Where We Stand
Section: Public Health
Policy: Healthcare Delivery and Advocacy for Persons Experiencing Homelessness or Houselessness

Appendix AA

 

Introduction

Patterns of disease among People Experiencing Homelessness or Houselessness (PEH) differ from the general population. The average age of death for unsheltered PEH is approximately 47 years [1]. Suffering on the streets, moreover, goes beyond the physical. Moral injury, while not widely studied, is likely to be significant on the streets. Factors such as high rates of trauma exposure, PTSD and social isolation are considered correlates to moral injury[2][3]. PEH commonly express feelings of invisibility, of not being heard. The OMA believes it is a responsibility of society to both deliver quality healthcare and advocate for PEH and public health. This type of legislation often disproportionately harms women or marginalized groups in our society.

 

Access to high-quality healthcare, independent of housing status or stability

PEH have unique healthcare needs. The American College of Physicians acknowledges this, citing the difficulty of managing chronic illness without consistent medication storage, disproportionate exposure to infectious disease and extreme weather, the stress and trauma inherent to the experience of becoming unhoused, and the simple fact that “injuries and minor illnesses can easily worsen without a safe and clean place to rest and recuperate.”[4]   

PEH additionally face enormous economic and social barriers to accessing healthcare. This is true in Oregon despite comparatively high rates of medical insurance.[5][6] PEH often lack consistent access to network-enabled smartphones and charging equipment, making signing up for and maintaining Oregon Health Plan coverage onerous. Attending appointments can also prove extraordinarily difficult: PEH often reside far from public transit corridors to avoid “sweeps” (forced relocations), lack access to transit fare, and risk permanently losing their possessions if their camp is “swept” in their absence. On arrival at their clinic, the stigmatization of PEH in healthcare settings is a well-known phenomenon: a 2020 systematic review found studies reporting on discrimination, paternalism and humiliation, dehumanization, and even loss of freedom experienced by PEH in clinical settings.[7] Individually and together, these experiences can lead PEH to avoid healthcare, even with emergent symptoms.  

Given these challenges, strong patient care for PEH involves both improving access to care in traditional medical settings and supporting patients through the use of outreach teams, often popularly known as “street medicine.” Street medicine programs have been shown to be beneficial both to individual patients and to the overall health of our medical system[8]. The American Medical Association (AMA) supports the use of funds, including Medicaid and other public insurance reimbursement, for the maintenance of these programs.[9] Medicaid’s new Place-of-Service code,[10] moreover, allows for billing of services in non-traditional settings. Active support of street medicine programs and traditional clinics serving PEH thus benefits individual patients, reduces overall system costs, and helps ensure clinicians are meeting their ethical and moral responsibilities to ensure that quality, evidence-based patient care is not conditional, but universal.  

 

Social Determinants of Health and the Impact of those living on the streets

Emerging evidence demonstrates that “Housing First” models are more effective models of care for PEH than previously standard “Treatment First” approaches. Treatment First requires individuals to be in psychiatric treatment and substance-free prior to receiving permanent housing, whereas Housing First provides permanent housing and support services without requiring adherence to psychiatric treatment or abstinence from substance use. A systematic review of 26 studies in the US and Canada found that Housing First decreased homelessness by 88%, leading to downstream benefits such as reduced emergency department use and hospitalizations.[11] Housing First is a cost-effective approach that has also demonstrated reduced substance use, improved mental health treatment engagement, and decreased arrests.[12] Thus, the OMA stands in accordance with the research and policies from the AMA, American Association of Family Physicians, and American Psychiatric Association, all of which endorse a Housing First model. [13]^{,[14],[15],[16]}

Involuntary displacement, also called forced relocations or “sweeps,” forces PEH to relocate to a new area with no effort to address the barriers they face. Sweeps have many negative impacts, leading to further instability for people already experiencing significant insecurity. Individuals who are involuntary displaced have higher odds of experiencing violence and life-threatening adverse outcomes, losing personal belongings (including medical items, which can lead to poorer health outcomes), and contracting infectious diseases[17][18][19]. Recommended alternatives to sweeps include permanent supportive housing, temporary shelters, sanctioned encampments with services, and storage facilities for PEH.[20] These more compassionate approaches focused on coordinating services and individualized help have proven successful in creating pathways to social assistance. In Philadelphia, for example, an encampment pilot program focused on building relationships with encampment residents has found success through making regular offers of housing, clearly communicating a closure deadline at least 30 days prior to closure, and providing free storage containers for personal belongings.[21] Strategies such as these minimize the disruption and adverse health outcomes that PEH experience when forced to relocate. 

