Mark Goldstein, RN, MSN, EMT-P I/C

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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

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Where I Now Work and Learn
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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 todays society.
• Identify some of the most common issues in
  treating homeless patients that healthcare
  workers face today.

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Faces of Homelessness
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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_200
  90218_recession

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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.

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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.
• HUDs July 2008 3rd Homeless Assessment Report to
  Congress

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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

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The Magnitude of the Problem
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Pennsylvania Homeless

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

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Philadelphia County
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Surrounding Counties

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

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Why Is It Getting Worse
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Causes of Homelessness Economic

• Loss of publicly supported affordable housing
  higher rents
• Roughly 50 of single room occupancy were lost in
  the 1970s
• 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

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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

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Psychiatric Illness and the Homeless

• Deinstitutionalization
• refers to the long-term reorganization of mental
  health care beginning during the 1960s
  (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.

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Phila State Hospa.k.a Byberry
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Philadelphia State Hospital- 1945
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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

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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

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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?

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Pediatrics

• Children are homeless all over the world
• Some have parents with them and some dont
• Some are orphans and some are abandoned

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Adolescents

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

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Young Adults

• Started as adolescents
• Estrangement from family
• Accumulated large amt of debt and then lost job
• Substance abuse
• Domestic violence

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Young Adults
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Families

• What constitutes a family
• If they are homeless, how can the children get
  health benefits and go to school

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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

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Veterans Today and Yesterdays 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

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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

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Mental Health Patients

• Workers have high case loads
• Emphasis when they are an inpatient is to be
  discharged not long term treatment

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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 ones health
• Health and safety of children of homeless mothers
  vs. nurturing needs of the child and a mothers
  right to keep her child

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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

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Most Common Medical Diagnoses for Admission

• Diabetes
• Pneumonia
• Frostbite
• Mental health
• Substance abuse

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Most Common Surgical Diagnoses for Admission

• Trauma
• Assault
• Fall
• Auto/ped
• Fractures
• Burns
• Infection/draining wounds
• Frostbite (amputation)

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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

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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

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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?

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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

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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

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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

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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

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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

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Illness and Chronic Pain Leading To Homelessness
and Liver Failure

• Is there an element of societal responsibility
  for the patients current predicament?
• How should we decide on resource allocation in
  treating the patient?

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Who/What Is Responsible For The Patients 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

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Who/What Is Responsible For The Patients 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

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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

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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

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Socio-Economic Influences On A Patients Health

• Patients of lower socio-economic status tend to
  have higher co-morbidities and worse prognoses
  than their wealthier counterparts who may have
  continuous primary care, better educational
  opportunities and fewer barriers to compliance.
• One must always consider social influences on a
  patients health including reduced societal
  economic status, homelessness, stereotyping and
  lack of primary care and support structures
• MSS Comm on Bioethics and Humanities, Virtual
  Mentor, Jan 2009, (11), p. 30

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How Should We Decide On Resource Allocation In
Treating This Patient?

• Compassion vs. justice
• individual vs. societal needs
• Liver transplant
• Physician responsibility as custodians of a
  scarce societal resource to transplant organs
  with greatest chance of success dont waste an
  organ
• Transplanting this patient with major
  psychosocial disabilities will almost certainly
  be met with rapid organ rejection and will not
  right the injustice that life and society has
  dealt him but may compound injustice by
  wasting a scarce organ

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How Should We Decide On Resource Allocation In
Treating This Patient?

• In absence of liver transplant, this man will die
  sooner rather than later of GI bleeding, hepatic
  encephalopathy and or liver failure
• At some point, he will need nursing home
  placement for nursing and medical care which will
  hopefully palliate his symptoms and diminish his
  suffering

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PROJECT H.O.M.E.Sister Mary Scullion and Joan
Dawson McConnon

• Started in Phila in 1989
• Nationally recognized organization that provides
• supportive housing
• employment
• education
• health care
• That enables chronically homeless and low-income
  persons to break the cycle of homelessness and
  poverty.

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Case 3 How Do We Decide On End-Of-Life Care For
The Homeless Patient Without Capacity?

• 58 yo man found unconscious on the street and
  brought by police to the hospital
• Odor of alcohol on breath, () urine tox for
  cocaine
• Brain MRI shows moderate intra-cerebral
  hemorrhage
• Placed on ventilator in NICU

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How Do We Decide On End-Of-Life Care For The
Homeless Patient Without Capacity?

