision, with little attention given to association between health literacy and mental health care; especially trauma-informed care. Once of few studies was conducted to examine the impact of diversity attributes on health care literacy, and this end, statistical data analysis on a nationally representative sample of 15,309 respondents was published [24]. The study revealed a significant difference between ethnic/racial minorities, as well as, between men and women. Most notable were the differences between social, economic, and educational factors that influenced outcomes. This research is especially relevant to the topic of older adults, race/ethnicity and effective prevention and intervention of homelessness. Furthermore, national advocacy reports and federal government sponsored initiatives consistently document the health disparities that racial and ethnic minority persons experience [23, 42].

Certain characteristics indicate the hypocrisy within mainstream U.S. society's view of the homeless, specifically the homeless that are veterans [16, 17]. In spite of the fact that the prevalence of homelessness is paramount and has many contributing factors, less humane approaches are taken to help them gain self-efficacy to be well, emotionally and spiritually. According to National Coalition for the Homeless [18], single individuals comprised 66.7% of all people experiencing homelessness (369,081 people), and about 33.3% are people in families (184,661 adults and children). Based on these data, approximately 7.2% are older adults and according to the National Coalition for the Homeless, some argue the number negatively impacted is too small to give an abundance of attention and resources. This marginalization of older adults should not be tolerated nor condoned. Especially, in the United States (US) which is often viewed as the "land of opportunity" or the "home of the free and the brave." Yet there are many people living in this country that do not have the means for basic human necessities like food and shelter, and older adults are disproportionately impacted [14, 42]. The perception of life in the US, in the general public, is far different than the reality of increasingly more people who have little to no "opportunity" and some segments of the population feel they are neither "free nor brave" enough fight to against the inequities and discriminatory practices that oppress them on a daily basis. In struggling to deal with this overwhelming adversity, there is often no attention or time made for the self-care of

*DOI: http://dx.doi.org/10.5772/intechopen.89731*

#### *Exploring Mental Health Treatment and Prevention among Homeless Older Adults DOI: http://dx.doi.org/10.5772/intechopen.89731*

Certain characteristics indicate the hypocrisy within mainstream U.S. society's view of the homeless, specifically the homeless that are veterans [16, 17]. In spite of the fact that the prevalence of homelessness is paramount and has many contributing factors, less humane approaches are taken to help them gain self-efficacy to be well, emotionally and spiritually. According to National Coalition for the Homeless [18], single individuals comprised 66.7% of all people experiencing homelessness (369,081 people), and about 33.3% are people in families (184,661 adults and children). Based on these data, approximately 7.2% are older adults and according to the National Coalition for the Homeless, some argue the number negatively impacted is too small to give an abundance of attention and resources. This marginalization of older adults should not be tolerated nor condoned. Especially, in the United States (US) which is often viewed as the "land of opportunity" or the "home of the free and the brave." Yet there are many people living in this country that do not have the means for basic human necessities like food and shelter, and older adults are disproportionately impacted [14, 42]. The perception of life in the US, in the general public, is far different than the reality of increasingly more people who have little to no "opportunity" and some segments of the population feel they are neither "free nor brave" enough fight to against the inequities and discriminatory practices that oppress them on a daily basis. In struggling to deal with this overwhelming adversity, there is often no attention or time made for the self-care of homeless individuals with substance use disorders (SUD).

From a Social Work perspective, what is understood about the standard of practice is the importance of looking for resources and strategies for assisting marginalized, disenfranchised, poor and underserved individuals, families, groups, communities, and a host of others. The Social Work Code of Ethics [19] speaks to the value of social justice, as well as, social and political action. To advocate for health care reform and especially, for the most effective intervention approaches, so that people can have greater access to mental health and substance abuse intervention is in keeping with the Code for the profession of social work.

Older adults, consistent with the reports on younger and middle-aged adults are impacted by substance use and addiction in ways that are shaped by biological, psychological, and social factors [11]. The social learning theory (SLT) suggests that homelessness, as well as, addiction recovery models are rooted the very opinions and beliefs that are perpetuated and learn from years of social conditioning and exclusion of specific racial and ethnic minority cultural preferences, norms and attitudes toward healthcare. Treatments based on this theory can disrupt patterns of negative thought and patterns of maladaptive behavior.

