Homeless Patients: Considerations

Many of our homeless patients are 'frequent flyers' who continually return to the hospital for the same health problems. Providing nursing care for homeless patients is filled with complexities due to social factors, limited resources, and problems with compliance of orders given at the time of discharge from healthcare facilities.

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Homeless Patients: Considerations

Jacob, a 23-year-old, patiently lays on the bed in a semi-private room on the medical-surgical floor of an urban county-run hospital. The doctors, nurses and other staff have seen him many times previously because he is one of those 'frequent flyers' who is admitted every couple of months or so.

His form renders him notable: his sandy blond hair falls halfway down his back, a ruggedly handsome face brings forward a pert nose below a pair of piercing blue eyes, and a slender 6'6" physique requires the use of a long bed. He has a wicked sense of humor and is always friendly and appreciative, so staff is always happy to see him in spite of the situation that leads to these recurring hospital stays.

When he arrived at the emergency room three nights ago, his blood glucose level was a whopping 748mg/dL. His systolic blood pressure was in the 70s and his pulse was elevated. Assessment also revealed a deep, odorous, yellow ulcer on his left heel that had not been present at the time of his last admission. Jacob was admitted to the medical ICU with multiple diagnoses, including septicemia, diabetic ketoacidosis, and a non-healing wound. After two days in the intensive care unit, he was transferred to the med/surg floor.

Dr. Clark, a statuesque internal medicine physician in her early 30s, visits Jacob during rounds. She bluntly asks, "Is there any reason you have trouble managing your diabetes?

You do realize you're more prone to nasty infections when your blood sugars remain elevated, do you not?"

Jacob calmly responds, "Madam, I've had type I diabetes since I was 6 years old and I know how to manage it, but things have been hard over the past couple of years. I lost my job at the paper mill, then I got evicted from my apartment a few months later. Sometimes I stay with my older sister and her three kids, but her landlord has a strict rule of no more than four people staying overnight, so I basically have to avoid detection when I'm there.

Sometimes I stay at the shelter when they have an open bed, and the rest of the time I pay $8 a day to spend the night at the state park where I sleep in my truck. I've been looking for a job with health insurance for the past two years, but it's hard. Insulin costs $40 a vial without insurance and I can't afford that right now. I cant afford test strips, either."

When a person or family becomes homeless, finding a way out of that situation is challenging. In most cases, first month's rent and a security deposit will be required upfront. Some landlords demand more, such as last month's rent plus acceptable credit. Saving enough money for these initial costs is a challenge because the poor often pay more for goods and services.

For instance, food expenses are higher because the homeless typically lack appropriate cooking amenities. Motel room rates are expensive, even in shady parts of town, so it is more affordable to sleep in the car or stay at a homeless encampment or shantytown. Shelter beds are available in very limited quantities, but come with daunting rules, and patients are allowed to stay for a limited number of days or weeks before they must go elsewhere.

Homeless patients and families who want to find employment with health benefits encounter bureaucratic problems. For starters, how does one expect to be taken seriously when he applies for jobs in wrinkled clothing without having taken a shower?

One can apply for Medicaid, but will be informed that (s)he must have a permanent mailing address. Social services might place a family's kids in foster care if the parent(s) disclose they currently live in a minivan. The patient can fib and provide the address of a family member or friend, but the application will be rejected if officials find out the truth. While a P.O. box provides a permanent address for as long as the bill is paid, the post office won't issue one without a fixed home address.

To be fair, drug addiction is a strong root cause in many peoples' descents into homelessness. Drug use also helps keep people on the streets. According to the United States Interagency Council on Homelessness, almost half of all homeless people, and 70 percent of homeless military vets, abuse substances such as alcohol and illicit drugs.

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TheCommuter

About TheCommuter, BSN, RN

TheCommuter, BSN, RN, CRRN is a longtime physical rehabilitation nurse who has varied experiences upon which to draw for her articles. She was an LPN/LVN for more than four years prior to becoming a Registered Nurse.

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Specializes in nursing education.

I have several patients like this. It's sad that this is the reality for many people. We do what we can for them but the need is so great.

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Specializes in ER.

It's so tough to be a type 1 diabetic and then have life happen like this. Some people just can't catch a break in life.

We see some young adult diabetics that don't have the coping skills to deal with life at all. They abuse drugs, alcohol, and on top of it keep coming in in DKA. It is sad, I hate to see it. I always see the little boy or girl who had to learn to give themselves shots, and then never got a chance in life.

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Specializes in PDN; Burn; Phone triage.

I work on a burn unit. It's winter -- probably anywhere from half to 3/4s of our patients on the unit at any given time right now are homeless.

The biggest hurdle to care and the one that surprised me the most was the fact that many of our long-term, transient homeless lack any form of ID. Nothing. Not even an old birth certificate copy or a social security card. Many haven't spoken to family in decades. Some were born in hospitals that are no longer standing or during a time before rigorous, centralized record keeping of birth certificates. They basically do not exist as far as the government is concerned as people -- which makes obtaining benefits, records, etc. on them next to impossible.

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Doctors visits and prescriptions cost money, and there are people who have to go without. It's not just people who are homeless, but other people who for various reasons can just not afford medical services. The long term unemployed who have gone through their COBRA benefits or couldn't afford them. People with long term disabilities who have yet to be approved for SSDI. I personally have been there. I think it's part of what drives me to become a nurse. I've been the person in the ER because I had bronchitis so severe I couldn't breath without an inhaler but I had run out weeks before and couldn't afford to refill it. It can be so demoralizing to have a doctor go "Well why weren't you managing your asthma, you know you have it." It's embarrassing to have to explain that you had to choose between having a place to live and filling all your prescriptions. I want to remember that feeling because I would hate to make one of my own patients feel that way.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
Doctors visits and prescriptions cost money, and there are people who have to go without. It's not just people who are homeless, but other people who for various reasons can just not afford medical services.
Hey, I'm the author of this piece checking back in.

I personally have not had insurance since June 2010 and have not seen a doctor since March 2010. Access to healthcare is staggeringly expensive without any type of health insurance, but hopefully I will be able to gain access due to the changing healthcare laws.

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Specializes in Critical Care/Coronary Care Unit,.

The issue of homelessness is a very sad and complex one. It's true that many end up homeless due to issues with substance abuse...many in this country are only a paycheck away from being homeless and living in a tent city. My husband was homeless for years before we married. He got himself cleaned up, was in school, and sober for years before we met. However, it wasn't easy. I'm very grateful to those programs and people who believe in a second chance. We've all needed a second chance at some point.

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Are doctors really in that much of a bubble so that they don't even think about these possibilities? I've heard of them being aloof and all, but I've always thought (read: hoped) that most of that is exaggerated...

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Poverty in the US is bad and getting much worse. The cuts to support programs is noticable and there has been nothing to replace them. Working in psych one of my personal diagnosis has been poverty, which afflicts many of our patients. It makes everything worse.

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I lost my insurance when my last job was outsourced. I've been without insurance since April 2012. I'm currently in school hoping to become a nurse. I just got some coverage with the new healthcare laws which is rather exciting for both me and my primary care, since she can actually get me to come in now.

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Living in the UK our homeless face problems accessing benefit if homeless but at least health care is free at the point of use I know diabetes care is free, other medication have charges of £7.00 per item.

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