Health Care of the Homeless

Aka: Health Care of the Homeless, Homeless Person, Homelessness, Homeless Health Concerns

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II. Definition: Homeless Person

  1. Individual without permanent housing
  2. No shelter in one third of cases
  3. Other transient shelters
    1. Living in vehicle or abandoned building
    2. Living in shelter or mission
    3. Living in constantly changing housing (e.g. moving between various family or friend's homes)

III. Epidemiology

  1. Prevalence: 3 million in U.S. (1% of population) per year (0.6 Million on any given night in U.S.)
  2. At risk for Homelessness in case of single catastrophic event (no reserve): 46 Million in U.S. (14% of population)
  3. Homelessness lasts for days to weeks in most cases
  4. Families represent one third of cases

IV. Risk Factors

  1. Unstable job
  2. Low wage
  3. Veteran status
  4. Mental illness
  5. Physical Disability
  6. Inadequate access to affordable housing
  7. Inadequate access to affordable health care
  8. Inadequate to public assistance
  9. Alcohol Abuse
  10. Substance Abuse
  11. Domestic Violence

V. Associated Conditions: Children

  1. Asthma
  2. Iron Deficiency Anemia
  3. Lead Poisoning
  4. Growth Delay
  5. Developmental Delay
  6. Learning Disorder
  7. Childhood Depression
  8. Childhood Anxiety
  9. Behavioral Disorders
  10. Child Abuse

VI. Associated Conditions: Adults

  1. Domestic Abuse (including sexual abuse, rape)
  2. Alcohol Abuse or Substance Abuse (20-30% of patients)
  3. Mental Illness (30-50% of patients)
    1. Schizophrenia
    2. Bipolar Disorder
    3. Major Depression
    4. Anxiety Disorder
    5. Post-Traumatic Stress Disorder
    6. Suicidality is common (especially <30 years old, hispanic, longer Homelessness duration, lower educational level)
  4. Infectious Disease
    1. Sexually Transmitted Disease (including HIV Infection)
    2. Tuberculosis
    3. Lice Infestation (risk of Bartonella infection such as Trench Fever, endocarditis)
    4. Scabies
    5. Foot infections, wounds and related disorders
    6. Cellulitis
    7. Pneumonia
  5. Uncontrolled or premature chronic disease
    1. Diabetes Mellitus
    2. Coronary Artery Disease
    3. Uncontrolled Hypertension
    4. Uncontrolled Hyperlipidemia
    5. Peripheral Vascular Disease
    6. Cancer risk (due to lack of routine cancer screening)
  6. Exposure related conditions
    1. Heat Illness
    2. Frostbite
    3. Hypothermia
    4. Immersion Foot

VII. Labs: Infectious Disease Screening

  1. HBsAg
  2. xHCV Antibody
  3. HIV Test
  4. RPR (Syphilis Test)
  5. Tuberculosis

VIII. Management

  1. Establish rapport with patient and family
    1. Provide accepting environment
    2. Establish trust
  2. Evaluate for significant health conditions
    1. See Associated Conditions above
  3. Develop evaluation and management plan
    1. Emergency contact
    2. Establish multidisciplinary approach to care
      1. Primary care
      2. Mental Health
      3. Social worker or case manager
    3. Future lab testing and other appointments
    4. Medications
    5. Follow-up plan

IX. Precautions: Medications

  1. Avoid medications with risk of rebound if stopped
    1. Beta Blockers
    2. Clonidine
  2. Avoid medications which predispose to Heat Illness or dehydration
    1. Diuretics
    2. Anticholinergics
  3. Avoid medications that may potentiate Drug Abuse habit
    1. See Drugs of Abuse

X. Prevention: Immunizations

  1. Tetanus Vaccine (Tdap or Td) every 10 years
  2. Influenza Vaccine
  3. Pneumococcal Vaccine (if indicated)
  4. Hepatitis B Vaccine

XI. Complications

  1. Adult Relative Risks
    1. Illness: 6x
    2. Hospitalization: 4x
    3. Early mortality (<52 years old): 3-4x
    4. Traumatic Head Injury: 5x
  2. Childhood Relative Risks
    1. Mortality under age 1 year: 9x
    2. Illness: 4x
    3. Delayed development: 4x
    4. Delayed Growth: 6x
    5. Learning Disorders: 2x

