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Health Care and Multiple Diagnosis Issues of Homeless People

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:
Why do we say homeless rather than houseless or without shelter?
One million homeless in USA, large number with medical, mental health and/or substance abuse problems.
There are multiple physical, logistical and psychological barriers to medical care for homeless people.
Most 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).
Characteristics of homeless people presenting for care:
Multiple psychosocial and medical problems.
Present with advanced disease and acute medical problems.
Priorities such as obtaining food and shelter placed above medical care.
Disorganization, especially difficulty keeping set appointments, adhering to medical plans, losing medications.
Heterogeneous 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).
Previous poor experiences with medical providers due to "outcast" and "scapegoat" process. High degree of fear, pain and suffering, despair and depression.
Violence and victimization are daily occurrences on the street, they are the constant accompaniment of the homeless person.
Inability 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.)
Frequent ongoing substance abuse.
Medical problems common among homeless people:
Infectious diseases: HIV, TB, STD's, respiratory infections, infestations (scabies, lice, etc.), skin infectior chronic viral hepatitis.
Muscle skeletal problems: foot diseases, post-traumatic arthritis, chronic pain syndromes.
Psychiatric disease: Underlying severe mental illness, undiagnosed mental illness, post traumatic stress disorder and other resultant mental illness from homelessness.
Substance abuse related illness: Permanent sequelae of substance abuse, brain dysfunction liver disease, lung and heart disease.
Chronic diseases: diabetes, hypertension, COPD.
Diseases of neglect: nutritional problems, dental disease.
Care for patients with multiple diagnosis.
Lack of curative treatment
Lack of models for effective care of chronic disease.
Substance abuse: Treatment often controversial, very labor intensive and costly.
Mental illness: Treatment models controversial, homeless people may not have access to most effective treatments, treatments may not be effective.
Health Delivery System Issues
Unlinked services and providers of service:
Scattered medical records.
Poor communication among providers.
Inability of systems to accommodate homeless people.
Lack of resources for intensive evaluation.
Lack of documentation.
Severe lack of capacity in mental health system.
Systems of care that work:
Make contact with use of outreach and high visibility in communities where homeless people are.
From first contact, treat individuals with dignity and respect. Proven value of "compassionate care".
Attempt 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.
Provide medical services in unconventional community settings
Homeless shelters and streets and parks
Homeless "encampments or areas people are "vehicularly housed"
Needle exchange sites
Recognize homelessness by asking patients about their "living situation" and the security/insecurity of their housing.
Use a multidisciplinary team approach when available and be knowledgeable of resources in the community.
Providers may need to take a more aggressive advocacy role than they ma accustomed.
Flexible scheduling and drop-in availability.
Attention to educating patients in using medical system and setting approp limits.
Create a nonthreatening environment.
Educate support staff about problems of homelessness and caring for diverse populations in nonjudgmental manner.
Avoid sense of exclusion in clinic setting and staffmanner.
Attempt to create family or community like milieu by limiting number of personnel interacting with patient, assigning primary care doctors, and individual case management.
Approach patients in highly empathic way; keep reasonable expectations.
Respect patients' integrity and limitations.
Use supportive listening, touch, frequent appointments to build bridges to patient even when medically you appear to be "doing nothing".
Continue 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.
Taking appropriate time and providing continuity are essential.
Recognize 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).
Recognize and develop expertise in common problems in homelessness and IDU (e.g. TB, skin and soft tissue infections, foot problems, psychiatric emergencies,...).