Unique Issues of Caring For The Homeless

1. Unique Issues of Caring For The Homeless Mark Goldstein, RN, MSN, EMT-P I/C Clinical Nurse Specialist & EMS Coordinator Beaumont Health System Grosse Pointe, MI

2. Where I Now Work and Learn

3. Learning Objectives Describe what factors affect and contribute to homelessness and its affects on healthcare. Define what populations are at risk for being homeless in today’s society. Identify some of the most common issues in treating homeless patients that healthcare workers face today.

4. Faces of Homelessness

5. Why Is This Topic Important “We are all only about 3 paychecks away from being homeless” Tent Cities in America: A Lisa Ling Special Report http://www.oprah.com/dated/oprahshow/oprahshow_20090218_recession

6. Homeless Statistics Depending on definition and the methods employed to count them, the estimates of the numbers of homeless in the US can vary widely from 444, 000 to 842, 000.

7. Homeless Statistics • January 2007 report on national homelessness by National Alliance to End Homelessness: 744, 000 homeless people in the United States in 2005 • A little more than half were living in shelters • A majority of the homeless were single adults, but about 41% were in families • Large differences in the numbers of temporary and chronic homeless: 75-82% were not chronically homeless: 18-25% are. • HUD’s July 2008 3rd Homeless Assessment Report to Congress

8. Definition of Homeless McKinney-Vento Act 1987 - defines a homeless person as “an individual who lacks a fixed, regular, and adequate nighttime residence” This includes not only persons living on the street but those in shelters or temporarily staying with friends

9. The Magnitude of the Problem

10. Pennsylvania Homeless • Where do you think they are? • Counties • Cities • Who keeps records? • Does it matter?

11. Philadelphia County

12. Surrounding Counties • Bucks, Montgomery, Berks, Chester, etc • It is everywhere • Look in your motels • Look in your parks and woods

13. Why Is It Getting Worse

14. Causes of Homelessness Economic • Loss of publicly supported affordable housing – higher rents • Roughly 50% of single room occupancy were lost in the 1970’s • US economic restructuring and loss of options for unskilled labor – increased poverty • Relative purchasing power of public benefits has decreased over the past few decades

15. Causes of Homeless Non-Economic • Substance abuse • Domestic violence • About 50% of all homeless women and children are victims of physical or other abuse by their own family members • Crosses all socio-economic classes

16. Psychiatric Illness and the Homeless • Deinstitutionalization • refers to the long-term reorganization of mental health care beginning during the 1960’s (Community Mental Health Act 1963) when nearly a half-million state psychiatric hospital beds were closed • pts were discharged and to be treated as outpatients in neighborhood-based mental health centers.

17. Phila State Hospa.k.aByberry

18. Philadelphia State Hospital- 1945

19. Psychiatric • New psychiatric medications played a role in reducing the demand for inpatient mental hospital care • Deinstitutionalization without adequate funding for community-based mental health care led to homelessness as many of the evicted wound up without shelter on the streets

20. Who Are We Talking About: A Snapshot of Homeless “Home core” homeless person with substance abuse and or mental illness-often a veteran (single men comprise 40% of homeless) Single woman victim of domestic violence (15%) Homeless family, typically headed by a single parent (85% are single mothers with children) victim of abuse, joblessness, and or inability to afford housing, represent the fastest growing segment of the homeless

21. Populations At Risk Are we all not vulnerable to this problem? Who in your own family would take you in? Take your family in? The family pet? Would you take people in?

22. Pediatrics Children are homeless all over the world Some have parents with them and some don’t Some are orphans and some are abandoned

24. Adolescents • Runaways from abuse, substance abuse • Involved in a bad relationship, struggling students, pregnant • Now families with teens are homeless • Emerging mental health issues

25. Young Adults Started as adolescents Estrangement from family Accumulated large amt of debt and then lost job Substance abuse Domestic violence

26. Young Adults

27. Families What constitutes a “family” If they are homeless, how can the children get health benefits and go to school

28. Senior Citizens Becoming a bigger and bigger problem Smaller families and more scattered around the country and the world Economics Have been called “our most vulnerable”

30. Veterans – Today and Yesterday’s Heroes Has been a problem since before the Revolutionary War Every war resurfaces the problems of what the toll has been taken on our fighting men and women

32. Mental Health Patients • Not enough money for outpatient therapy • Long lines for public assistance therapy • Hours not conducive to having a job • Limited funds for medication

33. Mental Health Patients Workers have high case loads Emphasis when they are an inpatient is to be discharged – not long term treatment

