Learning outcomes
In this chapter, readers will learn to:
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Describe the connection between health and homelessness.
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Explain challenges that people experiencing homelessness face trying to access health care and comply with medical recommendations.
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Identify health conditions that are common among people experiencing homelessness.
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Discuss strategies that health care providers can use to optimize care delivery to patients who are homeless.
Introduction
In recent years, on any one night in the United States, more than 550,000 people (or 17 out of every 10,000) experience homelessness. Among them, 33% are people in families with children, approximately 7% are veterans, and many have mental and physical disabilities. Over a lifetime, approximately 6% of Americans experience at least one episode of homelessness. Racial and ethnic minorities and historically marginalized groups, such as lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth, are disproportionately affected by homelessness. Common circumstances leading to homelessness include: lack of affordable housing, poverty, domestic violence, and unemployment (which can result from an inability to work because of poor health).
The homeless population experiences significant health disparities, including higher rates of diabetes, heart disease, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), mental illness, disability, and premature death than the general population. Social determinants of health, which are the conditions in which people are born, grow, live, work, and age, contribute to homelessness, which is itself a social determinant. Social determinants such as poverty, poor living conditions (e.g., unsafe, unsanitary conditions), low education level, social isolation, and lack of access to health care are directly linked to poor health outcomes that people without homes experience. When caring for people experiencing homelessness, health care providers must think beyond the traditional scope of medical services and consider other support services that are needed. Basic considerations include whether a patient can afford a medication, has transportation to a pharmacy, or can store a medication at required temperatures (e.g., a medication that must be refrigerated). Addressing broader issues, such as housing, employment, and food security, is very challenging but essential. People continually exposed to living conditions on the streets and in shelters cannot achieve and maintain good health, even if they receive effective medical care. Therefore health care providers in any setting that serves homeless individuals should be aware of resources and local programs that assist people without homes.
Despite the high prevalence of chronic disease among the homeless and other poor individuals, they are less likely than others to obtain routine health care, primarily because of a lack of insurance. They are significantly more likely than the general population, however, to visit emergency departments (EDs), where health care costs are very high. People experiencing homelessness generally obtain medical services at public hospitals, private not-for-profit facilities specifically committed to serving people with low incomes, and community health centers, which are government-funded clinics designed to serve populations with limited access to health care. In addition, mobile outreach clinics housed in vans or other vehicles may travel to shelters or other locations where homeless individuals congregate to provide basic medical care.
Because homelessness is directly linked to declines in physical and mental health, it is a significant public health concern. Consequently, the public health sector, such as state and county health departments, provide or support many of the resources, like housing assistance, that are available to the homeless population. All community health centers serve vulnerable populations; however, some receive federal grant funding through the Health Care for the Homeless (HCH) Program authorized by the U.S. Public Health Service Act to address the specific needs of homeless populations. Every state has at least one HCH site and, where available, these clinics serve as excellent resources for patients who are homeless.
Physician assistants (PAs) are often at the forefront of caring for homeless patients. Government-funded organizations, like community health centers, play a crucial role in treating homeless patients, and these facilities rely on PAs and nurse practitioners more heavily than health care facilities in the private sector. Therefore PAs have opportunities to improve the care that patients experiencing homelessness receive. To be effective, however, PAs and PA students must understand the unique circumstances and conditions that homeless people experience. This chapter discusses the relationship between homelessness and health, describes the best approach to dealing with homeless patients, reviews some of the medical conditions common among homeless individuals, and discusses a typical working environment in facilities that serve people experiencing homelessness.
Homelessness and health
Homeless individuals experience the same sorts of medical conditions that people with stable housing do, but extreme poverty, lack of shelter, and other adverse circumstances substantially impact their health and ability to manage it. Health and housing are directly related: deterioration of one often leads to the deterioration of the other. Consequently, providing health care to homeless patients is associated with significant challenges.
