hbm,homeless, post
TRANSCRIPT
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8:30-8:55 Smoking
8:55-9:00 Break
9:00-9:50 Alcohol Abuse and Dependence
9:50-10:00 Break 10:00-10:50 Substance Abuse Case
10:50-11:00 Break
11:00-11:25 Care of Patients Who are Homeless
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Care of Patients Who are
HomelessJessie Gaeta, MD
Medical Director for Boston Health Carefor the Homeless
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BHCHP
Mission: To assureaccess to quality carefor homeless people inthe Boston area
Annual Budget = $35million, FY2010
Revenue Paid visits, grants
Alliances with teachinghospitals
Sites
Street outreach
>70 shelter clinics
Hospital-based clinics 104 respite beds:
McInnis House
Inpatient attendings
Electronic medicalrecord
Research
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Outline
Who are homeless people? Local demographics
Medical Implications
MortalityHealth care utilization
Adapting care
Screening for homelessness
Clinical encounters
Conclusions
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Who Are Homeless People?
Heterogeneous Population
Living Environments
Causes
Persistence
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Living Environments
Sheltered
Unsheltered
Doubled Up
Housed
Transiently Housed
Hospitals Drug and Alcohol
Treatment ProgramsJails
Shelters
Streets
Bridges
Woods
Cars
Friends
Family
Abandoned Buildings Tents
Respite
Racetrack
Motels
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Causes of Homelessness
Why is therehomelessness in
our society?
Why has thisparticular
person becomehomeless?
Structural Trends:
Housing
Social Policy
Personal /Familial
Vulnerabilities
Wright, Rubin & Devine. Beside the Golden Door.1998.
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Persistence
0
1020
30
40
50
60
70
80
90
100
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.
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Homelessness in Boston
6300 (countable) homeless people
Not including rough sleepers
Emergency shelter system and services
Health care providers are the LINK
Health Care Providers
Community
Homeless People
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Homelessness is a marker for sickness.
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Increased Mortality
Six large scale mortality studies in USA
Mortality rates 3.5 5.0 times that of thegeneral public (even higher for women)
Average age at death = 47
The increased mortality is due to undertreatedchronic medical illnesses
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Medical Implications
Increased mortality
Severity of illness
Exposure
Violence Competing priorities
Chronic stress
Medication difficulties Health care provider
reactions
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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 andwater
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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. .
Presentation, MHSA 10th Annual Ending Homelessness Conference, Waltham, MA, 2005.
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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. . Presentation,MHSA 10th Annual Ending Homelessness Conference, Waltham, MA, 2005.
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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. .Presentation, MHSA 10th Annual Ending Homelessness Conference, Waltham, MA, 2005.
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How can we adapt care?
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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
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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 tocomply?
Aggressive assistance with benefit/disability applications Communication with case managers
Advocacy
Professionalism and respect
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Conclusions
The homeless population is heterogeneous.
Mainstream health care settings usually do notprovide 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.
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Resources
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
mailto:[email protected]://www.mhsa.net/http://www.nhchc.org/http://www.nhchc.org/http://www.mhsa.net/mailto:[email protected]