[Yellow Cohort] Module 6 2018-2019 – Homelessness

[John Dawdy]

Reflections here

[John Dawdy]

Homelessness is an ever-growing and consistent concern with our patient population. It also often carries a negative connotation and some believe the end result of some inherent vice or low moral compass that leads to people ending in this situation. In reality, homeless individual has their own story and set of circumstances that led them to where they are, often heavily influenced by powers beyond their control. It is an issue in cities/towns big and small, and it is not a uniform need, but rather a spectrum of experiences, whether somebody is bouncing between shelters for years or has had some change in status that has made it difficult for them to find somewhere to stay this week. Working in downtown Detroit, our patient population has higher rates of the risk factors for homelessness that makes them more vulnerable and this an important issue to be conscious of in our day-to-day practice. Whether it is low income, disability, history of incarceration, substance abuse, mental health, or rising housing costs, our patients face multiple stressors that put them at increased risk for experiencing homelessness. when it comes to treating these patients, this risk and uncertainty needs to be taken into account when developing care plans. As discussed in previous reflections, medication costs and storage, transportation, and mental health services are all important things that we often take for granted and that are barriers to optimize care in our population and which may be of particular importance in this subset of our patients. Ensuring that we have an awareness of these issues and that we’ve discussed these concerns with individual patients will help us provide care as best we can. Maintaining a patient-centered approach to these discussions remains a necessity to connecting to these patients and providing appropriate care. Detroit and WSU SOM offer a number of opportunities to connect with this patient population outside our GMAP clinic, including multiple free clinics, the Detroit Street Medicine group/street runs, as well as other organized volunteer opportunities at food pantries and health fairs. Our program could probably make a greater effort to engage with these organizations.

[Nabil Al-Kourainy]

CWC Module 6: PSYCHOSOCIAL AND BEHAVIORAL DETERMINANTS OF HEALTH AND HEALTH CARE, Case 2: (03-2019)

What does homelessness mean to me? How can I and my program better collaborate with the homeless community agencies I learned about?

Homelessness represents a fundamental challenge to health equity and a serious healthcare crisis. The rising issues with homelessness in large urban areas in particular are compounded by cuts in social services such as welfare and a lack of sufficient number of affordable housing options. We need look no further to the revitalization of downtown and midtown Detroit for examples of how purported progress leads to increase socioeconomic inequity as well as net decrease in affordable and government subsidized housing. It is important that as we seek to create jobs and to revitalize urban areas, that provisions are made, in writing to ensure that low income and subsidized housing are part of the deal. In addition to making provisions for affordable housing, throughout North America, and beginning with an initiative in Toronto, there is a growing movement for a housing-first option to tackle homelessness. Detroit joined this movement with the creation of the Veterans Community Resource and Referral Center (VCRRC) {https://www.detroit.va.gov/services/homeless/index.asp} with the goal to house veteran’s and provide essential services as well as job placement assistance. These programs while financially costly, have shown great improvement in the lives of those supported.

As was referenced in the video, a great number of the homeless suffer from chronic health conditions that coincidentally also disproportionately affect the low-income urban population. Conditions such as hypertension, diabetes, coronary artery disease, renal disease, congestive heart failure, mental health disorders and polysubstance use disorder are all too familiar to residents who care for this population on a daily basis. According to the video, over 50% of the homeless are over the age of 50. This age demographic is in line with the population that we see in our inpatient and outpatient medical practices. All too often, we see these patients at advanced stages of these diseases, due to lack of access to affordable care. The affordable care act (2010) and subsequent expansion of Medicaid, has likely improved healthcare access, however due to a lack of qualified primary care providers to address the growing number of insured, we now have an issue where economically disadvantaged individuals have the right to receive care, it is now a matter of adding social support services to facilitate greater access, as well as a need for more dedicated primary care providers.

