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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

    [email protected]

    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]