Health Care for Homeless Persons
http://www.100md.com
《新英格兰医药杂志》
We met him in the winter of 1996, when he had severe frostbite in both feet. Forty-eight years old and homeless, he had been living in shelters and on the streets since his early 20s. Saddled with a severe anxiety disorder that could be quieted only by sufficient alcohol, he was known in every emergency department in the city, with frequent medical complications, more than 50 admissions to detoxification units, and only two extended periods of sobriety during the past decade. During the months after we met him, the first and second toes of his left foot autoamputated, horrifying both of us. We saw him regularly on our outreach van, but he was too ashamed to accept offers of help. In 2000, he again suffered severe frostbite in both feet. Staying in our medical respite unit for several months, he battled chronic pain and lost several more toes. Ultimately, we won his trust and were able to help him secure sufficient government benefits to qualify for a rooming house and health insurance. Though still fragile, he now comes regularly to the clinic for treatment of hypertension and anxiety.
This patient's story illustrates the substantial challenges and hidden rewards that clinicians encounter when they provide health care to homeless people (Figure). Homelessness rates (the number of shelter beds per population) have increased by a factor of two to three over each of the past two decades; an estimated 3.5 million people now experience homelessness each year. No region of the country is spared, and homelessness does not discriminate on the basis of age, sex, race, or ethnic background. Persistent and abject poverty is the unifying thread in this demographic tapestry, and with the lack of stable housing come extraordinary health risks. The reasons for becoming homeless can include financial, legal, familial, social, and medical problems. Veterans are especially vulnerable, since they face several unique problems on reentry into civilian society. Tragically, the fastest growing segment of the homeless population is families, with mothers and children forced to live on the streets or in motel rooms far from the necessities of daily life.
Delivering Health Care to the Urban Poor.
By permission of Rick Friedman.
The struggle for survival on the streets means responding to immediate needs. One's priorities become shelter, food, and safety, and apart from emergencies, health becomes secondary. Because of the immediacy of life on the streets, appointments made for next week are easily forgotten and rarely kept, leading to episodic encounters with the health care system after wounds have festered or illnesses have grown severe. When questioned about their physical problems, most homeless people focus on their feet, teeth, and eyesight, rather than on acute or chronic illness.
Several key features of this population increase the prevalence of certain medical conditions. The inadequacy of clothes, basic first aid, and other essentials for personal hygiene predispose homeless people to trench foot and infestation with lice and scabies. The dangers of life on the street lead to a mistrust of others and social isolation, increasing the risk of psychiatric conditions. Substance abuse, depression, and personality disorders are common and are the result of homelessness at least as frequently as its cause; schizophrenia and dementia are also prominent. Homeless people are commonly victims of random violence: more than 50 percent of homeless women have been sexually assaulted, and one third of homeless people have evidence of active or past sexually transmitted infections. Exposure to extreme weather leads to dehydration, sunburn, frostbite, ulcers, and hypothermia. Living in group homes, missions, shelters, or prisons increases the risk of communicable illnesses, such as tuberculosis, influenza, and other respiratory and enteric infections. Dental caries, tooth loss, and periodontal disease are ubiquitous, and with no access to preventive or restorative dental services, most homeless people turn to emergency departments when tooth or jaw pain becomes intractable. Limited resources also lead to a high prevalence of uncorrected abnormal vision.