XII. Resources

  1. Health Care for the Homeless
    1. http://www.hchmd.org/resources.shtml
  2. SAMHSA Homelessness Resource Center
    1. http://homeless.samhsa.gov/default.aspx
  3. National Center on Family Homelessness
    1. http://familyhomelessness.org/
  4. National Health Care for the Homeless Council
    1. http://www.nhchc.org/
  5. U.S. Dept of VA - Veteran Homeless Initiative
    1. http://www.va.gov/homeless/

XIII. References

  1. DuPlessis (2005) Pediatrics 115(4): 1095-100 [PubMed]
  2. Maness (2014) Am Fam Physician 89(8): 634-40 [PubMed]

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Ontology: Homeless persons (C0019863)

Definition (MSH) Persons who have no permanent residence. The concept excludes nomadic peoples.
Concepts Population Group (T098)
MSH D006703
SnomedCT 32911000
English Homeless Person, Homeless Persons, Person, Homeless, Persons, Homeless, Homeless persons, Homeless person
Swedish Hemlösa
Czech lidé bez domova, bezdomovci
Finnish Kodittomat
Russian BESPRIZORNYE, BEZDOMNYE, БЕЗДОМНЫЕ, БЕСПРИЗОРНЫЕ
Polish Bezdomni, Osoby bezdomne
Italian Senzatetto, Persone senza fissa dimora
Norwegian Hjemløse personer
French Sans-abri, Personnes sans domicile fixe, SDF (Sans Domicile Fixe)
Portuguese Pessoas sem Lar, Moradores de Rua, Morador de Rua
German Heimatlose, Nichtseßhafte
Dutch Dakloze, Daklozen, Personen zonder vaste woon- of verblijfplaats, Thuislozen
Spanish Personas sin Hogar
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Homelessness (C0237154)

Definition (HL7V3.0) <p>Indication of status as homeless.</p>
Definition (HL7V3.0) <p><b>Definition:</b>Living arrangements lacking a permanent residence.</p>
Definition (HL7V3.0) <p><b>Definition:</b>Living arrangements lacking a permanent residence.</p>
Definition (NCI) Without a stable or permanent residence.
Definition (CSP) persons lacking permanent or reliable shelter, variously due to poverty, lack of affordable housing, mental illness, substance abuse, juvenile alienation, or other factors.
Concepts Finding (T033)
MSH D006703
SnomedCT 138091007, 42662003, 160699002, 160704005, 138087002, 32911000, 266935003
HL7 2.16.840.1.113883.1.11.19893, HL, HMLESS
English Homelessness, Housing lack NOS, homeless (history), homeless, Lack (of);housing, Housing lack NOS (finding), (Housing lack) or (homeless) (finding), (Housing lack) or (homeless), Living on the street (finding), lack of housing (history), lack of housing, Homeless, Living on the street, Housing lack, Homeless (finding), Housing lack (finding), homelessness, housing; lack of, lack of; housing, lack of; shelter, shelter; lack of
Italian Senza tetto
Japanese ホームレス, ﾎｰﾑﾚｽ
Czech Bez domova, bezdomovectví
Spanish carencia de vivienda (hallazgo), carece de alojamiento (hallazgo), carece de alojamiento, carencia de vivienda, carece de hogar, carencia de alojamiento, SAI (hallazgo), vivir en la calle, carencia de alojamiento, SAI, vivir en la calle (estilo de vida) (concepto no activo), Housing lack NOS, persona sin hogar (hallazgo), persona sin hogar, vive en la calle, Sin vivienda
Hungarian Hajléktalan
French Condition de sans-abri, Condition de SDF, Sans-abrisme, Sans domicile fixe
Dutch behuizing; gebrek, beschutting; gebrek, gebrek; behuizing, gebrek; beschutting, dakloos
Portuguese Sem abrigo
German obdachlos
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Homeless Health Concerns (C1456561)

Definition (MEDLINEPLUS)

Poor health can contribute to being homeless, and being homeless can lead to poor health. Limited access to health care can make it worse. That's why the health of homeless people in the United States is worse than that of the general population. Common health problems include

  • Mental health problems
  • Substance abuse problems
  • Bronchitis and pneumonia
  • Problems caused by being outdoors
  • Wound and skin infections

Many homeless women are victims of domestic or sexual abuse. Homeless children have high rates of emotional and behavioral problems, often from having witnessed abuse.

Help such as shelters, health centers, and free meals are available. Contact your local homelessness assistance agency.
Concepts Group Attribute (T102)
English Homeless Health Concerns
Derived from the NIH UMLS (Unified Medical Language System)

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