Homelessness

[Khaled Janom]

Group discussion this Monday was about the impact of homelessness on patient care. It is a difficult situation of course for any person to be homeless and try to focus on taking care of his health. How would BP control matter when one is outside in the cold weather and feeling incapacitated. Mental illness is also common in the homeless population making it more difficult for them and for caring physicians to set a plan of care. It is imperative when approaching these patient to have mental health care professional and social workers present to have a multidisciplinary approach to aid these patients.

[Hibah Ismail]

Homelessness has without a doubt a major impact on our patient’s healthcare. For one, patients would not be able to follow up on their diseases and get to their appointments, afford their medications, ect when they have no place to live in the first place. In addition, homeless people living on the streets and in shelters are more prone to develop diseases such as Tb, scabies, mental health ect due to their living situation, which would affect their healthcare as well as public health. For this reason it is importanant for us to understand the living situations that are patients are living in in order to develop plans with them to improve their healthcare. One way in doing so may be by serving at shelters in order to be in direct contact with the living situation that our patients are experiencing. In addition, working to improve our knowledge of resources available in our communities to help our patients is an imperative factor that should be included I our everyday practice.

[Hussam Tabaja]

During our rotations, whether on medical wards or clinic weak, we are coming across a descent number of homeless patients. As Hibah and Khaled already mentioned, homelessness is an obstacle to healthcare. Non-compliance with medications and doctor’s recommendations is a great issue with homeless patients but this is quite understandable. Those patients have so much on their minds and chronic medical conditions can be the last of their concern. At the same time, homeless patients don’t have the luxury that other patients have. They often lack means of transportation which makes them skip follow ups or even going to the pharmacy to fill their prescriptions. In the hospital setting, homelessness can lead to prolonged unnecessary hospital stay. Furthermore, we are sometimes coming across patients who are admitted for being homeless and with no medical indication at all. This leads to unnecessary hospital cost.

[Kunwardeep Dhillon]

Working in Detroit has given us all a lot of exposure to Homeless population, but many of us including myself are quite ignorant about the impact it has on their health. Most of these patients do not have access to preventative healthcare given lack of insurance and end up going to ER for medical issues. What surprised me more was how little I knew about the housing situation for homeless including the shelters (which are often separate for men/women and families). Mental health disorders (which are often undiagnosed) are more common with homelessness which could be a causative factor or just an association so it is vital to screen all homeless patients for mental health disorders.
This week’s discussion has provided me with knowledge and resources to better serve our population but recognizing patients who are at risk remains imperative.

[Nadine Abdallah]

Homelessness is an issue that I did not encounter during medical school, but I came across numerous times during residency in the inpatient as well as outpatient setting. As such, I found myself struggling to apply my medical knowledge , and providing comprehensive care with only limited resources. Furthermore, I was often surprised to see well-groomed, and well-dressed patients in clinic who turned out to be homeless. I learned that homelessness comes in different forms, and is by itself a spectrum in terms of resources and limitations. Homelessness affects compliance with medications, medical appointments, and even adherence to the recommended diet, as healthy food is often more expensive. I have picked up few ways to maneuver around these limitations, including buying cheap generics of anti-hypertensives at local pharmacies. In the inpatient setting, social workers have been helpful most of the times in terms of applying for insurance, and placement, but I often feel helpless in the outpatient setting, where social work assistance is lacking. I feel that we need more resources in the outpatient setting in term of social work, free drug samples, food coupons to allow us to provide more to this patient population. But this starts by identifying these patients, and being more familiar with the resources available to them, and this information is not always volunteered by the patient and requires us to establish rapport with them.

[Ali Saker]

Homelessness is a major problem we face in our daily medical care for our patient. It doesn’t only imply difficulties with patient adherence to medications but also implies increased rates of substance use disorder and mental health problems that make the care of the homeless more complicated. During this week I had a patient who was kicked out of NSO home, was eating whatever passengers were offering her in the street, and she was asking me about medications to decrease her weight. It was almost impossible to counsel her about dietary changes while all she can eat is what people offer her on the street and we were not in favor of starting any weight loss medications. We focused on addressing the major medical problems she has while she finds housing and addressing her depression which was most likely contributing to her weight gain. In the care of homeless, a whole team of pcp, substance use specialist, psychiatrist, and case manager should be involved to improve the healthcare for the patient.