A common stereotype of the homeless depicts alcoholism or drug addiction as the culprit. Although it is true that a significant number of single, homeless individuals have a substance use disorder, lack of affordable housing and poverty are far more prevalent problems. When someone is forced to choose between food and shelter, the basic drive for sustenance usually takes priority. Many individuals and families suffer precariously on the edge of homelessness while their health deteriorates, whether physically or mentally, which can exacerbate financial difficulties. This situation continues until something tips the scales into a health or financial crisis, and for those without a safety net, homelessness is the end result. The connection between health and homelessness is easy to see. Consider the following scenario:
Mark is a 57-year-old male who suffered a stroke that resulted in left-sided weakness. Before his stroke, Mark worked as an auto mechanic in a small family-owned business. Without the use of his left upper extremity, Mark could not do his job and subsequently lost his employer-provided health insurance. He was unable to obtain occupational rehabilitation and developed a severe contracture of his left arm and hand. Without a steady income, Mark could not afford his regular medications, including medications for type 2 diabetes. He eventually stopped taking them one by one as his savings ran out. To avoid homelessness, Mark started working part-time as a salesman at a car lot. The job did not provide health insurance and required him to walk a lot, but he managed with the use of a cane. He developed a foot ulcer but, because he had developed diabetic neuropathy, he did not notice it until he saw stains on his socks. He took care of the ulcer as best he could but without medical intervention, the ulcer progressed, ultimately leading to an emergent foot amputation. While hospitalized, Mark was evicted and lost all of his belongings. He was discharged from the hospital to a local shelter. Fortunately, the shelter was an HCH site, and he was provided basic health care free of charge until he became eligible for Medicaid (See Box 48.1 for a definition of Medicaid and other terms). A social worker helped Mark apply for Social Security Disability Insurance (SSDI), but the process took over a year. During that year, Mark developed multiple methicillin-resistant Staphylococcus aureus (MRSA) infections and was in and out of the hospital. He finally began receiving SSDI payments of $1300 per month and found a low-income apartment. Still, after paying rent and out-of-pocket medical costs, he was left with little money for food and other expenses. He continues to struggle with affording basic necessities while keeping a roof over his head.
Mark’s scenario actually represents a positive outcome. Some people who experience homelessness as a result of a disabling condition continue to deteriorate until their untimely deaths. In fact, the life expectancy of a chronically homeless person is around 50 years old, compared with 78 years for the general population. Disabling health conditions that can lead to unemployment include cerebrovascular accidents (CVAs) and their sequelae, vision loss, job-related accidents, and cancer. Disabled individuals can apply for government benefits, but the process is very lengthy, and many people suffer for years without income or help from family or friends. In addition, benefits such as SSDI are not an option for undocumented individuals with debilitating illness or injury. Without income or health insurance to pay for medical care, disabling conditions worsen, further solidifying the tie between poor health and homelessness.
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Behavioral health worker : Someone who provides various types of direct assistance to children or adults with behavioral health conditions.
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Case management : Assessment, planning, and coordination of services to address an individual’s or family’s health needs. Case management services are provided by case managers. A case manager may have a degree in social work or another related field.
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Community health center (CHC): A community-based organization designed to deliver comprehensive primary care to people with limited access to health care, regardless of their ability to pay. Health centers often integrate access to multiple services, such as pharmacy, mental health, and dental services. Federally qualified health centers (FQHCs) are health centers that meet strict requirements for funding from the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA).
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Low-income housing : Low-rent public or privately owned housing available to individuals and families with low incomes. Rent subsidies paid by the government allow private owners to offer reduced rents.
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Medicaid : Public health insurance coverage for adults and children with low incomes or disabilities who meet specific criteria. Each state administers its own Medicaid program according to federal requirements.
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Serious mental illness (SMI) : A mental, behavioral, or emotional disorder that causes functional impairment and substantially limits one or more major life activities.
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Social worker : A professional with a degree in social work who may perform a variety of tasks to help individuals or families resolve complex problems. Social workers may counsel clients or connect them to needed public or private resources. Some social workers work as case managers.
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Social Security Disability Insurance (SSDI) : A government benefit that provides a modest income to disabled workers who meet specific requirements.
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Supplemental Security Income (SSI) : A government program that provides a modest income to people who meet criteria for significant financial need.
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Supportive housing : A model of housing that combines affordable cost, health care, and support services to help individuals and families achieve and maintain stability. Permanent supportive housing (PMI) is supportive housing designed to be long term.