On average, homeless adults have eight to nine concurrent medical illnesses.1 Nearly every organ system is at risk. Cardiovascular diseases (such as hypertension, peripheral vascular disease, and cardiac arrhythmias), liver disease, human immunodeficiency virus infection and AIDS, chronic airflow obstruction, and malnutrition are prevalent and in many cases are probably secondary to the use of tobacco, alcohol, and illicit substances. Cancers commonly involve the skin and the aerodigestive, respiratory, and genitourinary tracts. In addition to traumatic injuries, musculoskeletal conditions resulting from manual labor are common. Together, street violence and these acute and chronic medical conditions contribute to markedly increased mortality among the homeless, resulting in an average life span of less than 45 years.2
Several types of barriers come between homeless persons and the health care system. More than one third of people living below the poverty line lack adequate health insurance, and the number of uninsured homeless adults continues to increase.3 These adverse trends are complicated by higher-than-average health care costs resulting from frequent hospitalizations, presentation with severe illness, and long hospital stays with relatively high daily costs.4 In addition, because of their social isolation, most homeless persons have a deep-seated mistrust of other people and institutions. Often, no family is available for emotional or financial support. This social disaffiliation creates a need for community outreach and a period of courting between patient and doctor that can be quite extensive, just to establish a relationship. Once trust is engendered, providers are often called on to play advocacy roles, with personalized attention, round-the-clock availability for emergencies, and travel with patients to visit unknown specialists in unfamiliar surroundings. These demands do not mesh well with the current emphasis on productivity in the health care system.
In recognition of the need to deliver first aid and preventive services in the homeless community rather than in physicians' offices or clinics, the first health services for the homeless were established in shelters in the early 1970s by nurses who appreciated the importance of patience, trust, and consistency. These providers established the foot soak as a practical and symbolic gesture of service and respect to weary sojourners, and they called all persons by name — an important antidote to the anonymity of the streets. In 1985, to help address the basic health care needs of homeless persons, the Robert Wood Johnson Foundation and Pew Charitable Trust funded 19 projects designed to ensure access to high-quality health care for homeless persons in their communities while serving as the "glue" between shelters and hospitals. As a multidisciplinary team, providers operate hospital-based primary care clinics and provide direct care services at shelters and soup kitchens, in vans, and in other sites frequented by homeless people. The Bureau of Primary Health Care (BPHC) of the U.S. Public Health Service now funds 160 programs located in every state and Puerto Rico. Respite care programs have been developed in Washington, D.C., and Boston to provide 24-hour medical care for homeless persons who are too ill for the streets and shelters and who might otherwise require costly inpatient care. The BPHC has funded a 10-city pilot program in respite care, recognizing the unmet needs for intermediate-level care for this vulnerable population.
Despite its effect on treatment, homelessness is often neither identified nor addressed in the care of hospitalized patients or in their discharge plans. Most residency programs are just beginning to provide opportunities for training in the community on the delivery of care to impoverished populations. Several medical schools and teaching hospitals have recently established elective and required educational opportunities for medical students, interns, and residents at area shelters and with Health Care for the Homeless Programs (HCHP) to introduce physicians-in-training to special issues surrounding efforts to provide effective care for this population. Following the early example of St. Vincent's Hospital in New York City, HCHP physicians in Boston, Miami, Houston, and several other cities are fully integrated into the clinical and educational programs at teaching hospitals, and their presence has facilitated both access to and continuity of care for homeless persons. Academic medical centers can thus play pivotal roles in promoting health care as a basic human right and facilitating its delivery to poor and underserved communities.
The patient with frostbite reminds us that cost-effective primary and preventive care for homeless people is possible if providers are willing to bring care directly to the streets and shelters. Even universal insurance coverage would not ensure universal access, especially for those whose next meal and night's shelter are far more pressing than health care needs. Successful health care delivery to this population will require personalized attention, round-the-clock availability of a primary care provider, extended physician's visits, and assistance with visits to specialists. Market forces and a desire for improved professional fulfillment have recently led some physicians to launch so-called concierge practices with similar attributes. Although the social circumstances of the patients may be diametrically opposed, there are similar opportunities for immense job satisfaction for physicians who provide health care for homeless persons.
Source Information
From the Departments of Internal Medicine, Brigham and Women's Hospital (B.D.L.), Massachusetts General Hospital (J.J.O.), and Harvard Medical School (B.D.L., J.J.O.) — all in Boston.
References
Breakey WR, Fischer PJ, Kramer M, et al. Health and mental health problems of homeless men and women in Baltimore. JAMA 1989;262:1352-1357.
