Monday, April 28, 2014

Patient-centered care for the homeless

- Jennifer Middleton, MD, MPH

An article in the April 15 AFP highlights the challenges - along with some solutions - for caring for the homeless, and I'd like to highlight the tables in this article, as they provide a wealth of practical information.

Table 1, "Special Considerations in Health Care for Homeless Persons," reviews the logistical and clinical challenges many homeless individuals face. The table reiterates what the authors also emphasize in the text - creating a safe, nonthreatening environment is key to establishing rapport with homeless patients. Many of the homeless patients I've cared for are deeply distrustful of society in general, and building rapport can take many visits.

Table 2, "Special Considerations for Medication Use in Homeless Persons," includes several useful pearls. Clinicians may want to consider a patient's homelessness when prescribing medication for hypertension, as the study's authors point out that diuretics can worsen dehydration in the summer for patients without access to air-conditioning and/or enough fluids to drink. Beta blockers' and clonidine's propensity to cause rebound hypertension when discontinued make them less than ideal choices in a population that may have sporadic access to care and medications.

Albuterol can enhance the effects of crack cocaine, seroquel can enhance the effects of heroin, and bupropion can be snorted to get high. Not that all homeless people are drug abusers, but the study's authors do point out that a significant portion of the homeless population struggles with addiction. Avoiding these medications in those individuals, when possible, certainly embodies the tenet of "first, do no harm."

Finally, Table 3, "Resources on Homelessness," provides a great starting point for family physicians who want to connect their homeless patients to resources. The Homeless Shelter Directory and the Homelessness Resource Center (with a great "Topics" section) are two websites with lots of practical information for family docs and their offices.

The patient-centered medical home (PCMH) movement centers on providing comprehensive, coordinated, accessible care. Meeting the needs of homeless persons certainly requires no less.  The AFP By Topic "Care of Special Populations" includes a section on "Homeless/Uninsured Persons" if you'd like to read more.

How is your office caring for homeless persons?

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