Racial disparities in treating mental health disorders are widely discussed in the healthcare literature [16, 20–23]. Yet, differences in use of recommended strategies to prevent homelessness as a mental health intervention, by race/ethnicity, have not been widely examined. Racial disparity in homelessness among older adults to growing national concern and questions about barriers to service provision, with little attention given to association between health literacy and mental health care; especially trauma-informed care. Once of few studies was conducted to examine the impact of diversity attributes on health care literacy, and this end, statistical data analysis on a nationally representative sample of 15,309 respondents was published [24]. The study revealed a significant difference between ethnic/racial minorities, as well as, between men and women. Most notable were the differences between social, economic, and educational factors that influenced outcomes. This research is especially relevant to the topic of older adults, race/ethnicity and effective prevention and intervention of homelessness. Furthermore, national advocacy reports and federal government sponsored initiatives consistently document the health disparities that racial and ethnic minority persons experience [23, 42].

*Healthcare Access - Regional Overviews*

in health social and physical environments [9, 10].

Much is written in the health promotion literature about the social determinants

of health for older adults, generally and more specifically, as it relates to disease and health promotion [4]. Moreover, it is well documented that a range of personal, social, economic, and environmental factors contribute to individual and population health [5, 6]. Specifically, people with better education, more stable employment, stable housing and living arrangements, and access to preventive health services tend to be healthier across the life course [7, 8]. Conversely, poor health care outcomes are often made worse by a lack of access and opportunities to engage

Worth noting is a surveys of patients' experiences with health care services that revealed how well a country's health system can be observed as meeting the needs of its population. Using data from a 2016 survey conducted in 11 countries— Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—research found that adults living in the United States (U.S.) reported poor health and well-being and were the most likely to experience accessibility hardships. Furthermore, the U.S. lagged behind other countries in making health care affordable and ranked poorly on providing timely access to medical care. Deficits in patient engagement and chronic care management were reported, in all countries, and at least one in five adults experienced a care coordination issue or problem. In particular, often, such challenges had high levels of acuity for low-income adults. In the Netherlands, performance at the top of the 11-country range on most measures of access, engage-

ment, and coordination was noteworthy as models of best practices [8].

From a psychological and legal perspective, researchers in the United States have argued that access to mental healthcare for diverse public health populations need improvement, if progress is to be made in the areas of addiction and recovery [11]. Sixty percent of people with mental illness do not get the mental healthcare that they need, and up to 90% of those with a substance abuse disorder do not receive services [12]. Some of the hindrances to those who need to receive mental healthcare include the negative stigma surrounding mental illness, cost of care, limited access in rural areas, and lack of transition between services, among other things. These obstacles have an even greater impact on those in the population without insurance, or lacking sufficient mental health coverage, and those who cannot afford to pay out of pocket for these services. Individuals within some minority groups often do not have the same health resources as the majority [13]. Adding these facts to the number of mentally ill people within the homeless population, it appears that those who need the services the most may be unable to obtain it. The history of homelessness, from a policy standpoint indicates certain patterns of viewing the issue of homelessness, and paints a picture of why the public perception is focused on the individual person and not the structure of our society. Current policies intended to address homelessness can be improved with the incorporation of social work frameworks and perspectives on creating more equitable, social and distributive justice treatments and interventions [14], as well as, affordable healthcare, public and political opinions span the necessary action or inaction of dealing with the social problems at the patient, provider, and policy levels, especially mental health services. Unfortunately, many fail to recognize the need for healthcare for the aging population. According to the World Health Organization [6], 15% of adults aged 60 and over suffer from a mental disorder. There are several mental disorders that older adults may be diagnosed with; including dementia, depression, anxiety disorder, or substance use problems. According to the American Psychiatric Association [15], one in four older adults experience some type of mental disorder. This number is expected to rise over the next several years due to

**154**

the overall increase among the aging population.

More specifically, racial minority groups, in the U.S., experience disproportionately higher rates of homelessness, than racially White groups. In considering homelessness as a public health problem that requires attention to access and acceptability of healthcare, food, shelter and social support, the clear link for older adults is the strong correlation between mental health and homelessness [11].