Hibbs JR, Benner L, Klugman L, et al. Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med 1994;331:304-309.
O'Connell JJ, Lozier J, Gingles K. Increased demand and decreased capacity: challenges to the McKinney Act's Health Care for the Homeless Project. Nashville: National Health Care for the Homeless Council, July 1997.
Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated with homelessness in New York City. N Engl J Med 1998;338:1734-1740.(Bruce D. Levy, M.D., and )
This patient's story illustrates the substantial challenges and hidden rewards that clinicians encounter when they provide health care to homeless people (Figure). Homelessness rates (the number of shelter beds per population) have increased by a factor of two to three over each of the past two decades; an estimated 3.5 million people now experience homelessness each year. No region of the country is spared, and homelessness does not discriminate on the basis of age, sex, race, or ethnic background. Persistent and abject poverty is the unifying thread in this demographic tapestry, and with the lack of stable housing come extraordinary health risks. The reasons for becoming homeless can include financial, legal, familial, social, and medical problems. Veterans are especially vulnerable, since they face several unique problems on reentry into civilian society. Tragically, the fastest growing segment of the homeless population is families, with mothers and children forced to live on the streets or in motel rooms far from the necessities of daily life.
Delivering Health Care to the Urban Poor.
By permission of Rick Friedman.
The struggle for survival on the streets means responding to immediate needs. One's priorities become shelter, food, and safety, and apart from emergencies, health becomes secondary. Because of the immediacy of life on the streets, appointments made for next week are easily forgotten and rarely kept, leading to episodic encounters with the health care system after wounds have festered or illnesses have grown severe. When questioned about their physical problems, most homeless people focus on their feet, teeth, and eyesight, rather than on acute or chronic illness.
Several key features of this population increase the prevalence of certain medical conditions. The inadequacy of clothes, basic first aid, and other essentials for personal hygiene predispose homeless people to trench foot and infestation with lice and scabies. The dangers of life on the street lead to a mistrust of others and social isolation, increasing the risk of psychiatric conditions. Substance abuse, depression, and personality disorders are common and are the result of homelessness at least as frequently as its cause; schizophrenia and dementia are also prominent. Homeless people are commonly victims of random violence: more than 50 percent of homeless women have been sexually assaulted, and one third of homeless people have evidence of active or past sexually transmitted infections. Exposure to extreme weather leads to dehydration, sunburn, frostbite, ulcers, and hypothermia. Living in group homes, missions, shelters, or prisons increases the risk of communicable illnesses, such as tuberculosis, influenza, and other respiratory and enteric infections. Dental caries, tooth loss, and periodontal disease are ubiquitous, and with no access to preventive or restorative dental services, most homeless people turn to emergency departments when tooth or jaw pain becomes intractable. Limited resources also lead to a high prevalence of uncorrected abnormal vision.
On average, homeless adults have eight to nine concurrent medical illnesses.1 Nearly every organ system is at risk. Cardiovascular diseases (such as hypertension, peripheral vascular disease, and cardiac arrhythmias), liver disease, human immunodeficiency virus infection and AIDS, chronic airflow obstruction, and malnutrition are prevalent and in many cases are probably secondary to the use of tobacco, alcohol, and illicit substances. Cancers commonly involve the skin and the aerodigestive, respiratory, and genitourinary tracts. In addition to traumatic injuries, musculoskeletal conditions resulting from manual labor are common. Together, street violence and these acute and chronic medical conditions contribute to markedly increased mortality among the homeless, resulting in an average life span of less than 45 years.2
Several types of barriers come between homeless persons and the health care system. More than one third of people living below the poverty line lack adequate health insurance, and the number of uninsured homeless adults continues to increase.3 These adverse trends are complicated by higher-than-average health care costs resulting from frequent hospitalizations, presentation with severe illness, and long hospital stays with relatively high daily costs.4 In addition, because of their social isolation, most homeless persons have a deep-seated mistrust of other people and institutions. Often, no family is available for emotional or financial support. This social disaffiliation creates a need for community outreach and a period of courting between patient and doctor that can be quite extensive, just to establish a relationship. Once trust is engendered, providers are often called on to play advocacy roles, with personalized attention, round-the-clock availability for emergencies, and travel with patients to visit unknown specialists in unfamiliar surroundings. These demands do not mesh well with the current emphasis on productivity in the health care system.