[Amjad Kanj]

As physicians we need to be aware that the health care of the homeless is different than that of other patients. Homeless live under tough circumstances, posing a particular problem when developing a treatment plan. Transportation and access to medications are two major obstacles in the care of this population. As such, the patient’s best interest should be carefully considered in every step of the plan. A crucial element in caring for homeless is to understand their living conditions by visiting them in the streets and shelters.

[Michael Hill]

Homelessness is something that I encountered both during my medical school journey and now residency training. It has changed my perception or more specifically my approach to patient care. I agree with the above-mentioned comments that Homelessness requires a multi-disciplinary approach but I also think that recognition of homelessness is important. From what I have witnessed homelessness cannot just be defined as “living on the street”. Most of the patients I have encountered do not fit the category of “living on the street”, they are usually living paycheck by paycheck, living in shelters or couch surfing. These facts can be delved into deeper in the social history and it is there where the initial step needs to be taken.Once we have a comprehensive understanding of the individual’s social history it may provide a global view on the type of assistance the individual may require or is able to sustain.

[Michael Hill]

Homelessness is something that I encountered both during my medical school journey and now residency training. It has changed my perception or more specifically my approach to patient care. I agree with the above-mentioned comments that Homelessness requires a multi-disciplinary approach but I also think that recognition of homelessness is important. From what I have witnessed homelessness cannot just be defined as “living on the street”. Most of the patients I have encountered do not fit the category of “living on the street”, they are usually living paycheck by paycheck, living in shelters or couch surfing. These facts can be delved into deeper in the social history and it is there where the initial step needs to be taken.Once we have a comprehensive understanding of the individual’s social history it may provide a global view on the type of assistance the individual may require or is able to sustain.

[Raja Rabadi]

Homelessness is and has always been a critical aspect of medical care. I believe in order to make an impact in this field there needs to be a preventative approach taken as well. From my experience, I have noted that many times those patients missing appointments or intermittently filling their prescriptions are demonstrating early signs of “making ends meet”. They are at the cusp of being homeless if even one shift or paycheck is missed. If we are able to assist and provide the above mentioned multidisciplinary services to them, we may be able to prevent them from reaching homelessness or at least manage it at an earlier stage.

[Mohammad Rauf]

To me homelessness means not having a home. I believe I can better serve my patients by acknowledging they are homeless, knowing the implications it may have on their health and adherence to care plans. I feel I should refer them to someone that is familiar with resources, as a physician I should treat my patient’s equitably according to the severity and complexity of their medical condition. I can’t spend more time with someone because they are homeless unless it has resulted in a severe degree of illness. Just as I refer to a specialist for diseases where I am unfamiliar/uncomfortable with intricacies and special procedures that may be involved, I must recognize the proper programs and defer management of these homelessness issues and focus on my role.

[LAKSHMI PATHAI]

Homelessness is a state when one does not have a permanent dwelling.
This week I had 2 homeless patients and I used the biopsychosocial model to understand their situation. I felt by asking these questions it creates a bond with my patients and it gives me opportunity to address their emotional aspects along with their health issues.
One of my patient lost her place last month after her boyfriend had a fight with her. She was living in shelters and was very much concerned that she is getting sick from the germs in the shelter and everyday she has to go and find a new shelter for herself. She had multiple crying episodes during the encounter, I counseled her and called the psychologist to talk to her and also spoke to concerned department regarding the requirements for the paper work so that she can get a place.
This patient was an example for me how a homeless person is affected physically and psychologically.

[Hamza Salam]

The usual way we treat patients with dietary, lifestyle modifications and the best treatment option for a typical disease does not necessarily apply when dealing with most homeless patients. I found out during my encounters this clinic week that most homeless people are unable to comply with the doctors recommendations due to lack of resources either buying the best medications available or to the lifestyle we want them to adopt to optimize their health. For example I had a patient this week who could not afford the basal-bolus insulin regimen due to the higher price when compared to the humulin 70/30 combination. It is harder to maintain a stable blood glucose level with the twice a day regimen than what we are used to seeing in other patients on a basal-bolus regimen, but these are the limitations that we have to learn from when dealing with this particular subset of population. What we might think of the best option for the patient is not universally applicable. Dealing with people who are homeless has allowed my clinical skills to become more patient centered and reinforced the importance of keeping the patient in the center of any frame and getting “guidance ” from guidelines and not applying guidelines first to every single patient regardless of socioeconomic background.

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