Given the many barriers that prevent PEH from accessing healthcare, leading to worse health outcomes, it is vital to meet patients where they are. Mobile team-based medical outreach programs, also called street medicine, help bridge these care gaps by providing free behavioral health, primary care, and social services to PEH where they live. These programs have been shown to improve access to care and decrease emergency department visits and hospitalizations, while increasing cost savings,[22] 

While mobile outreach programs for PEH help improve health outcomes, it is also critical to address the challenges PEH face when discharged from the hospital. Hospital discharge is focused on sending patients to a fixed address, which many PEH do not have. Inadequate discharge planning for PEH can result in care gaps, difficulty with medication adherence, and further burden on emergency departments due to frequent readmissions.[23] Discharge planning should leverage available community resources and enhanced communication between hospitals, shelters, and medical respite to coordinate appropriate long-term housing options for PEH.[24]  

 

Differing Patterns of Disease in the Homeless and Houseless Community

Very little is published on the prevalence and effectiveness of educational curricula in the care of PEH. Inconsistent education suggests that many providers lack the foundational training required to provide consistent, high-quality care for PEH. In November 2021’s AMA Journal of Ethics, Withers and Kohl published a concise review of practices and recommendations on the incorporation of street medicine into medical education.[25] In 2020, Canadian researchers developed the Homeless Health Curriculum Framework, centering on core competencies including communication, advocacy, leadership, and understanding of upstream causes. The framework aims to inform design, delivery, service learning, and evaluation for medical school curricula.[26]

Medical education doesn’t cease upon graduation. We applaud efforts to educate physicians to address the needs of marginalized populations, such as Oregon’s 3-hour Cultural Competency licensure requirement. As prevalent as homelessness is today, we endorse the implementation of CME to assist providers in caring for PEH, as supported by AMA policy.[27]^,[28]  

Practices such as street medicine and shelter-based care should be offered in medical school and PA training. The arguments for these educational experiences are threefold. First, early exposure to these practices promotes communication and active listening, inspiring the trainees to be more empathetic both to PEH and all other patients. Second, educational experiences less encumbered by administrative tasks allows students to appreciate healthcare delivery that is patient centered and direct, likely mitigating burnout. And finally, there is evidence that PEH and students can collaborate, thus lessening medical trauma and improving the lives of PEH.[29]

Finally, innovative, non-traditional experiences such as community forums or peer-based partnerships are effective in building relationships, improving outcomes and enhancing the educational experience.[30]

 

Patient right to self-determination in medical or health-related decision-making

While it is difficult to obtain exact rates of substance use disorder among PEH, available data suggest PEH and other vulnerably housed populations experience higher rates of substance use than their counterparts with secure housing.[31] Substance use disorder can be more difficult to overcome for PEH due to limited access to treatment, fewer social supports, a higher prevalence of co-occurring mental health disorders, and the way substances can provide a sense of safety and serve as a coping strategy for the overwhelming stressors of homelessness.[32] Harm reduction approaches have been developed to mitigate the adverse consequences of substance use and are particularly helpful for PEH with concomitant substance use disorders.  Approaches include medications for treating substance use disorders, opioid overdose response with naloxone, supervised consumption facilities, managed alcohol programs, and needle exchanges.[33] A systematic review found that harm reduction interventions reduced public injecting, other high-risk consumption methods, and morbidity and mortality associated with substance use.[34] Harm reduction services can also act as a bridge to engagement in healthcare and other social services.[35] The AMA supports harm reduction initiatives and promotes education on harm reduction methods.[36]  

Oregon has a long history of advocacy and outreach, and much has been learned from this work including the value of patient-centered approaches. Simply put, outcomes must be guided by quality of life, not length of life or disease cure. This approach, by necessity, can result in patient decisions that seem unwise or certain to result in illness, pain, or death from a purely clinician standpoint. Decisions like these are difficult to witness. A simple acknowledgement that this is part of the work and not unprecedented can ease inevitable moral discomfort for the clinician. In the end, the patient guides the team, and we are there to support the patient throughout the illness, to reduce harm wherever possible. 