In recognition of the need to deliver first aid and preventive services in the homeless community rather than in physicians' offices or clinics, the first health services for the homeless were established in shelters in the early 1970s by nurses who appreciated the importance of patience, trust, and consistency. These providers established the foot soak as a practical and symbolic gesture of service and respect to weary sojourners, and they called all persons by name — an important antidote to the anonymity of the streets. In 1985, to help address the basic health care needs of homeless persons, the Robert Wood Johnson Foundation and Pew Charitable Trust funded 19 projects designed to ensure access to high-quality health care for homeless persons in their communities while serving as the "glue" between shelters and hospitals. As a multidisciplinary team, providers operate hospital-based primary care clinics and provide direct care services at shelters and soup kitchens, in vans, and in other sites frequented by homeless people. The Bureau of Primary Health Care (BPHC) of the U.S. Public Health Service now funds 160 programs located in every state and Puerto Rico. Respite care programs have been developed in Washington, D.C., and Boston to provide 24-hour medical care for homeless persons who are too ill for the streets and shelters and who might otherwise require costly inpatient care. The BPHC has funded a 10-city pilot program in respite care, recognizing the unmet needs for intermediate-level care for this vulnerable population.
Despite its effect on treatment, homelessness is often neither identified nor addressed in the care of hospitalized patients or in their discharge plans. Most residency programs are just beginning to provide opportunities for training in the community on the delivery of care to impoverished populations. Several medical schools and teaching hospitals have recently established elective and required educational opportunities for medical students, interns, and residents at area shelters and with Health Care for the Homeless Programs (HCHP) to introduce physicians-in-training to special issues surrounding efforts to provide effective care for this population. Following the early example of St. Vincent's Hospital in New York City, HCHP physicians in Boston, Miami, Houston, and several other cities are fully integrated into the clinical and educational programs at teaching hospitals, and their presence has facilitated both access to and continuity of care for homeless persons. Academic medical centers can thus play pivotal roles in promoting health care as a basic human right and facilitating its delivery to poor and underserved communities.
The patient with frostbite reminds us that cost-effective primary and preventive care for homeless people is possible if providers are willing to bring care directly to the streets and shelters. Even universal insurance coverage would not ensure universal access, especially for those whose next meal and night's shelter are far more pressing than health care needs. Successful health care delivery to this population will require personalized attention, round-the-clock availability of a primary care provider, extended physician's visits, and assistance with visits to specialists. Market forces and a desire for improved professional fulfillment have recently led some physicians to launch so-called concierge practices with similar attributes. Although the social circumstances of the patients may be diametrically opposed, there are similar opportunities for immense job satisfaction for physicians who provide health care for homeless persons.
Source Information
From the Departments of Internal Medicine, Brigham and Women's Hospital (B.D.L.), Massachusetts General Hospital (J.J.O.), and Harvard Medical School (B.D.L., J.J.O.) — all in Boston.
References
Breakey WR, Fischer PJ, Kramer M, et al. Health and mental health problems of homeless men and women in Baltimore. JAMA 1989;262:1352-1357.
Hibbs JR, Benner L, Klugman L, et al. Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med 1994;331:304-309.
O'Connell JJ, Lozier J, Gingles K. Increased demand and decreased capacity: challenges to the McKinney Act's Health Care for the Homeless Project. Nashville: National Health Care for the Homeless Council, July 1997.
Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated with homelessness in New York City. N Engl J Med 1998;338:1734-1740.(Bruce D. Levy, M.D., and )