Health care for the homeless: a family medicine perspective

Author: Richard P. Usatine, Lillian Gelberg
Date: Jan, 1994

Homelessness in America is a problem that is not going to disappear overnight. As family physicians, we will be responsible for providing health care to the homeless in many settings - in emergency rooms, public hospitals, community and free clinics and, occasionally, even health maintenance organizations and private practices. Providing care to the homeless is difficult, and intellectually and emotionally challenging.

The homeless comprise a diverse group of individuals and families living in many different settings. Being homeless does not necessarily mean that a person is without a bed to sleep in. People who are homeless may live in emergency shelters or single-room-occupancy hotels or with family or friends.

Homeless persons also live in garages and abandoned buildings, under freeway overpasses, in bus terminals and airports, and in cars, vans or buses. Families living in transitional housing are one step removed from the ranks of the homeless but technically are often considered homeless.

The factors that may lead to homelessness have a tremendous effect on both the health of homeless persons and the Provision of health care to them. Sometimes health problems such as drug abuse and chronic mental illness precipitate homelessness.[1] A battered woman escaping from an abusive husband may end up living on the streets. Unemployment, with its attendant loss of benefits, and eviction from housing also affect a person's access to medical care.

In addressing the prevention and treatment of health problems of the homeless, it is helpful to view the situation from two perspectives. First in this article, we consider the factors that decrease a person's ability to resist illness or the complications of disease. Second, we consider the main health consequences of these identified factors and discuss essential points for those providing health care to homeless persons.

Factors Contributing to Disease

The health problems of the homeless derive from many factors, including exposure to the elements, overcrowding in shelters, unusual sleeping accommodations, unsanitary living conditions, poor hygiene, poor nutritional status, alcoholism, drug abuse, mental illness, and exposure to trauma and crime.[2]

Homeless persons are exposed to the elements even if they have temporary shelter, because they must spend much of their days outdoors (many emergency shelters are open only at night). Homeless persons who spend much of their time outdoors in warm climates may suffer severe sunburns or heatstroke. In cold weather, they are at risk for hypothermia. Homeless persons walking the streets in the rain often have water-soaked shoes and socks, a predisposing factor for fungal infections of the feet (Figure 1).

Overcrowding in shelters can lead to the transmission of lice and scabies, along with contagious diseases. Lice infestation tends to run rampant in many shelter situations, and outbreaks of scabies are common (Figures 2 and 3). Impetigo can be spread in overcrowded shelters, and outbreaks of tuberculosis,[3-5] meningococcal disease,[6] pneumococcal pneumonia,[7] diphtheria[8,9] and diarrhea[10] have been reported among the homeless.

The lack of a home often results in unusual and bizarre sleeping accommodations. Even in shelters, beds may not be available. Homeless persons may be forced to sleep on floors, in chairs or on church pews. Such sleeping conditions can cause various medical problems, such as exacerbation of peripheral vascular disease. A person sleeping in an upright position may develop massive pedal edema from poor venous return. This chronic venous stasis can predispose the person to cellulitis and leg ulcers.

Unsanitary living conditions and lack of hygiene are also factors that contribute to skin infections and infestations of lice and scabies. Homeless persons scavenging through garbage cans are at risk of cutting their hands, and these cuts may become infected (Figures 4 and 5). Lack of personal hygiene contributes to significant dental pathology.

Malnutrition is common among the homeless. It may result from limited access to food, poor quality of food, alcoholism," drug abuse or mental illness. When a patient is unable to follow a specific diet, some diseases, such as diabetes, hypertension or hyperlipidemia, may be difficult to control or treat. Exacerbations of diabetes occur, for example, when a homeless person is unable to follow a diabetic diet while living in a shelter or eating at a soup kitchen.

About one-third of the homeless persons in the United States have a substance abuse problem.[12,17] Indeed, in one study, it was found that as many as 85 percent of homeless men were substance abusers (chiefly alcohol).[1]

Alcoholism and drug abuse predispose the homeless to numerous illnesses. The acute consequences of alcoholism include increased exposure to trauma and crime. It is not unusual for alcoholic persons to be hurt in fights or to be set afire while lying drunk on the ground.

Alcoholic persons also injure themselves by falling or engaging it dangerous activities. The chronic "skid row" alcoholic is subject to the long-term effects of alcohol, including cirrhosis, gastrointestinal bleeding, anemia and neuropathies. Psychiatric disturbances and anorexia related to alcohol use are common in this group.

The deinstitutionalization of patients with chronic mental illness and curtailed community mental-health treatment programs are a major cause of homelessness.[18] Severe mental illness is present in at least one-third of homeless adults and includes such diagnoses as schizophrenia, major depressive disorders and bipolar affective disorders.[12,13,19] These illnesses may precipitate homelessness and are exacerbated by life on the streets.

