8:30-8:55 8:55-9:00 9:00-9:50 9:50-10:00 10:00-10:50 10:50-11:00 11:00-11:25

Smoking Break Alcohol Abuse and Dependence Break Substance Abuse Case Break Care of Patients Who are Homeless

Care of Patients Who are Homeless

Jessie Gaeta, MD Medical Director for Boston Health Care for the Homeless

BHCHP

Mission: To assure access to quality care for homeless people in the Boston area Annual Budget = $35 million, FY2010 Revenue

Sites

Paid visits, grants

Street outreach >70 shelter clinics Hospital-based clinics 104 respite beds: McInnis House Inpatient attendings

Alliances with teaching hospitals

Electronic medical record Research

Outline

Who are homeless people?

Local

demographics

Medical Implications
Mortality

care utilization Adapting care

Health

for homelessness Clinical encounters Conclusions

Screening

Who Are Homeless People?

Heterogeneous Population
Living Environments Causes Persistence

Living Environments
Bridges Racetrack Abandoned Buildings Streets Tents Cars

Unsheltered
Woods

Sheltered
Shelters

Doubled Up
Friends

Motels Respite

Family

Transiently Housed
Drug and Alcohol Treatment Programs

Hospitals

Housed

Jails

Causes of Homelessness
Why is there homelessness in our society?

Why has this particular person become homeless?

Structural Trends:

Housing
Social Policy

Personal / Familial Vulnerabilities

Wright, Rubin & Devine. Beside the Golden Door. 1998.

Persistence
100 90 80 70 60 50 40 30 20 10 0 Transitional Episodic Chronic Total
Kuhn R, Culhane DP. Applying cluster analysis to test a typology of homelessness by

pattern of shelter utilization. Am J Community Psych 1998; 26: 207-232.

Homelessness in Boston

6300 (countable) homeless people

Not including rough sleepers

Emergency shelter system and services Health care providers are the LINK

Community
Health Care Providers

Homeless People

Homelessness is a marker for sickness.

Increased Mortality

Six large scale mortality studies in USA Mortality rates 3.5 5.0 times that of the general public (even higher for women) Average age at death = 47 The increased mortality is due to undertreated chronic medical illnesses

Medical Implications

Increased mortality Severity of illness Exposure Violence Competing priorities Chronic stress Medication difficulties Health care provider reactions

Medical Implications
Behavioral health issues Developmental discrepancies Risk of communicable diseases Barriers to disability assistance Lack of transportation Lack of social supports Criminalization Limited access to nutritious food and water

Boston Street Cohort

119 street dwellers Mean age = 47 Male : Female ratio = 3 : 1 76% white; 12% black 80% covered by Medicaid 69% with tri-morbidity

OConnell JJ, Swain S. Rough Sleepers: A Five Year Prospective Study in Boston, 1999-2003. Presentation, MHSA 10th Annual Ending Homelessness Conference, Waltham, MA, 2005.

Boston Street Cohort

Utilization of medical services, 1999-2003

Emergency

room visits = 18,384 Medical hospitalizations = 871 Respite admissions = 836 BHCHP encounters = 9,912

OConnell JJ, Swain S. Rough Sleepers: A Five Year Prospective Study in Boston, 1999-2003. Presentation, MHSA 10th Annual Ending Homelessness Conference, Waltham, MA, 2005.

Boston Street Cohort

Five years later, 2004:

Still

on streets 20% (annual medical costs $28,436) Housed 32% (annual medical costs $6,056) Deceased 28% Shelter 8% Nursing home 6% Unknown 4% Incarcerated 2%

OConnell JJ, Swain S. Rough Sleepers: A Five Year Prospective Study in Boston, 1999-2003. Presentation, MHSA 10th Annual Ending Homelessness Conference, Waltham, MA, 2005.

How can we adapt care?

Screening for Homelessness

Settings where status would affect mgmt

ER Inpatient setting Outpatient clinics

How can we ask?

Are you homeless?? Where do you stay? I frequently see people who have no fixed place to stay and it often affects their health

Clinical Encounters

Get the story

Recognition of link between social issues and health Realistic care plans (consider limitations of environment) Patient-centered decision making
Encourage ANY positive change What can I do to make it 1 step easier for the patient to comply? Aggressive assistance with benefit/disability applications

Communication with case managers Advocacy Professionalism and respect

Conclusions

The homeless population is heterogeneous. Mainstream health care settings usually do not provide homeless patients with acceptable care. Adapting care to this population is essential. The relationship with the patient is everything. Listening to the story enables me to feel compassionate again.

Resources

Jessie.gaeta@bmc.org Boston Health Care for the Homeless Program

www.bhchp.org

Massachusetts Housing & Shelter Alliance

www.mhsa.net

National Health Care for the Homeless Council

www.nhchc.org