• No identifying data on the patient, no visitors
  come to the hospital. Fingerprints () for
  military
• After 2 weeks, he shows no significant signs of
  recovery although he responds to voice by moving
  his head slightly
• He develops sepsis and renal failure
• Even with aggressive tx, his best case prognosis
  is for total lifetime disability probably trach
  and PEG in a nsg home with minimal to mild
  responsiveness.

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How Do We Decide On End-Of-Life Care For The
Homeless Patient Without Capacity?

• How do we decide on aggressiveness of tx?
• Should he be made a DNR?
• Should he be treated aggressively for sepsis with
  CV drugs and antx and given CVVH for renal
  failure?
• How significant should the healthcare teams
  assessment of quality of life factor in tx
  decision?

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Treatment Preferences For Resuscitation and
Critical Care Among Homeless Persons

• Comparison between groups of homeless men and
  women to each other, to physicians and to
  patients with COPD who were not homeless
• Conclusion
• Each group of homeless individuals preferred more
  care than either the COPD patients or physicians
  would have chosen for themselves
• Physicians making end-of-life decisions for
  homeless pts are likely to chose less care than
  what the pt desires.
• Norris, et al. Chest. Treatment preferences for
  resuscitation and critical care among homeless
  person. 2005 127 (6) 2180-2187

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How Do We Decide On End-Of-Life Care For The
Homeless Patient Without Capacity?

• Healthcare providers are tempted to make their tx
  choices based on what they would want for
  themselves
• African-Americans are less likely to forgo
  life-sustaining tx than other races
• 48 of the particpants were AA in the homeless
  group in the Chest article

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Case 4 Homeless Single Mother And Her Child

• Ms. P delivers child in a comm hosp and is ready
  for d/c
• OB discovers she is homeless, living in her car,
  stays with friends on occasion
• She refuses to go to a shelter, asks SW not be
  contacted
• Her plan live in car until she gets back on her
  feet in a few months
• What should her physician and the maternity
  nurses do?

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Risks Facing Homeless Children

• 6x more likely than poor, housed children to have
  multiple health problems infections such as URI,
  scabies, diarrhea
• Go hungry 2x as often as housed children
• 2x as likely to repeat a grade in school
• Delays in immunization, poor access to medical
  care, higher risk for injury and toxic exposure
  (lead)

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Homeless Single Mother and Her Child Ethical
Dilemma

• Balancing the autonomy rights of the mother to
  keep her child and her ability to love and
  nurture her child better than a foster parent
  vs. the rights of her child for health care,
  security and well-being.
• It is an increasing problem.

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Difficulty In Weighing Maternal and Child Rights

• Parental rights are not absolute the capacity
  of a parent to act in the best interest of the
  child must be assessed
• Nurturance and stability of attachment during
  the first years of life, when essential
  characteristics such as the capacity to love and
  trust are developed, are critical to emotional
  health
• Is the mothers inability to supply a stable
  physical environment outweighed by her provision
  of a stable emotional bond?
• Virtual Mentor, A Mother and Infant Wish No Home,
  Jan 2009, vol 11, p.15

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What Are The Options?

• Identify resources available to assist mother and
  child
• Social workers must be contacted to determine
  options available to help the mother
• Local shelters that can house mothers with
  infants
• Maternity homes
• Extended family members
• Address the fears of the mother regarding
  notifying a social worker

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Case 5 Homeless Patient Coming To The ED
Primarily For Food and Shelter

• On a cold winter night homeless Mr. Smith returns
  to the ED with complaints of chest pain his
  sixth visit to the hospital this winter
• Should he be sent out immediately?
• What would constitute an adequate reevaluation of
  his complaints?
• What can be done to prevent this behavior in the
  future?

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Homeless Patient Coming To The ED Primarily For
Food and Shelter

• Societal responsibility for the care of the
  homeless and how he got there
• abuse by the pt of the ED facility meant for
  emergency medical tx, not for food and shelter

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Homeless Patient Coming To The ED Primarily For
Food and Shelter

• A brief H P should suffice assuming normal VS
  and appearance
• Unacceptable to d/c him to the elements risk of
  pneumonia, etc
• Physician and hospital's beneficence and
  non-maleficense apply as much for the 6th as the
  first ED visit

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Homeless Patient Coming To The ED Primarily For
Food and Shelter

• Keep pt overnight and feed
• Re-address placement options
• Consider systemic approach to local problem such
  as San Diego Serial Inebriate Program (SIP) which
  provides housing and tx to chronically ill
  homeless alcoholics
• From 2000-2003 SIP reduced episodic ER visits,
  improved rates of sobriety and produced cost
  savings of more than 70, 000 per month
• Virtual mentor, Hospital Resources A Practical
  Treatment Plan for Homeless Patients, Jan 2009,
  Vol 11, p. 21.