In order to address these health inequities, service models with adequate government support are desperately needed. In Detroit, one such resource is Detroit Central City, a federally qualified health care (FQHC) facility, which offers both primary care services, as well as mental health services and transitional housing. In my own experience treating patients at this facility, this is a model that can have success, however there is often a lack of continuity of care, access issues due to transportation, as well as insufficient funding and support for this facility. I have often referred my primary care mental health patients to DCC, as a way for them to be connected to one facility that can provide primary care as well as mental health services, as well as social support. I find it deeply disappointing that as residents we operate in a clinic that while it has many committed attending physicians and residents, does not have a single social worker or psychiatrist on staff. This omission is doing a disservice for the patients that we are trying to help and I would imagine the lack of support is due to a lack of funding. Unfortunately, due to the current pay-for-service model of reimbursement, the patients who need to most help and the most services, end up costing the practice the most, in time and resources, and reimbursement is not in line with the hours spent helping these patients. One could hope that in the upcoming pay-for-performance model, there is a potential to increase reimbursement for preventive services as well as counseling on the management of chronic diseases.

As we currently lack financial support to bring essential social services in house, residents can employ assistance from local community organizations in order to try to bridge the gap. As previously mentioned DCC is a facility that I have often referred patients to, as I have personal experience with this practice. Another resource that we learned about during our SDH group discussion this week is the United Way. The United Way provides the 211 hotline to assist patient to find referrals for food, shelter and medical assistance. While I do not have personal experience with this organization, they seem to be well organized and funded through numerous non-profit partners. Another resource for Detroiters is Focus:Hope Focus: HOPE which provides resources for those in need of food assistance and career training. The organization’s Commodity Supplemental Food Program supports single parents and low-income senior citizens over the age of 60. It is reported to have helped more than 21 million people since its inception in 1968. I will make renewed efforts to both identify homeless patients both in inpatient and outpatient care and offer them services to local community resources.

I contacted the local United Way and they will be emailing me shelter and food pantries that we can refer our patients to. I will be sure to share with my resident colleagues once received.

[Shivani Agrawal]

Homelessness is a large issue in society. The video brought up interesting statistics. I tried this week in clinic to ask about people’s housing situations. Also, as I completed CCR tasks – I wondered about people’s living situations when trying to reach patients/fill their meds. Nabil made a nice list of resources which I will use to help our patients.

[Sahrish Ilyas]

What does homelessness mean to me?
Homelessness means not having access to a safe and secure place to live and dwell in. What comes to mind usually is lack of income or unsteady income contributing to inability to secure a place to live. Using the BPS model, we can make a conscious effort to screen all patients not just for physical and mental health problems but also inquire about their social environment and whether or not they have a place to live that they call their own. If we come across such patients we can provide them with a list of shelters in the metro Detroit area (list provided by Nabil). Additionally we can make them aware of 211, which is a comprehensive source of social services available in the US. They would have to call 211 and would be able to speak to a community resource specialist in their area who can help with providing information on shelters/housing,
utilities assistance, food programs and employment opportunities to name a few. Although these programs are helpful and may aid someone in need, what we really need is to elect individuals who are intent on making policy changes regarding affordable housing and decreasing unemployment. Having one’s own place to live and source of income would leave to a more fulfilling life rather than having to persistently rely on social services.

[Dana Kabbani]

The most recent HUD report on homelessness estimated that 564,000 homeless people in the US live in shelters and on the streets. A recent analysis revealed that death rates for homeless youth are more than 10x greater than for the general population. Housing First offers timely access to a home without requirements such as sobriety, psychiatric treatment, etc, and provide clients opportunities to connect with caregivers who can help address mental and physical health needs. Using preintervention and postintervention designs, associate Housing First with less alcohol use as well as fewer hospitalizations and emergency department services

[Leslie Kao]

Homelessness or housing insecurity appears is a constant problem that we encounter in our general practice.

One of my regular clinic patients is homeless. She fits every risk factor for being homeless including a chronic psychiatric disease and growing up in a socially depressed situation. Since she became my patient, Ms. W has never had a permanent address, variably living in her car, in a long-term motel and on the couch of her “friend’s” brother’s house. She comes in repeatedly for treatment resistant hypertension, complicated by the fact that her diet is normally high is sodium, due to her not having a kitchen. The patient has difficulty making appointments – she is always 30-45min late, affording her medication and controlling her risk factors including diet and obesity. Her chronic condition is relatively simple to control and she is fairly lucky in always having a (temporary) roof over her head, but following other homeless patients that have been admitted inpatient, I sometimes wonder what happens to them after discharge. Do their wounds stay clean? Will they be able to take their 5 medications several times per day to decrease overall mortality?

