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Home > Knowledge Base > Viral Hepatitis: Related Resources > HIV, Hepatitis, Abscesses and Social Suffering > Handout
Health Care and Multiple Diagnosis Issues of Homeless People
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Hear Barry Zevin's case presentation of a homeless addict (Launches the Real Audio Player: Case Presentation begins at 5:28)

Defining homelessness and extent of problem:
transparent gifgrey bulletWhy do we say homeless rather than houseless or without shelter?
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transparent gifgrey bulletOne million homeless in USA, large number with medical, mental health and/or substance abuse problems.
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transparent gifgrey bulletThere are multiple physical, logistical and psychological barriers to medical care for homeless people.
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transparent gifgrey bulletMost homeless people are alienated from existing social structures. Their scope of living is narrowed to mere survival and existence marked by multiple traumas and losses. Homeless people are frightened, distrustful and extremely sensitive to any threat, real or perceived, to what remains of their integrity (humanity and dignity).
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Characteristics of homeless people presenting for care:
transparent gifgrey bulletMultiple psychosocial and medical problems.
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transparent gifgrey bulletPresent with advanced disease and acute medical problems.
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transparent gifgrey bulletPriorities such as obtaining food and shelter placed above medical care.
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transparent gifgrey bulletDisorganization, especially difficulty keeping set appointments, adhering to medical plans, losing medications.
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transparent gifgrey bulletHeterogeneous ethnicity, race, sexual orientation, gender.
Many are "sociopaths" or ex-convicts (jails and prisons may provide medical care but release inmates without medications or medical follow up).
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transparent gifgrey bulletPrevious poor experiences with medical providers due to "outcast" and "scapegoat" process. High degree of fear, pain and suffering, despair and depression.
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transparent gifgrey bulletViolence and victimization are daily occurrences on the street, they are the constant accompaniment of the homeless person.
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transparent gifgrey bulletInability to work due to discrimination and/or disability (often defined by deficits which are multiple and difficult to classify resulting in rejection of claims for benefits.)
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transparent gifgrey bulletFrequent ongoing substance abuse.
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Medical problems common among homeless people:
transparent gifgrey bulletInfectious diseases: HIV, TB, STD's, respiratory infections, infestations (scabies, lice, etc.), skin infectior chronic viral hepatitis.
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transparent gifgrey bulletMuscle skeletal problems: foot diseases, post-traumatic arthritis, chronic pain syndromes.
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transparent gifgrey bulletPsychiatric disease: Underlying severe mental illness, undiagnosed mental illness, post traumatic stress disorder and other resultant mental illness from homelessness.
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transparent gifgrey bulletSubstance abuse related illness: Permanent sequelae of substance abuse, brain dysfunction liver disease, lung and heart disease.
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transparent gifgrey bulletChronic diseases: diabetes, hypertension, COPD.
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transparent gifgrey bulletDiseases of neglect: nutritional problems, dental disease.
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Care for patients with multiple diagnosis.
transparent gifgrey bulletLack of curative treatment
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transparent gifgrey bulletLack of models for effective care of chronic disease.
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grey bulletSubstance abuse: Treatment often controversial, very labor intensive and costly.
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grey bulletMental illness: Treatment models controversial, homeless people may not have access to most effective treatments, treatments may not be effective.
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transparent gifgrey bulletHealth Delivery System Issues
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grey bulletUnlinked services and providers of service:
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grey bulletScattered medical records.
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grey bulletPoor communication among providers.
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grey bulletInability of systems to accommodate homeless people.
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grey bulletLack of resources for intensive evaluation.
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grey bulletLack of documentation.
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grey bulletSevere lack of capacity in mental health system.
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transparent gifgrey bulletSystems of care that work:
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grey bulletMake contact with use of outreach and high visibility in communities where homeless people are.
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grey bulletFrom first contact, treat individuals with dignity and respect. Proven value of "compassionate care".
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grey bulletAttempt to provide immediate necessities and practical help (referrals for housing, food, immediate medical care) along with education on prevention anc referral to continuity medical care.
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grey bulletProvide medical services in unconventional community settings
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grey bulletHomeless shelters and streets and parks
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grey bulletHomeless "encampments or areas people are "vehicularly housed"
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grey bulletNeedle exchange sites
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grey bulletRecognize homelessness by asking patients about their "living situation" and the security/insecurity of their housing.
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grey bulletUse a multidisciplinary team approach when available and be knowledgeable of resources in the community.
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grey bulletProviders may need to take a more aggressive advocacy role than they ma accustomed.
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grey bulletFlexible scheduling and drop-in availability.
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grey bulletAttention to educating patients in using medical system and setting approp limits.
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grey bulletCreate a nonthreatening environment.
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grey bulletEducate support staff about problems of homelessness and caring for diverse populations in nonjudgmental manner.
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grey bulletAvoid sense of exclusion in clinic setting and staffmanner.
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grey bulletAttempt to create family or community like milieu by limiting number of personnel interacting with patient, assigning primary care doctors, and individual case management.
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grey bulletApproach patients in highly empathic way; keep reasonable expectations.
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grey bulletRespect patients' integrity and limitations.
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grey bulletUse supportive listening, touch, frequent appointments to build bridges to patient even when medically you appear to be "doing nothing".
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grey bulletContinue to provide treatment and care to the patient who is actively using drugs. Encourage recovery and hope but avoid moral judgment. Treat intoxicated patients compassionately, set clear limits to the treatment you c provide on that visit but arrange follow up or outreach to the patient.
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grey bulletTaking appropriate time and providing continuity are essential.
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grey bulletRecognize and set up services for social groups (e.g. homeless women, substance nabusers and those in early recovery, triple diagnosed, terminal patients requiring hospice care, transgender patients).
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grey bulletRecognize and develop expertise in common problems in homelessness and IDU (e.g. TB, skin and soft tissue infections, foot problems, psychiatric emergencies,...).
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