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Transitional housing : Low cost, temporary housing aimed at bridging the gap between homelessness and permanent housing by providing structure and support in times of transition, such as when transitioning from jail, a shelter, or an addiction treatment center to independent living.
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Wraparound care : An approach to care involving a team of different types of professionals collaborating to implement an individualized plan designed to address all of a patient’s health needs.
Homelessness itself presents a health risk. Homeless individuals are vulnerable to attack and suffer rape, assault, theft, and injury. Traumatic brain injuries (TBIs) are more common in the homeless population than the general population, and repeated events can lead to memory loss, cognitive deficits, agitation, paranoia, and depression. Poor living conditions contribute to the development of wounds and other skin disorders that are not only common among the homeless but also difficult to manage. Dental and periodontal disease are widespread, and communicable diseases are prevalent, especially among people living in shelters and among intravenous (IV) drug users and those who engage in high-risk sexual behaviors. As demonstrated by Mark’s story, once health problems come to medical attention, homelessness complicates the ability to manage them.
Approach to patients
Patient–provider encounter
People who are homeless experience social isolation and may feel shame, guilt, or embarrassment about living on the streets. They are subject to high rates of violence and may feel marginalized or criminalized by society. To establish trust during patient encounters, providers should express interest, empathy, and respect. An easy to remember approach is to use the acronym “NURS” as a reminder to express empathy and validate a patient’s concerns. NURS stands for Name, Understand, Respect, and Support. When the opportunity arises, n ame (or state) the emotion the patient appears to be experiencing, perhaps by saying, “I can see that you’re feeling frustrated.” Express u nderstanding by explaining your perception of what the patient is telling you, by saying, for example, “If I understand you correctly, you’re frustrated because your condition is not improving.” Show r espect by praising the patient for his or her strength, and provide s upport by explaining the care you plan to provide, such as letting the patient know that you will be available when he or she returns. Communication techniques often take very little time and can help establish a rapport and alleviate a patient’s anxiety.
Health care for the homeless extends beyond addressing medical needs; therefore facilities that serve homeless patients may have a standard format for taking a history that incorporates information about socioeconomic factors. Such information may include whether a patient has a source of income, specific job skills, or has friends or family willing to provide some form of support (e.g., temporary housing). Details related to legal issues (e.g., a record of incarceration) are also important because they provide insight into potential behavioral health concerns, such as substance abuse, and may affect the patient’s ability to secure employment or housing. Asking a patient to tell their story of how they became homeless and to describe their experience of homelessness is a good way to show genuine interest and gain an appreciation for the patient’s perspective and needs. Is the patient at risk for communicable diseases or susceptible to violence, abuse, or sexual exploitation? Does he or she have access to a stable source of food, clean water, and shelter, which is particularly important in the summer and winter months when patients may be exposed to extreme temperatures?
Mental illness and trauma are prevalent among the homeless; therefore a mental status examination including screening for depression and suicidal ideation should be performed (See Chapter 24 ). A dental assessment and examination of the feet are also necessary. During the physical examination, patients who have a history of physical or sexual abuse may feel particularly vulnerable. Providers should maintain trust by describing the components of the exam that will be performed, explaining why they are necessary, and asking permission before touching the patient. Regarding aspects of the exam that are not absolutely essential, if a patient gives permission to proceed but is hesitant or appears uncomfortable, deferring to a later visit when the patient–provider relationship may be more established is appropriate.
Meeting patients where they are
The unique challenges associated with health care for the homeless sometimes require specific strategies. One good approach is to meet patients “where they are.” Quite literally, this may mean engaging in outreach, as in packing a bag with medical supplies and bringing “the clinic” to a patient. In a figurative sense, meeting patients where they are means considering the patient’s circumstances when determining treatment goals and, when necessary, modifying goals to be realistic and attainable. A diabetic patient taking insulin may not be able to achieve a hemoglobin A1c of less than 7% while living on the streets. Challenges that he or she may face include having syringes stolen or confiscated by police and being unable to properly store insulin, which degrades in hot weather. Providers may consider a less strict A1c goal and should use discretion when deciding whether to initiate insulin to manage diabetes.