 

PEH with terminal or long-term debilitating medical conditions

We acknowledge that PEH are especially vulnerable to inadequate discharge plans from inpatient care. Innovative healthcare delivery models such as medical respite have been shown to lessen morbidity in PEH.[37] AMA policy supports further funding and standardization of respite for PEH.[38]  

Palliative care and hospice services are also largely inaccessible to people without permanent residence[39] despite the development of effective, innovative programs,[40]^,[41] Given that hospice services are delivered to where an individual resides and requires a place for safe storage of medical supplies and medications, a lack of stable housing proves to be a large barrier for providing these services. Additionally, without knowing where someone lives there is an inability to provide 24 hour care, provide medical supplies and deliver controlled substances, which must be sent through the mail and be signed for.  The unique prescribing needs of people with Substance Use Disorder Syndrome presents an additional barrier to palliative/ hospice care for many PEH[42] 

Estimates of the prevalence of disability among PEH range from 30-80%, with a 75% reported rate in Multnomah County by the 2017 Lund report.[43] Healthcare teams must be familiar with the Americans with Disabilities Act (ADA)[44] and advocate for those with both visible and invisible disabilities. For example, the act of moving one’s home and belongings can take days. The ADA specifically expects that “reasonable accommodation requests” be fulfilled; medical care facilities and public services must adhere to both the letter and the intention of the law. 

 

Providing care for PEH and the possibility of clinician burnout

The potential impact of working with people who have experienced trauma has been recognized in medical literature as a form of vicarious trauma.[45]^,[46] PEH, meanwhile, are significantly more likely to have experienced trauma than the general public, via both Adverse Childhood Experiences (ACEs)[47] and traumas specific to the experience of homelessness and houselessness.  

It comes as no surprise, then, that a study of professionals working with PEH found that “homeless clients often have experienced high levels of trauma, with histories of child abuse, domestic violence, violent crime, and war; these stories are often disclosed to frontline workers… constant exposure to trauma can lead to a normalization of the trauma in frontline workers and can reduce their empathy for their clients and others.”[48] 

Healthcare professionals (HCP) who specialize in working with PEH, then, are more likely to experience vicarious trauma. Beyond this, HCPs working with PEH observe the trauma inherent to being unhoused: complex social issues made worse by a direct lack of resources and, sometimes, mental health and/or substance abuse issues. HCPs must confront the moral injustices of “sweeps”, harassment by law enforcement,[49]  and extreme inequality more than many of their colleagues, and must often reckon with our inability to prescribe the medicines many PEH truly require: housing, food, and social support. As PEHs are at a high risk of death, HCPs working with them are also more likely to confront the deaths of their patients.  

This work is challenging, requiring HCPs to “listen, reflect, provide support, and assist in problem solving and behavioural change while maintaining an attitude of hope, respect and optimism. However, maintaining a positive approach can be difficult as progress is often slow… may involve relapses, especially where addictions play a role.”[50] 

One single-city study of frontline workers (both healthcare and non-healthcare) found that 23% of workers suffered from burnout and compassion fatigue, and 30.6% experienced PTSD symptoms.[51] 

It falls on healthcare organizations, then, to ensure that clinicians working with PEH have training appropriate to perform their role well, up-to-date knowledge of local resources to better assist patients, and mental health support to ensure provider well-being.  

The ability to adequately and easily connect patients experiencing homelessness and houselessness to service organizations and nonprofits makes clinical encounters more effective and helps avoid provider burnout. Healthcare organizations should take an active role in helping to curate and update easily usable guides or databases for HCPs to use in connecting patients to services.  

Beyond the clinic, various interventions have shown promise in preventing and mitigating provider burnout,[52]including trauma-informed mental health resources, peer support groups, and debriefing sessions. Institutions should work to make these resources available to clinicians, and to integrate them within paid work hours so that the burden is not placed on caregivers to pursue them outside of service hours.  

 

 

[1] Rabell L. Mortality and homelessness fact sheet. National Health Care for the Homeless Council. December 5, 2024. Accessed March 25, 2025. https://nhchc.org/resource/mortality-and-homelessness-fact-sheet/.

[2] Serchen J, Hilden DR, Beachy MW; Health and Public Policy Committee of the American College of Physicians. Meeting the Health and Social Needs of America's Unhoused and Housing-Unstable Populations: A Position Paper From the American College of Physicians. Ann Intern Med. 2024 Apr;177(4):514-517. doi: 10.7326/M23-2795. Epub 2024 Feb 27. PMID: 38408358.