Homeless persons miy also suffer from personality disorders, anxiety disorders and acute depressive episodes. Many of the most severely ill street persons, such as the "shopping bag lady" or the "man directing traffic on the streets," avoid seeking health care for their physical and mental problems.

Exposure to trauma and crime has many health consequences, including abrasions, lacerations, burns, fractures, rape and death. Many homeless women living on the streets have been raped. A woman engaging in alcohol and drug abuse may be raped by male companions. Runaway adolescents are victimized through involvement in prostitution ad illegal drug use.[20]

Access to Health Care

Homeless persons often seek health care too late or do not seek health care at all.[21] Disaffiliation and estrangement from society, along with the extreme poverty of homelessness, limit access to conventional health care.[22] Homeless persons sometimes fear visiting hospital emergency departments because of previous bad experiences with the health care system. They may also fear they will be turned away from medical facilities because they have no money or insurance. Lack of transportation is another barrier to obtaining health services. Care may be delayed while homeless persons struggle to fulfill basic needs for food, clothing, shelter and employment.

As a result, homeless persons often are not seem by medical personnel until they are in advanced stages of illness. An infection such as impetigo may have spread to cover large areas of a person's body before medical attention is sought.

One of the goals of treating the homeless is to break down the barriers to health care. For example, while a person living in a house with access to running water and soap might be able to change a dressing on a daily basis, this procedure is quite difficult for a homeless person. When the patient is not mentally or physically capable of changing a dressing, it is important that a health care worker see him or her daily to change the dressing.

Compliance

To encourage compliance with frequent clinic visits, follow-up appointments should De made for convenient hours, and clinic Waiting time should be kept to a minimum.

Another major compliance problem occurs when a diet is prescribed for a homeless person. While it may be in the patient's best interest to be on a low-salt, low-cholesterol or low-calorie diet, this may not be possible ff the patient depends on a shelter or soup kitchen for food. In these circumstances, the physician may need to seek alternative approaches to the management of health problems that should be treated with dietary intervention. The physician might need to rely less on a diet and start medication earlier in the treatment process.

Common Health Problems

Some particular health problems are common in homeless persons, as observed in the Robert Wood Johnson Health Care for the Homeless Program (Table 1).[23] For adult patients, upper respiratory infections, trauma and skin ailments are the most common acute physical disorders. Skin problems usually include impetigo, cellulitis (Figure 6), abscesses, lacerations, fungal infections, eczema, lice and scabies.[24]

