HOMELESS PATIENT EMERGENCY CARE
Category: Emergency Medicine
Abstract : The Homeless Patient: Homelessness is a social problem of epidemic proportions worldwide. In the United States alone, estimates of the homeless population range between 3 and 13.5 million, and as much as 7.4 percent of the general population will experience homelessness in their lifetime. Homelessness affects a diverse population of all ethnic groups and includes both urban and rural families,
The Homeless Patient:
Homelessness is a social problem of epidemic proportions worldwide. In the United States alone, estimates of the homeless population range between 3 and 13.5 million, and as much as 7.4 percent of the general population will experience homelessness in their lifetime.
Homelessness affects a diverse population of all ethnic groups and includes both urban and rural families, the elderly, children, veterans, migrant farm workers, mentally ill persons, and persons with substance use disorders. Minority groups are overrepresented in this population, most likely due to disparities in economic opportunities. Causes of homelessness are related to divorce or separation, domestic violence, pregnancy, adolescent runaways, substance use, eviction, acute or chronic unemployment, and the deinstitutionalization of persons with mental illness. A disparity between the need for low-income housing and its availability has also contributed to the epidemic of homelessness.
Homelessness has been defined in a variety of ways, including living on the street, in shelters that provide temporary residence, or in single-room occupancy hotels with shared bathrooms. The consequences of homelessness are profound. Homeless adults have an age-adjusted mortality rate nearly four times higher than that of the general population, with a median age of death of 44. Infant mortality rates among homeless mothers are more than twice those for nonpoor, domiciled mothers, and 50 percent higher than those for poor domiciled mothers. The effects of homelessness on children may be profound, with a higher incidence of acute illnesses and medical treatment. Other risks important to homeless populations include communicable diseases, environmental exposures to extreme heat or cold, and traumatic injury due to violent encounters, foraging for food, and seeking shelter. These factors contribute greatly to acute medical illness among the homeless. Some of the increased risks are associated with poverty, and others are specific to undomiciled patients. Chronic illnesses, such as hypertension and diabetes, are neglected or poorly managed due to desperate living circumstances. Homeless individuals often delay care of minor medical problems until they become severe or unbearable.
The ED is often used as a primary source of medical care for acute and nonacute illnesses of the homeless. Homeless persons have emergency department utilization rates that are 1.5 to 3 times that of the general population, with up to 20 percent reporting that the emergency department was their sole source of medical care. Outpatient community- and shelter-based clinics provide medical care in a limited fashion and can lead to ED referral for more extensive evaluation and management. In some cities, homeless patients may arrive by police or emergency medical services because of extreme weather emergencies or other health and safety mandates. All of these factors make knowledge of this population important to emergency physicians. The management of the homeless patient is complex, and similarities to the domiciled patient are limited. Decision analysis for this vulnerable population is distinctly different and admission criteria are uniquely dependent on the environment.
Care and Evaluation
Homeless patients may have both specific and nonspecific medical complaints. Once the primary reason for the visit is addressed, a thorough examination of the entire body, including the skin and particularly the feet, should be considered. This is especially necessary for the homeless patient who is disheveled, intoxicated, or has a significant psychosis. A valuable medical history may include the last evaluation for tuberculosis exposure, tetanus immunization status, vaccination status in children, psychiatric history, history of chemical dependence, and potential for substance withdrawal while receiving care in the ED. A social history may include family support, precipitants of homelessness, and prior contact with a social worker.
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