Each day in the United States, at least 800,000 persons are homeless. This includes 200,000 children in homeless families.¹ As of the beginning of the 21st century, 2.3 to 3.5 million persons were homeless at some time during an average year.² Approximately 33 percent of these are families with children, and another 3 percent are unaccompanied minors.³ Two percent of children in the United States are homeless in the course of a year.⁴ Figure 1³ shows the composition of the homeless population in the United States.

The Federal Bureau of Primary Health Care defines homelessness using the following descriptors⁵:

• An individual without permanent housing who may live on the streets; stay in a shelter, mission, single-room occupancy facility, abandoned building or vehicle; or in any other unstable or nonpermanent situation.

• An individual may be considered homeless if that person is “doubled-up”, a term referring to a situation in which individuals are unable to maintain their housing situation and are forced to stay with a series of friends or extended family members.

• Previously homeless individuals who are to be released from prison or a hospital may be considered homeless if they do not have a stable housing situation to return to.

• Recognition of the instability of an individual’s living arrangement is critical to the definition of homelessness.

State, city, or private definitions (e.g., ones used for grants or to receive certain subsidies) may differ from this.

At the beginning of this century, clinicians from the National Health Care for the Homeless Council (NHCHC) began to adapt clinical practice guidelines for patients who are homeless. In 2004, the National Guidelines Clearinghouse placed eight NHCHC guidelines on its Web site, including seven relating to specific disease processes and one on general care (online Table A). Well-researched evidence that differentiates care for the homeless population from the general population is almost nonexistent. Therefore, the method used to assess the quality and strength of the evidence for those criteria and to formulate recommendations was based almost entirely on expert consensus.

This article summarizes some of the NHCHC guidelines that apply to a variety of conditions that pertain to persons who are homeless. Although some of this information is duplicated in other NHCHC guidelines, most of it comes from the NHCHC’s general recommendations,⁶ except when noted otherwise. In addition, some relevant information from more recent literature on the topic is included.

Overcoming Barriers to Care

Millions of persons in the United States with minimal health care access experience barriers to care, but persons who are homeless face additional unique obstacles. Difficulties can arise when a physician tries to build trusting relationships in a population where histories of mental illness and abuse are often the norm. Even when trust is won, finding the appropriate prescribing patterns and education techniques to help ensure adherence can be a challenge for any physician, particularly when food and housing concerns often outweigh those for ongoing health care. Ideally, physicians should develop individualized care plans that incorporate the meeting of basic daily needs.

Unrealistic expectations by physicians are a key cause of patient nonadherence.⁵ When adherence is a problem, the physician should reassess goals with the patient. Knowing some of the issues that affect adherence for persons who are homeless may help clarify any unrealistic expectations (Tables 1 and 2^6–10).

BUILDING TRUST

A full-body, unclothed, comprehensive examination of an adult who is homeless is rarely possible before patient-physician trust and engagement is achieved. Approximately 25 percent of these patients have at some time experienced severe mental disorders such as schizophrenia, major depression, or bipolar disorder, and many are survivors of physical or sexual abuse and/or assault.^11–14 In addition, many have experienced negative interactions with authority figures, and because anxiety is highly prevalent in the homeless population, these patients may be averse to the private aspects of the physical examination.

At the first visit at which a full physical examination is appropriate, explain what a comprehensive physical examination entails and ask permission to perform one. If the patient prefers not to disrobe at the first visit, defer nonurgent genital examinations until comfort levels allow.^7,8 Consider using an assistant for examinations of all clothed and unclothed patients who appear emotionally fragile.^8,15

Persons who are homeless can feel vulnerable within the health care system; some have never used it. Others have no idea how to navigate the system and may not follow through for that reason alone. Providing a client advocate to accompany such patients can be invaluable. Consider contacting a local homeless advocacy group, a faith-based group involved with community service projects, or a hospital auxiliary. Such groups may be able to identify a person to assist the patient by providing transportation or directing guidance regarding appointments, testing, and other issues.

Emphasizing patient strengths is important. Seeking health care, keeping appointments, and adhering to treatment are all examples of basic patient strengths that should be acknowledged. Thank patients for showing up (even if they are late) and for any attempt by them to follow a plan of care. The NHCHC guidelines point out that just meeting survival needs while homeless takes resourcefulness, patience, and tenacity.⁶

DIET

Many shelters and soup kitchens serve food that makes adherence to special diets difficult for those with chronic medical conditions such as diabetes or hypertension. It is imperative to be familiar with the types of food available to patients before suggesting how to structure their diet.

ACCESS

Approximately 18 percent of adults who are homeless are employed.¹⁶ After-hours clinic time is essential if physicians hope to accommodate working patients who cannot take time off without risking their jobs. Whenever possible, create a drop-in time when no appointment is required, particularly for new patients. Encourage routine follow-up for established patients, supplemented by an open-door policy for drop-ins.

Consider using small incentives (e.g., phone cards, bus tokens, hygiene kits, free condoms, new socks, food coupons) to encourage patients to return for laboratory results.^8,9

NOMADIC LIFESTYLE

Although some patients who are homeless become well known to their physicians and have relatively good follow-up potential, others are nomadic and often travel across several neighborhoods, cities, or even states in the course of a month. A key aspect of caring for these patients is to assess their mobility and the likelihood that they may stay in one place long enough to work on gaining better control of a chronic medical condition.