Recommending lifestyle modifications to homeless patients is usually ineffective. The homeless population in general has limited dietary choices. Storing fresh fruits, vegetables, eggs, or milk is often not possible. As a result, their diet generally consists of elevated levels of carbohydrates and fats and low levels of protein. Consider a diabetic patient whose only source of food is meals provided at a local food kitchen; he or she may have difficulty modifying carbohydrate intake. The approach to cigarette smoking and substance abuse also requires thoughtful consideration: abstinence may be an unrealistic expectation. Motivational interviewing (as described in Chapter 24 ) and harm reduction education can be much more effective. For example, patients using IV drugs should be educated about how to avoid communicable disease transmission and referred to needle exchange programs where available. Harm reduction should also be employed when caring for patient who engage in sex work, which is often a means of survival for homeless individuals. Patients engaging in sex work should be advised of the associated dangers; however, they should also be educated, without judgment, about how best to prevent unwanted pregnancy and sexually transmitted infections (STIs).
Homelessness and medical management
Chronic disease
Homeless people with chronic conditions often present with advanced disease, which complicates the approach to treatment. Managing conditions that require medication adherence and regular follow-up appointments, such as asthma, chronic obstructive pulmonary disease, hypertension, diabetes, or mental illness, can be especially challenging. Unfortunately, the consequences of uncontrolled chronic illness often result in complications requiring hospitalization, with subsequent discharge back into homelessness and poor continuity of care. Patients unable to access care for chronic diseases may present to a clinic with extremely elevated blood pressure or blood glucose; in these cases, providers must distinguish a medical emergency from a circumstance suitable for outpatient management. Referrals to the ED for asymptomatic hyperglycemia or hypertension can often be avoided by using in-office treatments and initiating or reinitiating prescription medications. Barriers to maintaining treatment compliance include medication costs and lack of consistent access to care.
Communicable diseases and acute infections
The challenges when diagnosing and managing communicable diseases in the homeless population are similar to the difficulties associated with chronic conditions. Patients commonly no-show for follow-up visits and, because they often have no dependable means of communication, do not receive test results. Consequently, they may experience detrimental lapses in care. A patient with HIV who misses doses of antiviral medication, for example, can become significantly immunocompromised.
Because of the higher prevalence of transmissible diseases in the homeless compared with the general population, providers who regularly see homeless patients should feel comfortable evaluating patients with HIV, tuberculosis, hepatitis C, and other infectious diseases. Recognizing complications that can be managed in the outpatient setting helps avoid unnecessary ED visits. To better serve their patients, primary care providers can establish relationships with HIV and other infectious disease specialists that they can call or refer to when consultation is needed.
Treating acute infections in the homelessness population may vary from typical management. For example, an antibiotic that targets MRSA may be prescribed for an infection (e.g., skin infection) to minimize the potential for transmission or complications, even when the likelihood of MRSA is low. Whenever possible, point-of-care (POC) testing, which is testing performed in-office, should be used. POC testing is an important tool when caring for the homeless because it facilitates timely diagnosis and appropriate treatment. When an STI is suspected, because follow-up may be uncertain and the risk of transmission is high, patients should be treated empirically rather than wait for confirmatory testing.
Skin and foot conditions
Patients experiencing homelessness frequently present with abscesses, cellulitis, rashes, and wounds. Lice and scabies spread easily in congregate settings like shelters and are endemic among the homeless. Unfortunately, some patients have chronic wounds that are unlikely to heal without daily care, which is generally not attainable while homeless. A wound clinic referral can be made but may not be a realistic option. For patients with chronic wounds, dressing changes, antibiotic coverage (when necessary), and emergency precautions (i.e., educating patients about signs and symptoms that require immediate evaluation) are fundamental.
The primary mode of transportation for many homeless people is walking, which, in combination with poor hygiene, can wreak havoc on the feet. Homeless individuals may have to walk for long distances on a regular basis or walk while wearing ill-fitting shoes. Among the list of podiatric conditions encountered, tinea pedis, pitted keratolysis, ulcers, painful calluses, bunions, and other arthritic conditions are some of the most common ( Fig. 48.1 ).