34. Common Ethical Issues in Treating the Homeless General issues of patient autonomy vs. physician beneficence Coerced psychiatric care and safe placement Just allocation of scarce resources and individual responsibility for one’s health Health and safety of children of homeless mothers vs. nurturing needs of the child and a mother’s right to keep her child

35. Common Ethical Issues in Treating the Homeless The ER homeless recidivist vs. appropriate use of medical resources Attitudes of health care givers towards the homeless – often “difficult” patient – and the responsibility of healthcare educators to deal with student, nursing and physician biases. Who and how to decide for the homeless patient who does not have decisional capacity in the end-of-life scenarios

36. Most Common Medical Diagnoses for Admission Diabetes Pneumonia Frostbite Mental health Substance abuse

37. Most Common Surgical Diagnoses for Admission • Trauma • Assault • Fall • Auto/ped • Fractures • Burns • Infection/draining wounds • Frostbite (amputation)

38. Case 1: Homeless Veteran and Post-Traumatic Stress Syndrome • 61 year old male, Vietnam veteran, disabled with leg injury, HIV, s/p Rx, TB, living on subway, admitted with pneumonia • Alcohol and prior IVDA • Allows treatment with IV antibiotics • Demands discharge without safe disposition – bitter cold winter weather • Angry and abusive

39. Hill 937 in Vietnam May 11-20, 1969 60 Minutes camera man and reporter in soup kitchen in Newark, NJ “I am somebody” 101st Airborne of “Hamburger Hill” was made into a movie

40. Homeless Veteran and Post-Traumatic Stress Syndrome • What is the ethical obligation of the staff to provide for a safe placement? (autonomy vs. beneficence) • Can/should he be coerced to enter a shelter or nursing home? • Does he have decisional capacity? • Should we allow AMA discharge?

41. Homeless Veteran and Post-Traumatic Stress Syndrome • Outcome: • Discharged to HIV/AIDS Services Admin to set up housing in a single resident occupancy • Encourage follow up at Phila VA for HIV tx • Provided with cab to take directly to HIV/AIDS services

42. Case 2: Illness, Chronic Pain and Alcoholism Leading to Homelessness 40 yo male construction worker with 2 children who developed back pain diagnosed with spinal lymphoma Laminectomy relieved spinal compression but he was left disabled by severe pain and lower extremity weakness Only income SSI/disability, inadequate to cover expenses

43. Illness, Chronic Pain and Alcoholism Leading to Homelessness Placed on methadone for pain relief Became depressed, unable to afford adequate pain medication and visits to pain physician Turned to alcohol for help with pain relief Became alcoholic; wife and children left him He became homeless

44. Illness, Chronic Pain and Alcoholism Leading to Homelessness Lived in shelters for next 5 years Shelters have strict limits on narcotic pain meds – he relied ever more on alcohol for pain relief Hospitalized repeatedly with intoxication and upper GI bleeds – diagnosed with cirrhosis and varices – needs liver transplant

45. Assessing “Responsibility” for Illness • How responsible are the homeless for their predicament? • Does it matter? • Do patients who are “morally responsible” for their illnesses (alcoholics, smokers, obese pts, sub abusers, non-compliant with tx) have a weaker claim on social resources than do individuals whose health needs are no fault of their own? • AMA Medical Student Section Comm on Bioethics and Humanities, Virtual Mentor, Jan 2009, (11), p. 29

46. Illness and Chronic Pain Leading To Homelessness and Liver Failure Is there an element of societal responsibility for the patient’s current predicament? How should we decide on resource allocation in treating the patient?

47. Who/What Is Responsible For The Patient’s State of Health? • Element of societal responsibility: • Inadequate financial support and medical coverage that if it had been there might have prevented his descent into alcoholism. The health care system failed the patient. • Generic question of societal allocation of resources in cushioning citizens from the inevitable outcomes of life

48. Who/What Is Responsible For The Patient’s State of Health? • Element of individual responsibility is difficult to assess: • Degree of pain and individual tolerance • Initiative in seeking appropriate treatment • Role of family support

49. To What Extent Are the Homeless Morally Responsible For Their Predicament? Questions of “responsibility” and “fault” are complex, relate to value judgments and are open to wide societal disagreement. Delivering care based on determined responsibility is not within the “norms or goals of medicine or nursing”

50. To What Extent Are the Homeless Morally Responsible For Their Predicament? • “The medical profession is one in which needs are evaluated and met whether or not an individual is deemed ‘deserving of care” • MSS Comm on Bioethics and Humanities, Virtual Mentor, AMA J of Ethics, Jan 2009, vol 11, p. 29