Evaluate all patients for residential stability. Note their form of shelter and how often they have access to bathing facilities. Check to see if they have a safe place to keep hygiene items and medications, including those that require refrigeration. If the patient is not living in a shelter or on the street, ask if they are doubled-up.

Consider using wallet-sized monitoring cards or cards kept in pouches worn around the neck to record laboratory results, vital signs, examinations, and follow-up visits. Patients can use these cards as a self-management tool or share the information with their next health care provider.^9,10

MEDICATIONS

When recommending the use of water, including for ingestion of medications, be sure the patient has access to it.

Avoid prescribing medications likely to have significant sedative side effects unless they initially can be tried out in a safe environment.⁹ Medications that make the patients feel nauseous or that diminish alertness may compromise their safety on the streets or in shelters.

Be aware that diuretics can be problematic for persons who have little access to bathroom facilities throughout the day.⁹

Use caution if prescribing medications such as alpha or beta blockers that can result in rebound hypertension. Do not use beta blockers for persons who may also use cocaine because the combination is dangerous unless an alpha blocker (e.g., clonidine [Catapres]) or a combination blocker (e.g., labetalol [Normodyne]) also is used. Be sure to include careful education about the medication.⁹

There is a high prevalence of hepatitis among perons who are homeless. Liver function tests should be followed with particular care when using medications such as statins.⁹

Medications with significant gastrointestinal side effects, particularly diarrhea, can be exceptionally difficult to handle in a homeless setting.^8,9

Aside from the more obvious ethical reliability concerns about prescribing scheduled medications, a few unscheduled medications (e.g, albuterol [Ventolin], clonidine, pseudophedrine) and some tools (e.g., insulin syringes) also can be sold or traded on the street (Table 2^6–10). Their illicit use is uncommon, but physicians should still be alert to multiple lost prescriptions of these medications.

Provide particularly clear instructions for patients with diabetes about the use of insulin or oral hypoglycemic agents when food is not available.¹⁰

Negotiate the amount of medications to dispense at a given time based on clinical indications, the patient’s wishes and ability to hold onto the medications, and availability of transportation. Some patients lose medications if larger quantities are provided. For some patients, dispensing smaller amounts can provide an incentive to return for follow-up, but only if transportation to and from the clinic is available and affordable.⁹

Patient Education

Adult patients with mental illness or chronic substance use may have impaired reasoning and delayed social development. When discussing behavioral change with such patients, focus on immediate concerns rather than possible future consequences.

Ask patients what has prompted them to use emergency departments in the past. Use their answers to educate them about appropriate emergency department use. Help the patient or family make a plan for emergencies. Be sure they know the location of emergency facilities as well as how to contact a primary care physician, if one is available, before going to the emergency department.

The prevalence of smoking is significantly higher in the homeless population than in the general population.¹⁷ Physicians should acknowledge that smoking cessation may be a low priority for the patient in this situation, but the importance of reducing nicotine use should still be stressed. Use the harm reduction approach (e.g., encourage patients to reduce the number of cigarettes daily).

At the end of each clinic visit, consider asking the patient if anything discussed was unclear or if there was anything in the plan of care that would be difficult for the patient to do.

One of the most helpful and healthful services that the physician can perform is to send for old patient records, review them, and write out one succinct wallet-sized medical history review for the patient to carry.

Children and Adolescents

Homelessness in childhood is an independent predictor of poor health and the frequent need for medical care. Children who are homeless have a higher incidence of trauma-related injuries, developmental delays, sinusitis, anemia, asthma, bowel dysfunction, eczema, visual and neurologic deficits, and poor academic performance. However, their verbal and nonverbal intelligence scores are similar to those of their housed peers.^18,19

Many homeless adolescents have experienced violent physical or sexual abuse for many years. A higher rate of abuse has been reported in females compared with males and in persons with an alternative sexual orientation compared with heterosexuals.^15,20,21

Use every patient visit as a potential opportunity to perform a general physical examination, including standard screenings and oral screenings for age-appropriate teeth and obvious tooth decay.

Assist parents in learning effective parenting skills. Recognize that plans to shape new behaviors in children or extinguish old ones are difficult to carry out in group living situations where parent-child interactions may be subject to public scrutiny, criticism, and interference from others.

Update childhood immunizations at every clinical encounter. Given the high risk of exposure to respiratory infections in group living situations, immunize against influenza annually.

Ancillary Care

Whenever possible, provide recuperative care or medical respite facilities where patients can convalesce when ill, recuperate following hospitalization, or receive end-of-life care. Medical respite services are cost-effective because they prevent future hospitalizations.²²

Permanent housing will help alleviate many of the barriers that individuals and families who are homeless face. Work with social workers and case managers to pursue all entitlements for which a family is eligible. Connect with outreach programs and coalitions, physicians, mental health board members, alcohol and drug abuse organizations, or other advocates for at-risk populations in the community.

Education

Physicians should educate themselves and their colleagues about the special needs of patients who are homeless (Table 3). Dialogue with consultants, shelter staff, food workers, and volunteers about the health needs of these patients. Recognize that treatment adherence and successful outcomes are possible, even for persons with mental health or substance abuse problems.

An additional educational tool, a slideshow entitled Health Care for the Homeless 101, can be downloaded free of charge from the NHCHC Web site (http://www.nhchc.org/HCH101/). It contains information on the history and service delivery of health care for the homeless, successful approaches to care, and a list of resources that may be useful when caring for this patient population.