[3] Borges, L.M., Desai, A., Barnes, S.M. et al. The Role of Social Determinants of Health in Moral Injury: Implications and Future Directions. Curr Treat Options Psych 9, 202–214 (2022). https://doi.org/10.1007/s40501-022-00272-4

[4] Serchen J, Hilden DR, Beachy MW; Health and Public Policy Committee of the American College of Physicians. Meeting the Health and Social Needs of America's Unhoused and Housing-Unstable Populations: A Position Paper From the American College of Physicians. Ann Intern Med. 2024 Apr;177(4):514-517. doi: 10.7326/M23-2795. Epub 2024 Feb 27. PMID: 38408358.

[5] Terry L. Oregon tops country in share of people retaining Medicaid, study finds. Oregon Capital Chronicle. Published July 24, 2024. Accessed March 20, 2025. https://oregoncapitalchronicle.com/2024/07/24/oregon-tops-country-in-share-of-people-retaining-medicaid-study-finds/

[6] Health Insurance Coverage of the Total Population 2023. KFF State Health Facts. Accessed March 20, 2025. https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Uninsured%22,%22sort%22:%22desc%22%7D

[7] Reilly J, Ho I, Williamson A. A systematic review of the effect of stigma on the health of people experiencing homelessness. Health Soc Care Community. 2022 Nov;30(6):2128-2141. doi: 10.1111/hsc.13884. Epub 2022 Jun 28. PMID: 35762196.

[8] Kaufman RA, Mallick M, Louis JT, Williams M, Oriol N. The Role of Street Medicine and Mobile Clinics for Persons Experiencing Homelessness: A Scoping Review. Int J Environ Res Public Health. 2024 Jun 12;21(6):760. doi: 10.3390/ijerph21060760. PMID: 38929006; PMCID: PMC11204218.

[9] American Medical Association. Eradicating Homelessness H-160.903. Published 2023. Accessed March 2, 2025. https://policysearch.ama-assn.org/policyfinder/detail/homeless?uri=%2FAMADoc%2FHOD.xml-0-718.xml

[10]CMS Code Change Bolsters Street Medicine programs | healthcare innovation. Accessed March 25, 2025. https://www.hcinnovationgroup.com/population-health-management/complex-care/article/53074284/cms-code-change-bolsters-street-medicine-programs.  

[11] Peng Y, Hahn RA, Finnie RKC, et al. Permanent Supportive Housing With Housing First to Reduce Homelessness and Promote Health Among Homeless Populations With Disability: A Community Guide Systematic Review. J Public Health Manag Pract. 2020;26(5):404-411. doi:10.1097/PHH.0000000000001219

[12] National Low Income Housing Coalition. The Evidence is Clear: Housing First Works. National Low Income Housing Coalition. Available at: https://nlihc.org/sites/default/files/Housing-First-Evidence.pdf. Accessed March 2, 2025.

[13] American Medical Association. Eradicating Homelessness H-160.903. Published 2023. Accessed March 2, 2025. https://policysearch.ama-assn.org/policyfinder/detail/homeless?uri=%2FAMADoc%2FHOD.xml-0-718.xml

[14] American Medical Association. Housing Insecure Individuals with Mental Illness H-160.978. Published 2022. Accessed March 2, 2025. https://policysearch.ama-assn.org/policyfinder/detail/homeless?uri=%2FAMADoc%2FHOD.xml-0-792.xml

[15] American Academy of Family Physicians. Homelessness and Health Policy. Published October 2023. Accessed March 2, 2025. https://www.aafp.org/about/policies/all/homelessness.html.

[16]Rafla-Yuan E, Castillo EG, Halpin L, Starks S, Trestman R. Position Statement on Housing, Homelessness, and Mental Health. American Psychiatric Association. Approved by the Board of Trustees, December 2023; Approved by the Assembly, November 2023. Accessed March 2, 2025. https://www.psychiatry.org/getattachment/9db151ca-94b5-4aec-b599-e4172a52c4ef/Position-Housing-Homelessness.pdf.