Traveling around the country, I have seen different regions deal with and treat their homeless population differently. In Boston, you rarely saw a large homeless population. The panhandlers lived in houses and actual homeless people all appeared to have underlying psychiatric issues, but routinely received handouts from passers by. On the west coast, I have seen the homeless population explode over the last decade since the last economic downturn. There are variable safety nets that have been popping up to take care of this population including temporary tent towns in San Diego (possibly harkening back to the Great Depression days), billion dollar taxes to build more permanent housing (Los Angeles), guerrilla housing (housing in backyards/pool houses subsidized by the SF county) or states giving their homeless a one-way ticket to CA or HI. In a country that is so wealthy with so much need, how are we still allowing over a half million people go homeless every year?

[Deya Obaidat]

To understand what homelessness mean, we need to understand what home means, and despite everyone of us might be having a different definition of home, we all do agree that home is the safe place that you go to by the end of the day and forget about your long tiring day, there you will have food, medicine, people that you love and care about, you sleep on your bed and under a roof in a warm cozy weather when there is a storm outside. Now imagine that you have non of these, that after your long day, you have no where to go, you have no warm meal, you have no place to eat or sleep, you are restless continuously and that what it means to be homeless.

the modern society defines a homeless person as a person who doesn’t have an address, whether they live in a shelter, living at a family member or a friend house or bouncing around different houses. which in the modern era makes it a challenging thing, as without an address you have no chance to get medical insurance, starting a business or even getting a job or education, It’s a vicious circle where homelessness leads to unemployment and that will lead to further decrease in income and unavailability of medical or health insurances which are basic needs in the modern era.

In the medical field and from our day to day experience in the hospital, we find that homeless people have higher chances of getting admitted to the hospital, having more severe diseases, and being re-admitted within 30 days period from discharge. which gives an indication that the outpatient setting follow up for homeless people is not optimum, and the reason behind that might goes back to the fact that those patient can’t be enrolled in health insurance, can’t afford transport in and out of the physician office or simply can’t afford the medications prescribed to them at the time of discharge, those reasons and many others makes homelessness a really challenging matter to deal with on the physician level and the decision makers level as well.

There has always been efforts from the decision makers to improve the homeless situation by either providing shelters, food, providing disability status for disabled homeless and walk in clinics and many other ways, but despite that we still have a gap where homeless people still don’t get the optimum care that they deserve and they would benefit from.

On physician level, it is challenging to provide the optimum care for patients, and I think the best way that physician can help is to be aware with the situation of homeless patients in a judgment free zone, providing resources that homeless people can benefit from is also another way we can contribute to the cause.

The talk about homelessness is huge talk and unfortunately it won’t fit in a day or 2 discussions. There are efforts from everyone that has been made to improve the mental and physical health for homeless patients, but we are still far away from achieving the optimum care for the patients.

[Muhammad Usama]

The patient population we serve are just one health care bill or just one accident away from homelessness. Of the 1 million personal bankruptcies in 2007, 62% were caused by medical debt. Healthcare problems and their expenses can result in homelessness but then homelessness results in multiple health problems as well. Living on the street or in crowded homeless shelters is personally stressful and made worse by being exposed to communicable disease (e.g. TB, respiratory illnesses, etc.), violence, malnutrition, and harmful weather exposure. Hence, common conditions such as high blood pressure, diabetes, and asthma become worse because there is no safe place to store medications or syringes properly. Maintaining a healthy diet is difficult in soup kitchens and shelters as the meals are usually high in salt, sugars, and starch (making for cheap, filling meals but lacking nutritional content. Behavioral health issues such as depression or alcoholism often develop or are made worse in such difficult situations, especially if there is no solution in sight. This clinic week I asked every patient in detail about their living situation and provided patients who needed help with a list of resources to help them. I intend to continue doing that to help our patient population get out of this downward spiral.

