The man, recently homeless, was admitted for pneumonia.
But he didn't show up at the emergency department complaining about shortness of breath, said Mark Rabiner, MD, chief hospitalist for the community medicine department at St. Vincent's Hospital in New York City.
“He just became homeless—it's new for him,” said Dr. Rabiner. “So he's been sleeping on the subway for five days. He came in for leg pain.”
A routine exam picked up some lung issues; a chest X-ray confirmed the pneumonia. The man was admitted for intravenous antibiotics. Clinicians also were elevating the man's legs and looking into post-discharge housing options for him.
Dr. Rabiner also reminded the medical resident involved to update the patient in order to maintain communication and trust. “We need to say, ‘You're sleeping over because you have an infection in your lungs, not because of your legs. Your legs brought you here. But you're staying because of your lungs.’”
Patients who are homeless or teetering on the verge can present an additional set of logistics for busy hospitalists. They may have a multitude of medical conditions, both immediate and chronic. Preventive care may have been jettisoned long ago. Long-standing psychiatric and substance abuse issues can flare during hospitalization.
Physicians who work regularly with homeless individuals say these patients can particularly benefit from the intervention of a sensitive hospitalist.
While in the hospital, the patient can catch up on some primary care, including screenings and vaccines. The discharge process can provide an opportunity to connect, or reconnect, the individual with social service programs.
There also may be an opportunity to tackle seemingly entrenched habits. In one study, published in 2006 in Nicotine & Tobacco Research, three-fourths of homeless individuals who smoked said they wanted to quit within the next six months.
Hospitalization is a “huge teaching moment because it may be the only time the person has been sober in the last many months,” said Jim O’Connell, MD, president of the Boston Health Care for the Homeless Program.
“Homeless people, in our experience, tend to be admitted to the hospital more frequently than most,” he said. “And very profound things go on in their health care during these admissions. Hospitalists, if they take a little time, can become very important people in the lives of each homeless person who is admitted.”
Identifying homeless patients
Determining whether a patient is homeless can require some detective work and sensitivity, physicians said. A patient may appear to have a home, but may be sleeping on a sister's couch or with friends. He or she may provide an address that, if scrutinized more closely, is the local shelter.
Jennifer Best, FACP, a hospitalist practicing at Seattle's Harborview Medical Center, typically includes housing-related questions as part of the social history she takes, along with sexual experience and other sensitive subjects. Once she gets some detail, she might probe a little more. “I'll often throw in, ‘How's that going?’” With that question, she might gain better insight into the overall stability of the patient's housing situation, which is key for discharge planning, she said.
Identifying the housing situation early on is not only helpful for discharge, but also may assist in diagnosis, Dr. Rabiner said. Some patients, for example, may sleep propped up in a drop-in shelter or on the subway, instead of in a bed. The result can be venous stasis, which can be misdiagnosed as the infection cellulitis, if the physician doesn't ask about the patient's sleeping circumstances, he said.
The difficulty in identifying homeless individuals may be one reason why research on inpatient treatment is limited, said Dr. Best, who published an article about treatment for the homeless last year in the Journal of Hospital Medicine. A literature review of homeless medical care, published in 2005, identified 45 studies but only one involving hospital treatment, she said.
Bases to cover
Despite the limited evidence, Dr. Best and other physicians have found ways in which hospitalists can make significant treatment strides for homeless patients, even during a limited hospital stay.
The first step is a thorough medical exam. This is not always easy, as homeless individuals may be reluctant to temporarily part from their clothes for a hospital gown, Dr. Best said. “At a risk of generalization, some people really do wear everything they own at one time,” she said.
Along with addressing any concurrent medical issues, such as wounds, skin rashes or sexually transmitted diseases, physicians should consider starting patients on drugs for chronic medical conditions, like high blood pressure or diabetes, the experts said.
Plus, hospitalists can catch up patients on the basics, such as mammograms, pap smears and tuberculosis screening. “For homeless folks, that may be the only opportunity to get it,” Dr. O’Connell said.
Dr. Rabiner also suggested a colonoscopy for individuals at the recommended screening age, given the infeasibility of the bowel cleansing preparation for those in unstable housing situations.
In her Journal of Hospital Medicine article, Dr. Best also recommended initiating a discussion about end-of-life preferences, including determining whether the patient would want aggressive intervention. She incorporates those questions into her discussion, letting her patients know they are routine. But Dr. O’Connell urged caution, as the subject may unnerve some patients. “Homeless folks, unless they know you and trust you, will hear the discussion about end-of-life care as a means of abandoning them,” he said.
Transitioning to discharge
Hospitalists should be developing a discharge plan, and sharing the details with the patient, from the moment of admission, Dr. Rabiner said. Contrary to what one might assume, homeless men and women may have appointments to keep and people watching out for them in the community, so they need to know the treatment details and timing, he said.
Housing and lifestyle circumstances also can shape that plan, he said. When hospitalists are lining up follow-up care, they should ask not only about their transportation options, but also if patients have the needed fare. Other scheduling factors also matter, Dr. Rabiner said. If the appointment is scheduled for 8 a.m., when the local church serves breakfast, the patient is less likely to make it, he said.
And don't assume anything, he said. If the patient is starting insulin, for example, you should discuss where he or she is going to store it and how he or she will dispose of the needles.
Some hospitalists can tap the resources of a nearby respite care program. Essentially a step-down facility, the programs provide onsite nursing for homeless individuals not sick enough to be hospitalized, but who still need a bed and some medical support to recover.
Currently, there are 47 respite programs in the United States and a few more in development, according to the Respite Care Provider's Network, part of the National Health Care for the Homeless Council. The facilities range in size from fewer than 10 beds to more than 50.
If no respite program is available, it's even more crucial to train the patients in necessary skills, such as wound care, significantly in advance of discharge, physicians said.
Above all, try to find a bridge to the outside community, the experts stressed. A local outreach coordinator or a shelter director might be willing to keep tabs on the patient once he or she leaves the hospital. Another route might be to work with the local shelter to establish a designated medical bed on an ongoing basis, Dr. O’Connell said.
Sometimes the best step is to delay discharge until the necessary support has been lined up, Dr. O’Connell said. “The financial pressures are not to do that,” he said. “But I would argue that keeping a homeless person for another day or two, to make sure there is a safe discharge plan, will more often than not avoid an early readmission.”