[17]Chiang JC, Bluthenthal RN, Wenger LD, Auerswald CL, Henwood BF, Kral AH. Health risk associated with residential relocation among people who inject drugs in Los Angeles and San Francisco, CA: a cross sectional study. BMC Public Health. 2022;22(1):823. Published 2022 Apr 25. doi:10.1186/s12889-022-13227-4

[18]Qi D, Abri K, Mukherjee MR, et al. Health Impact of Street Sweeps from the Perspective of Healthcare Providers. J Gen Intern Med. 2022;37(14):3707-3714. doi:10.1007/s11606-022-07471-y 

[19]Meehan AA, Milazzo KE, Bien M, et al. Involuntary displacement and self-reported health in a cross-sectional survey of people experiencing homelessness in Denver, Colorado, 2018-2019. BMC Public Health. 2024;24(1):1159. Published 2024 Apr 25. doi:10.1186/s12889-024-18681-w

[20]Qi D, Abri K, Mukherjee MR, et al. Health Impact of Street Sweeps from the Perspective of Healthcare Providers. J Gen Intern Med. 2022;37(14):3707-3714. doi:10.1007/s11606-022-07471-y

[21]Kruger J. How Philly offers help and closes encampments with compassion. City of Philadelphia. February 1, 2019. Available at: https://www.phila.gov/2019-02-01-how-philly-offers-help-and-closes-encampments-with-compassion /. Accessed March 2, 2025

[22]Kaufman RA, Mallick M, Louis JT, Williams M, Oriol N. The Role of Street Medicine and Mobile Clinics for Persons Experiencing Homelessness: A Scoping Review. Int J Environ Res Public Health. 2024 Jun 12;21(6):760. doi: 10.3390/ijerph21060760. PMID: 38929006; PMCID: PMC11204218

[23],²⁵Marcus ER, Carreras Tartak JA, Halasz H, Chen D, Lee J, He S. Discharge process for patients experiencing homelessness in the emergency department: A thematic qualitative study. PLoS One. 2024;19(6):e0304865. Published 2024 Jun 7. doi:10.1371/journal.pone.0304865

 

[25] AMA J Ethics. 2021;23(11):E858-863. doi: 10.1001/amajethics.2021.858

[26]Hashmi, S.S., Saad, A., Leps, C. et al. A student-led curriculum framework for homeless and vulnerably housed populations. BMC Med Educ 20, 232 (2020). https://doi.org/10.1186/s12909-020-02143-z  

[27] American Medical Association. Eradicating Homelessness H-160.903. Published 2023. Accessed March 2, 2025. https://policysearch.ama-assn.org/policyfinder/detail/homeless?uri=%2FAMADoc%2FHOD.xml-0-718.xml

[28]American Medical Association. Housing Insecure Individuals with Mental Illness H-160.978. Published 2022. Accessed March 2, 2025. https://policysearch.ama-assn.org/policyfinder/detail/homeless?uri=%2FAMADoc%2FHOD.xml-0-792.xml  

[29]King, C., Fisher, C., Johnson, J. et al. Community-derived recommendations for healthcare systems and medical students to support people who are houseless in Portland, Oregon: a mixed-methods study. BMC Public Health 20, 1337 (2020). https://doi.org/10.1186/s12889-020-09444-4   

[30] Waghwala S, Annapureddy D. Community Partner Perspectives on a Medical-Student-Led Patient Navigator Program for Persons Experiencing Homelessness. Ann Fam Med. 2023;21(Suppl 3):5469. doi:10.1370/afm.22.s1.5469

[31]National Coalition for the Homeless. Substance abuse and homelessness. Published June 2017. https://nationalhomeless.org/wp-content/uploads/2017/06/Substance-Abuse-and-Homelessness.pdf

[32]National Coalition for the Homeless. Substance abuse and homelessness. Published June 2017. https://nationalhomeless.org/wp-content/uploads/2017/06/Substance-Abuse-and-Homelessness.pdf

[33] Magwood O, Salvalaggio G, Beder M, Kendall C, Kpade V, Daghmach W, Habonimana G, Marshall Z, Snyder E, O'Shea T, Lennox R, Hsu H, Tugwell P, Pottie K. The effectiveness of substance use interventions for homeless and vulnerably housed persons:  A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder. PLoS One. 2020 Jan 16;15(1):e0227298. doi: 10.1371/journal.pone.0227298. PMID: 31945092; PMCID: PMC6964917