[salina faidhalla]

Home!! is safety, stability, love, family, its the source of food, water, clothes and all the essential supplies in our daily lives. for our patients Homelessness is a very serious issue, that impact all aspects of their health care, physically and mentally.
Our patient population specifically suffer from a lot of socioeconomic issues that add on to their already existing health issues.
I feel homelessness is one of the most important determining factors in the patient health and improvement, because we can deliver the best care and management that we can in the 30 minutes to 1 hour that we spend with the patient in the clinic, or the few days that we spend with them in the hospital, but what happens after that???? what happens next is even more important than all the work than we do.
we can manage a patient asthma or COPD as tight as we can, but spending few minutes in that freezing weather breathing will throw them back in the ED, add to that access to medication, food, self hygiene, sleep. all these factors and the lack of them will detrimentally affect that patient health.
unfortunately we deal with these situations almost everyday, and there is not that much that we can do, its a system defect, a bigger problem. hopefully one day a long term solution to homelessness will be available

[Marvin Kajy]

The social determinants of health discussion touched on the subjects of homelessness and mental health. The existence of homeless people is still evident even in our advanced society today. Everywhere you look around our cities, parks and streets it is likely that you will witness a homeless person struggling to survive. This is most certainly a social justice issue. Every person deserves a secure and comfortable place to live, not left on the streets to perish. The health implications associated with being homeless makes it that much worse. Homeless people are at major risk for premature death and a wide range of health problems such as cardiovascular disease, infectious disease, mental illness et cetera. It is very difficult for homeless people to fix their health issues due to the difficulty of accessing health care which can be attributed to multiple reasons; having no insurance, no money, no transportation or simply because of the stigma placed on them when they enter a public facility. A majority of people view homelessness as the result of individuals personal failings in life, and believe that a person chooses to be homeless. However the causes of homelessness are a complex interplay between a person’s individual circumstances and factors which are outside their control. These problems can build up over years, until a point where everything has reached crisis, this is when an individual becomes homeless.

Mental illness, physical disabilities or dependency issues can also trigger or be a part of a chain events that lead to someone becoming homeless. Isolation created by being homeless often means that people find it difficult to access support with services. Most psychiatric disorders present symptom patterns that cause severe impairment on the emotional, cognitive and social level. Therefore, the individuals who suffer from a mental disorder risk finding themselves in a downward spiral caused by the psychological symptoms and negative school, work or social experiences that may manifest gradually over time. Unfortunately, this often leads to the patient leaving school/work and abandonment by family.

Multiple studies have shown that screening for physical health problems falls well below agreed standards for patients with mental health problems. Only about one fifth of people with schizophrenia had their physical health properly monitored. At GMAP, I have taken care of a young gentleman in his 20s who suffered from major depressive disorder, cigarette use disorder, alcohol use disorder and marijuana use disorder. He was a product of the foster system and he grew old enough, he was sent out into the real word with little schooling. He has been living in his car, shelter and friends’ places. I initially took care of this patient during my intern year when he presented for a physical exam. He didn’t talk much initially, but a little probing revealed that the patient had a history of major depressive disorder after the passing of his grandmother in 2005. He has been tried on multiple antidepressants and without much success. At times, he would stop following up with doctors because he thought that they would often times blow off his symptoms. he patient has been following up with me for the past 1 year and I would provided him with resources to cut down on his substance use and start him on an antidepressant. His mood has improved and he is able to hold a job and he has cut down significantly on his substance use. Giving these individuals an extra 5 minutes of our time and ensuring regular follow up really uplifts these kind of patients. Ensuring that we have an awareness of the above mentioned issues and that we’ve discussed these concerns with individual patients will help us provide care to the best of our abilities. The medical school in collaboration with DMC has provided a lot of resources for the community in terms of free clinic, food distribution and clean up of Detroit. At times, I have referred my patients to these resources. Throughout my medical training, I have been very fortunate to be part of these programs and to serve the underprivileged of Detroit and improving the overall health of the city.