[1.] Breakey WR, Fischer PJ, Kramer M, Nestadt G, Romanoski AJ, Ross A, et al. Health and mental health problems of homeless men and women in Baltimore. JAMA 1989;262:1352-7. [2.] Brickner PW, Scanlan BC, Conanan B, Elvy A, McAdam J, Scharer LK, et al. Homeless persons and health care. Ann Intern Med 1986;104:405-9. [3.] Nardell E, McInnis B, Thomas B, Weidhaas S. Exogenous reinfection with tuberculosis in a shelter for the homeless. N Engl J Med 1986;315:1570-5. [4.] Drug-resistant tuberculosis among the homeless - Boston. MMWR Morb Mortal Wkly Rep 1985;34: 429-31. [5.] Barry MA, Wall C, Shirley L, Bernardo J, Schwingl P, Brigandi E, et al. Tuberculosis screening in Boston's homeless shelters. Public Health Rep 1986;101:487-94. [6.] Filice GA, Englender SJ, Jacobson JA, Jourden JL, Burns DA, Gregory D, et al. Group A meningococcal disease in skid rows: epidemiology and implications for control. Am J Public Health 1984;74:253-4. [7.] DeMaria A Jr, Browne K, Berk SL, Sherwood EJ, McCabe WR. An outbreak of type 1 pneumococcal pneumonia in a men's shelter. JAMA 1980;244:1446-9. [8.] Heath CW, Zusman J. An outbreak of diphtheria among skid-row men. N Engl J Med 1962;267:809-12. [9.] Pedersen AH, Spearman J, Tronca E, Bader M, Harnisch J. Diphtheria on Skid Road, Seattle, Wash., 1972-75. Public Health Rep 1977;92:336-42. [10.] Gross TP, Rosenberg ML. Shelters for battered women and their children: an under-recognized source of communicable disease transmission. Am J Public Health 1987;77:1198-201. [11.] Gelberg L, Linn LS. Assessing the physical health of homeless adults. JAMA 1989;262:1973-9 [Published erratum appears in JAMA 1989;262:31321]. [12.] Farr RK, Koegel P, Burnam A. A study of homelessness and mental illness in the Skid Row area of Los Angeles. Los Angeles: County Department of Mental Health, 1986. [13.] Fischer PJ, Shapiro S, Breakey WR, Anthony JC, Kramer M. Mental health and social characteristics of the homeless: a survey of mission users. Am J Public Health 1986;76:519-24. [14.] Bassuk EL, Rubin L, Lauriat A. Is homelessness a mental health problem? Am J Psychiatry 1984; 141:1546-50. [15.] Sacks JM, Phillips J Cappelletty G. Characteristics of the homeless mentally disordered population in Fresno County. Community Ment Health J 1987;23:114-9. [16.] Arce AA, Tadlock M, Vergare by, Shapiro SH. A psychiatric profile of street people admitted to an emergency shelter. Hosp Community Psychiatry 1983;34:812-7. [17.] Koegel P, Burnam MA. Alcoholism among homeless adults in the inner city of Los Angeles. Arch Gen psychiatry 1988;45:1011-8. [18.] Brickner PW, et al, eds. Health care of homeless peoplp. New York: Springer, 1985. [19.] koegel P, Burnam MA, Farr RK. The prevalence of specific psychiatric disorders among homeless individuals in the inner city of Los Angeles. Arch Gen Psychiatry 1988;45:1085-92. [20.] Health care needs of homeless and runaway youths. Council on Scientific Affairs. JAMA 1989;,162:1358-61. [21.] Gelberg L, Linn LS, Usatine RP, Smith LM. Health, homelessness, and poverty. A study of clinic users. Arch Intern Med 1990;150:2325-30. [22.] Wright J. The health of homeless people. In: Brickner PW, et al, eds. Under the safety net: the health and social welfare of the homeless in the United States. New York: Norton, 1990. [23.] Wright JD, Weber E. Homelessness and health. Washington, D.C.: McGraw-Hill, 1987. [24.] Usatine R. Skin diseases of the homeless. In: Wood D, ed. Delivering health care to homeless persons: the diagnosis and management of medical and metal health conditions. New York: Springer, 1992. [25.] Gelberg L, Linn LS, Rosenberg DJ. Dental health of homeless adults. Spec Care Dentist 1988;8:167-72. [26.] U.S. Preventive Services Task Force. Guide to clinical preventive services. Baltimore: Williams & Wilkins, 1989. [27.] Leeds S, Heneson-Walling R, Schwab J, eds. EPSDT: a guide for educational programs. Washington, D.C.: Department of Health and Human Services, 1992. [28.] Prevention and control of tuberculosis among homeless persons. Recommendations of the Advisory Council for the Elimination Of Tuberculosis. MMWR Morb Mortal Wkly Rep 1992;41(RR5):13-23. [29.] American Thoracic Society. Medical Section of the American Lung Association. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986;134:355-63. [30.] Michael M, Brammer S. Medical treatment, Of homeless hypertensives [Letter]. Am J Pub Health 1988;78:94. [31.] Jubelier J. Mental health considerations in homeless families. hi: Wood D, ed. Delivering health card to homeless persons: the diagnosis and management of medical and mental health conditions. New York: Springer, 1992. [32.] Hilfiker D. Are we comfortable with homelessness? JAMA 1989;262:1375-6.

The Authors

RICHARD P. USATINE, M.D. is the director of the UCLA Family Medicine Predoctoral Education Program. Dr. Usatine is also faculty advisor for the UCLA/Salvation Army Family Outreach Clinic, which is run by UCLA medical students and provides free medical care to homeless families living in transitional housing. He is also an assistant professor of medicine in the Division of Family Medicine at UCLA. He was previously the medical director of the Venice (Calif.) Family Clinic. Dr. Usatine graduated from Columbia University College of Physician? and Surgeons, New York City.

LILLIAN GELBERG, M.D., M.S.P.H. is an assistant professor of medicine in the Division of Family Medicine at UCLA. Dr. Gelberg has conducted surveys of homeless populations served by the Venice Family Clinic and has published articles on the physical and mental health of homeless persons. She graduated from Harvard Medical School, Boston, Mass.

MARY H. SMITH, F.N.P.-C., M.S.N. is a family nurse practitioner at the Venice Family Clinic. She graduated from California State University of Long Beach, School of Nursing, Long Beach, Calif.

JANNA LESSER, M.N., R.N., C.S. is a nurse psychotherapist. She is also a doctoral student at the UCLA School of Nursing, where she received her master of nursing degree. With Dr. Usatine, she conducted a parenting support group for low-income and homeless families at the Venice Family Clinic.

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