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Margot Kushel, MD, director of UCSF’s Benioff Housing and Homelessness Initiative, talks about aging, the structural and individual factors that contribute to homelessness, and much more in the GeriPal podcast with Eric Widera, MD, and Alex Smith, MD, MPH, MS. During the conversation, Dr. Kushel said, "I like to say homelessness is a state and not a trait. It’s not an intrinsic quality of a person. It is an experience that they go through."

In this Grand Rounds at Dartmouth Medical School, Margot Kushel, MD, one of the world’s leading experts on homelessness, discusses the drivers and precipitants of homelessness, the demographics of homelessness, and the health consequences of aging in the homeless population. Dr. Kushel is a professor of medicine and directs both the UCSF Center for Vulnerable Populations and the UCSF Benioff Homelessness and Housing Initiative.

The UC Center Sacramento hosted a "Special Winter Symposium: Dimensions of Chronic Homelessness and the Search for Solutions." In session 4, Margot Kushel, MD, director of UCSF’s Benioff Housing and Homelessness Initiative, joined State Senator John Laird and Dr. Toby Ewing to discuss how California is addressing the issue of people who are chronically unsheltered and what barriers remain.

Margot Kushel, MD, director of UCSF’s Benioff Housing and Homelessness Initiative, wrote an editorial in JAMA about a recent study on the negative health consequences of involuntary displacements on the lives of people experiencing homelessness. Dr. Kushel writes, "The question is not whether living in unsheltered settings is dangerous, but rather what is the role of forced displacements in addressing the harm caused by them."

This study from BHHI researchers describes five distinct subgroups of the highest users of the health care system in San Francisco with differential comorbidities, health care needs, and social determinants of health, spanning from patients with medical comorbidities solely using medical services to patients grappling with housing insecurity, incarceration, substance use disorder, and mental health comorbidities. Frequent users of the health care system are not a homogenous population as previously thought. This study sheds new light on how to help the most vulnerable patients and inform clinicians and care coordination teams on making sure patients get the care they need the most. 

Patients with prolonged hospitalizations often require alternative levels of care (ALC) and there stays strain hospital capacity and patient flow. This study aimed to descriptively compare prolonged ALC and short ALC. Researchers found that patients with prolonged ALC were more likely to be older and have experienced homelessness. Furthermore, prolonged ALC patients were more likely to be admitted for acute care and had greater psychosocial complexity.

LifeMoves Mountain View is an interim shelter program that provides supportive services to help people who experience homelessness find stable housing in 3 to 4 months. However, data has shown that many of those experiencing homelessness are unable to find stable housing within that timeframe. Margot Kushel, MD, director of UCSF’s Benioff Housing and Homelessness Initiative, said, "People are not homeless because they need services. People are homeless because there isn't any housing."

Oregon and California lawmakers are reconsidering their approaches to mental health and involuntary confinement. Parallel debates in both states reflect the ongoing homelessness crisis. Margot Kushel, MD, director of UCSF’s Benioff Housing and Homelessness Initiative, said, "If you try to fix homelessness by tinkering with the health care system, we're not going to get anywhere."

California state lawmakers say they need more tools to help get people experiencing homelessness into treatment, debating the use of involuntary commitments. Homelessness is caused by a lack of affordable housing, not mental illness. “The problem of homelessness is that people don't have housing. If you had all the treatment in the world and you didn't have the housing, we would still have this problem,” said Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative.

California is trying to tap federal health care funding to cover rent for homeless people and those at risk of losing their housing. Yet, health care experts say that, while six months of rent can be a bridge while people wait for permanent housing, there’s a bigger obstacle: California’s affordable housing shortage. “We can design incredible Medicaid policies to alleviate homelessness and pay for all the necessary supportive services, but without the adequate housing, frankly, it’s not going to work,” said Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative.

California passed the Community Assistance, Recovery, and Empowerment (CARE) Act in 2022 to provide behavioral health and housing services to individuals with psychotic spectrum and schizophrenia disorders who are deemed unable to care for themselves. This policy brief from the Benioff Homelessness and Housing Initiative at UCSF and the California Policy Lab uses anonymized data to estimate how many San Franciscans in a database of individuals who have contact with the urgent and emergent care system may be eligible for referral to CARE Court and describe their service needs.

As San Francisco works to launch the CARE Court program, even some supporters are skeptical it will have a big impact on tragedies unfolding on the streets, arguing there aren’t enough treatment beds, housing, and intensive case managers. Maria Raven, MD, an author of the study who is chief of Emergency Medicine at UCSF Medical Center and co-leads the Benioff Homelessness and Housing Initiative COORDINATE HOME program, said there’s not enough permanent supportive housing. She hoped the report could start a conversation between the state and the city on how to fill gaps—"Otherwise it’s just going to be another program that doesn’t really have any impact."

Manny's organized a four-part series on understanding homelessness in San Francisco. In part one, the host spoke with Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, about the root causes of homelessness in San Francisco to demystify the realities and complex factors that keep people homeless. Dr Kushel said, "The difference in community level of homelessness is entirely trackable by the availability of housing for the lowest income households."

Violence against people who lack housing "is astronomically higher than we see in other populations," explains Margot Kushel, MD. "We know from studies that when people obtain housing, no matter what type of housing it is, over the next six months they are at dramatically less risk of experiencing violence."

As part of the National Low Income Housing Coalition's (NLIHC) Housing First Promotes Health call in February 2023, Margot Kushel, MD, director of the UCSF Benioff Housing and Homelessness Initiative, shared research on how housing improves health outcomes.

Over 70% of people experiencing homelessness report current tobacco use, compared to 14% in the general population. One of the structural barriers that hinder cessation attempts among people experiencing homelessness is inadequate access to health care and other smoking cessation services. Researchers in this study aimed to explore tobacco use behaviors and factors influencing acceptability of engaging in a clinical trials. Researchers found that participants had attempted to quit smoking, and were interested in engaging in clinical trials as a method to quit smoking.

In this op-ed, DeForrest (DeDe) Hancock, a UCSF Benioff Homeless Housing Initiative Lived Expertise Advisory Board member, tells her story about experiencing homelessness. She writes, [when] “I was homeless, 2009 to 2016, I came to believe that we are all ordinary people simply each living out the scripts of our lives. Some of our scripts include life-challenges which provide lived experience to build the expertise and skills for survival.”

Seniors are the fastest growing unhoused population. From 2017 to 2021, California’s overall senior population grew by 7% but the number of people 55 and older who sought homelessness services increased 84%. Margot Kushel, MD, director of UCSF’s Benioff Housing and Homelessness Initiative, said, "Nearly half of single adults 50 and over experiencing homelessness had never been homeless before age 50."