[James Bathe]

Homelessness, tingling, relieving the lack of security and the lack of stability. One does not have a place to treat to from society, it is easy to feel without safety without the sensation that things are going to stay stable. In fact they don’t. Being unable to maintain a regular place to live and maintain things in that space except incredibly difficult to monitor anything else related little all other facets of the life. When a big part of your time has to be devoted to finding a place to sleep or to find food to eat, is very difficult to provide any focus on any other areas of her life until that secured. In fact, with our patients, this is a huge consideration. Hard to ask the patient to take the blood pressure regularly when they sleep outside or other car. It is incredibly difficult to have the patient take 10 different medications when the best area for steroids or medications at the globe box of the car or just their pocket. Let alone any medications that need to be refrigerated. Just asking for basic lifestyle changes is like asking the impossible for many of these patients.
Spending time with each patient to address their home situation is very important. We can altogether search for solutions to common problems that face homeless patients in the clinic and thus ensure the best possible outcome for him. However, we need to do more. Homelessness is a problem that is symptom of issues in society that need to be addressed. There are currently no standing structures to supply at home through all homeless people in the United States. However many homes, apartments, and condos stayed empty as their owners have either no incentive to let others use them for lower cost or simply hold them as assets. As members of some of the most visible professional lobbying organizations in United States, physicians are uniquely poised to have a much louder voice clinical and social discourse regarding this condition. We should pressure our professional organizations to strive to advocate for solutions to this chronic issue. He evidently must both focus not only on her individual patients but also on changes that we can help enact in society improve the health safety, safety, and security of us all.

[Aliza Rizwan]

Homeless has many origins for different people and is associated with enormous health inequalities, including shorter life expectancy, higher morbidity and greater usage of acute hospital services. Viewed through the lens of social determinants, homelessness is a key driver of poor health, but homelessness itself results from accumulated adverse social and economic conditions. Indeed, in people who are homeless, the social determinants of homelessness and health inequities are often intertwined, and long term homelessness further exacerbates poor health. In order to reduce the enormous health inequalities seen in the homeless population, we need to view homelessness as a combined medical and social issue. Addressing homelessness is, itself, an important form of healthcare, not a separate “non-health” issue. If we are to reduce the impact of homelessness on health, it’s critical to recognize the futility of treating the medical issues associated with homelessness without first acknowledging and then addressing the underlying social issues. Our contribution to the well-being of a homeless person is only one brick in redeveloping a person’s foundation. Upon addressing the immediate health concerns, we should identify the appropriate resources to facilitate the completion of a person’s basic life foundation. This might be acheived through social workers, non profit-foundations, shelters, education institutions, and psychological institutions. We as a society have many holes in supporting people less fortunate or constrained based on their health and we have to be innovative to find solutions with the resources available to us.

[Lea monday]

We talked about homesless this week. Dr nnodim taught me the 211 social emergency number and I had never heard of that. Later that day I met a young patient who was staying with friends and I identified her as having questionable stability to her housing. Her mom died when she was 11 and she was send to live with her dad who had “problems” and was not able to parent so at age 15 she moved out on her own, got pregnant, terminated the pregnancy because she wasn’t ready and didn’t want her baby to live in poverty. She is doing better working home care and finished getting her phlebotomist degree last month but last week her car died so she has been unable to go do home care since the houses are far away in w Bloomfield and she was trying to Uber but the Uber’s cost more than she made so now she is doing hair for money. She was so up beat and positive. I don’t know how she finished her degree with all this going on. I told her she is amazing and is a queen and that I have met very few people with the drive and courage and resilience she has. I can’t stop thinking about her and how hard things have been and how she has continued to overcome.

[Mahvish Khalid]

As physicians we see several patients every day, treat their medical issues and send them home with prescriptions. Most of the time, however, we fail to realize that many of these patients do not have adequate housing. Not only is the homeless population predisposed to several mental and physical health problems, it also has worse health outcomes due to poor living conditions and lack of resources.

From the discussions during this clinic week, I learnt about the 211 social emergency number and about the available shelters in the metro Detroit area. From now on, I will try to make a conscious effort that I not only treat my patients’ medical conditions but also inquire about their living situation and social structure. If I learn that they do not have adequate housing, I will make sure to share the resources that are available.

[wsumed]

TimeBomb • Scott K. Andrews • 9781444752069

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