[34]^,36 Magwood O, Salvalaggio G, Beder M, Kendall C, Kpade V, Daghmach W, Habonimana G, Marshall Z, Snyder E, O'Shea T, Lennox R, Hsu H, Tugwell P, Pottie K. The effectiveness of substance use interventions for homeless and vulnerably housed persons:  A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder. PLoS One. 2020 Jan 16;15(1):e0227298. doi: 10.1371/journal.pone.0227298. PMID: 31945092; PMCID: PMC6964917

 

[36] American Medical Association. Prevention of Drug-Related Overdose D-95.987. AMA PolicyFinder. Updated 2024. Accessed March 2, 2025. https://policysearch.ama-assn.org/policyfinder/detail/D-95.987?uri=%2FAMADoc%2Fdirectives.xml-0-2069.xml

[37]David Buchanan, Bruce Doblin, Theophilus Sai, and Pablo Garcia: The Effects of Respite Care for Homeless Patients: A Cohort Study, American Journal of Public Health 96, 1278_1281, https://doi.org/10.2105/AJPH.2005.067850

[38] American Medical Association. Eradicating Homelessness H-160.903. Published 2023. Accessed March 2, 2025. https://policysearch.ama-assn.org/policyfinder/detail/homeless?uri=%2FAMADoc%2FHOD.xml-0-718.xml

[39] de Veer, A.J.E., Stringer, B., van Meijel, B. et al. Access to palliative care for homeless people: complex lives, complex care. BMC Palliat Care 17, 119 (2018). https://doi.org/10.1186/s12904-018-0368-3

[40]Jensen, Francine Bench PhD, RN; Thorpe, Deborah PhD, APRN. Social Model Hospice: Providing Hospice and Palliative Care for a Homeless Population in Salt Lake City, Utah. Journal of Hospice & Palliative Nursing 26(2):p 91-97, April 2024. | DOI: 10.1097/NJH.0000000000001000

[41]University of Washington Medicine. Palliative care for the homeless. Accessed March 16, 2025. https://www.uwmedicine.org/specialties/palliative-care/homeless-care   

[42]Klop, H.T., de Veer, A.J., van Dongen, S.I. et al. Palliative care for homeless people: a systematic review of the concerns, care needs and preferences, and the barriers and facilitators for providing palliative care. BMC Palliat Care 17, 67 (2018). https://doi.org/10.1186/s12904-018-0320-6  

[43]Schmid T. Multnomah County homeless count reveals nearly 3 in 4 unhoused report disabilities. The Lund Report. June 21, 2017. Accessed March 16, 2025. https://www.thelundreport.org/content/multnomah-county-homeless-count-reveals-nearly-3-4-unhoused-report-disabilities  

[44] U.S. Department of Justice. Americans with Disabilities Act of 1990, as Amended. Accessed March 16, 2025. https://www.ada.gov/law-and-regs/ada/

^[45] Isobel S, Thomas M. Vicarious trauma and nursing: An integrative review. Int J Ment Health Nurs. 2022 Apr;31(2):247-259. doi: 10.1111/inm.12953. Epub 2021 Nov 19. PMID: 34799962.7.

^[46] Søvold LE, Naslund JA, Kousoulis AA, Saxena S, Qoronfleh MW, Grobler C, Münter L. Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority. Front Public Health. 2021 May 7;9:679397. doi: 10.3389/fpubh.2021.679397. PMID: 34026720; PMCID: PMC8137852

^[47] Adverse childhood experiences and homelessness: advances and aspirations
Koh, Katherine A et al. The Lancet Public Health, Volume 6, Issue 11, e787 - e788

[48]Dadani, Aliza. “BURNOUT AND PTSD IN WORKERS IN THE HOMELESS SECTOR IN Edmonton,” 2016.

[49] NHLC Statement on Police Brutality Against People Experiencing Homelessness. National Homelessness Law Center. https://homelesslaw.org/criminalization/police-brutality-statement/.

[50]^,52 Dadani, Aliza. “BURNOUT AND PTSD IN WORKERS IN THE HOMELESS SECTOR IN Edmonton,” 2016.

 

[52] Kim J, Chesworth B, Franchino-Olsen H, Macy RJ. A Scoping Review of Vicarious Trauma Interventions for Service Providers Working With People Who Have Experienced Traumatic Events. Trauma Violence Abuse. 2022 Dec;23(5):1437-1460. doi: 10.1177/1524838021991310. Epub 2021 Mar 9. PMID: 33685294; PMCID: PMC8426417