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Common Issues in Treating Homeless Patients

• Difficult to discharge patients
• Difficult to treat patients
• Other

• Appropriate consent
• Past medical history and records
• Outpatient follow-up
• Admission and transfer
• Health insurance
• Recidivism

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Types of Consent

• Informed three parts that must be presented to
  the pt by the MD/NP before procedure
• Describe procedure to be performed
• Explain alternatives
• Detail risks of procedure
• Informed Dilemmas
• Sedated - Pain
• Language - Psychiatric hx
• Medical condition (TBI, learning, etc)

• Expressed - voluntary consent of an individual
  seeking medical treatment
• Implied when an individual is in a life or limb
  threatening situation and is unable because of
  unconsciousness or incompetence to provide
  expressed consent
• Involuntary individual refuses to consent to
  needed medical tx and another person (physician,
  police, judge) can ensure that the individual
  receives treatment

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Obtaining Medical History and Records

• Can you tell me where you been treated before and
  whats wrong?
• Hospital - Clinic VA
• Can we get copies?
• Paper -Electronic
• HIPPA
• Camden, NJ - piloting electronic clinic/hospital
  record exchange to combat this problem.
• Microchips are coming!

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Outpatient Follow-Up

• Can be a nightmare!
• Lack of insurance and money
• Making and keeping appointments
• Transportation
• Lab work and radiology studies scheduling
• Perceptions (office staff and other patients)

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Health Insurance

• You need an address, social security info, a bank
  account for health insurance.
• How much more do you really think hospitals are
  going to get in the new plan?

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Recidivism

• Do you believe three hots and a cot?
• Do you really think they want to be with us?
• It is no excuse for unprofessional behavior.

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Difficult to Discharge Patients

• Do not want to leave
• No money for meds
• They need a supervised environment
• No VNA or support
• They will be lost to follow-up

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Difficult to Treat Patients

• What have they been thru in their lifetime to
  make them react this way?
• They need to be bathed, clothed and assessed.
• What can we do to assist them thru this trying
  time?

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Analyzing Different Issues

• Enrolling in clinical research trials
• Dealing with the homeless family
• Discharge planning
• The future

• Assessing responsibility for illness
• Deciding on resource allocation
• Deciding end-of-life care for those without
  capacity

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The Soloist Nathaniel Ayers

• Homeless, musician, schizophrenic man kindles
  interest in LA Times reporter Steve Lopez
• Writes columns on Mr. Ayers, gives him cello
  donated by a reader, tries to help him
• Frustrations of trying to assist the mentally ill
  homeless

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The Soloist Nathaniel Ayers

• Primal fear of being locked up memories of
  previous shock therapy and forced hospitalization
• Fear of being lured by threats into captivity
• Ultimately Mr. Ayers needed to trust his friend
  Mr. Lopez before entering a home

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Lessons From The Soloist

• Appreciate the enormous effort it takes to get
  Nathaniel to agree to be housed
• Will he stay in his apartment?
• Can we extrapolate any useful lessons from this
  unique story of homelessness?

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All Homeless People Are Soloists

• Cut off from society at large, they all have
  their own unique sagas that led them to
  homelessness, and to their distinctive needs and
  sufferings
• Nathaniel Ayers is unique in being so talented
  that his solo song resonates more loudly and more
  easily with us, and his story was taken up by a
  prominent newspaper
• Although his homeless colleagues at LAMP do not
  have his musical talent, they do share his
  dignity as a human being and his sufferings and
  are equally deserving of our respect and help

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60 Minutes Mr. Lopez Meets Mr. Ayers (3/22/2009)

• The fact that he has people who understand him
  and respect him and wish him well is incredibly
  therapeutic for him.
• Robert Gupta, violinist virtuoso, Los Angeles
  Philharmonic Orchestra.

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The Ancient and Enduring Problem of Homelessness

• For there will never cease to be needy ones in
  the land, therefore I do command thee saying,
  thou shalt open wide they hand unto thy brother,
  to thy poor, and to thy needy, in thy land
• Deuteronomy 1511

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Our Mission Still Remains

• Commitment
• Dedication
• Passion
• Provide the Highest Quality Care

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Questions???
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Thank You For Coming!!!

• Be thankful for what you have.
• May you all never have to face what our patients
  face.
• Fall is like the spring ..except instead of
  flowers, all the leaves bloom.
• Albert Camus

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Thank you!!!

• Mark.goldstein_at_beaumont.edu
• 313-473-6487