Health Care of the Homeless

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

1. 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)
2. 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
3. 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
4. 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
5. 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
6. Labs: Infectious Disease Screening
   1. HBsAg
   2. xHCV Antibody
   3. HIV Test
   4. RPR (Syphilis Test)
   5. Tuberculosis
7. 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
8. 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
9. Prevention: Immunizations
   1. Tetanus Vaccine (Tdap or Td) every 10 years
   2. Influenza Vaccine
   3. Pneumococcal Vaccine (if indicated)
   4. Hepatitis B Vaccine
10. 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
11. 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/
12. References
    1. DuPlessis (2005) Pediatrics 115(4): 1095-100 [PubMed]
    2. Maness (2014) Am Fam Physician 89(8): 634-40 [PubMed]