Homelessness complicates everything from managing chronic conditions like diabetes to getting a bath or a night’s sleep.

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A few years ago, Heather Barr, a nursing supervisor with Neighborcare Health in Seattle had the swine flu. The things that she took for granted were having a safe place to sleep, undisturbed, for two or three days while she recuperated; a bathroom just down the hall from her bedroom to go to whenever she needed; and access to clean drinking water.

“I remember thinking, ‘oh my god if I was homeless how could I possibly tolerate this,’” she says.

Barr has been working with the homeless population through Neighborcare Health and the Health Department since 1984.

“Small things you don’t even consider if you’re housed become a stark reality when a person does not have housing,” she says.

Dr. David Levitt, a hospitalist and internal medicine physician at Harborview Medical Center explains, “every challenge we have is amplified (when homeless).”

And while this includes somewhat obvious things like access to clean water, a place to use the bathroom, a place to shower or take care of personal hygiene, and a safe place to sleep, there are many medical hurdles one must clear when living homeless.

“Everyone – homeless or not – can have trouble with taking medications,” Levitt says.

In addition to working at Harborview, Levitt spends part of his time working as the doctor available to residents in supportive housing buildings like DESC’s The Estelle and Plymouth Housing’s Plymouth on First Hill.

When thinking of specific medical hurdles, Levitt says “Homelessness and diabetes is a terrible combination.”

Not only is insulin expensive, it often needs to be refrigerated, a problem for those without constant access to cold storage.

“And stuff gets stolen all the time, so even if you’re working hard to keep your blood sugar under control, your bag could get stolen and insulin needles get used for other things,” Levitt says.

Missing insulin could lead to what he calls an “acceleration of complications” from diabetes. Consistent high blood sugar can cause loss of nerve sensation. If a person with no sensation injures their foot, they might not feel it, and then the wound could get infected and eventually lead to amputation.

“It’s an everyday disease that’s turbocharged by homelessness.”

People living homeless spend a lot of energy on simply meeting basic needs, making it nearly impossible to think about preventative health care. That’s not to say housing is a magic bullet that helps end all medical issues.

Still, a stable place to live is a key component in helping any person lead a better life and have greater agency over their own health. Nurses that work in supportive housing help residents make that critical connection to preventive care, even accompanying them to appointments.

“If you are supposed to get a colonoscopy – getting that done is monumental for most of us because you need a whole day to prepare. You need people around you to support you; someone to give you a ride to the hospital and wait around for you and then take you home where you can recover from a procedure like that where you feel safe and supported,” Barr says.

Outside of chronic diseases, basic hygiene can also be incredibly difficult to keep on top of when living homeless; sometimes something as simple as a bath isn’t so simple.

Barr recounts the story of a resident who had not bathed in a number of years prior to moving into supportive housing due to homelessness and a deep trauma associated with bathing. A Neighborcare Health registered nurse who  worked in the building was immediately concerned about the condition of the resident’s feet.

Over the course of months, the nurse worked to build trust with the resident with gentle care and repeated contact. The resident eventually felt safe and supported enough to maintain a regular bathing routine. It turned out that the feet were not as bad as initially feared, and the resident felt much better both physically and emotionally.

“What a difference a bath makes,” says Barr.

Levitt says the most surprising thing he’s experienced over the past year of working in supportive buildings was how much of a difference building up personal connections can make.

“I was able to, just by repeat encounters with people over time, establish a trusting relationship to the point where I’ve had several patients agree to come to the hospital and be admitted for the care they needed because they know I’m working there. Which is really amazing.”

Plymouth Housing works to eliminate homelessness and address its causes by preserving, developing and operating safe, quality, supportive housing and by providing adults experiencing homelessness with opportunities to stabilize and improve their lives.