It's hard to be homeless in the hospital

Research and advice from an internist who treats homeless patients.

Treating homeless patients can be frustrating for hospitalists, acknowledged ACP Member David Munson, MD, a physician with the Boston Health Care for the Homeless Program (BHCHP). Physicians become “burnt out and really fatigued taking care of the same person for the same thing over and over again and not really seeing any solution,” he said.

But think about the issue from the opposite perspective, he urged attendees of the Hospital Medicine precourse at Internal Medicine Meeting 2015. “It's hard to be a homeless person and be in the hospital,” he said.

David Munson MD ACP Member Photo by Kevin Berne
David Munson, MD, ACP Member. Photo by Kevin Berne

Homeless patients have many of the same chronic diseases as the general population, but at much greater prevalence. According to data from the BHCHP's electronic medical records, 18% of homeless patients have diabetes, 37% have hypertension, and 23% have hepatitis C.

Being homeless also complicates treatment of these conditions. “As you can imagine, it's quite difficult to manage your cirrhosis outside,” said Dr. Munson. A diabetic homeless patient is not likely to have access to a low-carbohydrate diet. “The shelters do a good job of trying to provide what food they can, but it's often starchy, with not great access to fruits and vegetables,” he said.

Or consider the challenge of preparing for a colonoscopy while living in a shelter. “This is a gymnasium where about 350 men spend the night. They share 1 bathroom with 3 stalls,” said Dr. Munson, showing photos of Boston shelter facilities.

Homeless patients also face increased rates of mental illness and substance use disorders. The analysis of BHCHP records revealed that 68% of patients had a mental illness, including 19% with schizophrenia and 30% with bipolar disorder. Sixty percent of the homeless patients had a substance use disorder.

“There's a striking amount of co-occurring disorders,” said Dr. Munson. “You overlap that with the medical illness and get a sense … those folks tend to be really at risk for increased mortality.”

Specifically, homeless people in Boston between the ages of 25 and 44 have 9 times the death rate of the state's nonhomeless residents of the same age. “For younger folks, folks under the age of 45, it's drug overdose that's really driving a lot of the mortality,” noted Dr. Munson.

For older homeless patients, between ages 45 and 64, the mortality rate is still high (4.5 times the average), but the causes are more typical. “It's chronic diseases that are killing homeless people that are over 45—cancer and heart disease,” he said.

The same causes were also responsible for the most deaths among homeless people aged 65 to 84, according to the analysis, which was published in JAMA Internal Medicine in February 2013. Their mortality rate, though, was the same as their nonhomeless peers. “If folks live to 65, there tends to be this hearty survivor effect,” said Dr. Munson.

Homeless patients also develop unusual diseases. Dr. Munson showed photos of scabies, a burn from sleeping on a subway grate, and a foot that had partially autoamputated after a patient refused surgery for frostbite. “We watched the natural history of frostbite,” he said.

Perhaps not surprisingly, given their typical and atypical health problems, BHCHP patients have been found to use the hospital a lot. One analysis found that 20% of the program's patients made 6 or more ED visits per month, and 4% to 5% were admitted more than 7 times per year.

In a 2011-2012 study of 876 homeless patients admitted to Massachusetts General Hospital, 110 had more than 3 admissions and 1 patient was admitted 23 times, Dr. Munson reported.

“Most of these folks are seeing you on the medical service, although psychiatry is second,” he told the hospitalists. “Between alcohol and drug use and injuries, toxins, and poisons, about 20% of the primary reason for admission was substance use disorder … not counting the endocarditis from drug injection use, aspiration pneumonia from being intoxicated.”

Homeless patients also tended to have a fairly long length of stay (about 6 days) and a high rate of leaving against medical advice (AMA). “We documented 11% of our patients leaving AMA, which is probably an underestimate. My guess is it's close to 15% or 20%,” said Dr. Munson.

He offered hospitalists some tips to try to prevent these AMA discharges. “Diagnosing addiction and treatment of withdrawal is really important for patients, because the prevalence is so high. We know that's a big driver of why folks are leaving AMA,” Dr. Munson said.

Patients may also balk at the close quarters and supervision associated with hospitalization, especially if they've chosen the freedom of living on the street over the greater comfort of a shelter. “They go into the hospital and then every time they get up out of bed, there's a bed alarm and 50 people run in,” he said.

One solution is to offer patients a little more freedom. “Consider letting folks go off the floor and take a break. They just don't like being cooped up and sometimes just being able to go out and walk around and take a break, when it's safe and medically OK, can often go a long way,” Dr. Munson said.

When patients are ready for discharge, clinicians should consider where they're going in the development of discharge instructions. “Ask them where they stay. The person that stays in his car outside in the winter versus the person that goes into the shelter at night is a different person,” he said.

For some homeless patients, a medical respite facility could be the appropriate discharge destination. “It's a place for homeless people to go who are too sick to be where they are usually but not sick enough to need to be in the hospital,” said Dr. Munson. Medical respite can treat patients who need to be on intravenous antibiotics after hospitalization, for example, or those recovering from surgery. In some cases, it can be used in place of admission for alcohol detox or treatment of a chronic obstructive pulmonary disease exacerbation.

BHCHP has a 104-bed respite facility, with a 1:13 nurse-patient ratio (which goes down to 1:26 at night). “In other respite programs, it may be even less than that. That can limit sometimes the complexity of the patient that can come,” noted Dr. Munson. “I would encourage you to work with your local homeless providers to try to get a sense of who's appropriate for the respite programs.”

Attendees at Internal Medicine Meeting 2015 got a chance to see firsthand how BHCHP's medical respite facility works during tours held on Wednesday and Friday of the meeting. A total of 40 attendees toured the facility, some with BHCHP founder James J. O’Connell, MD, FACP.

They also saw BHCHP's dental and primary care clinic, located in the same facility. Much of the program's work is scattered at sites around the city, however, noted Dr. Munson. “Wherever the patients are, homeless people are, that's where we try to be,” he said. “We're trying to provide the primary care and longitudinal relationships for the homeless community in the city.”

The clinicians generally work in teams. “We know often it's not the doctor that the patient will relate to best—that's the case manager or the nurse or some other part of the team,” said Dr. Munson.

Their treatment ranges from urgent issues to preventive care, such as smoking cessation. “About 85% of our patients smoke,” noted Dr. Munson. “A lot of folks are holding on to smoking as the 1 thing they can control in their life.”

He encouraged hospitalists to get to know the clinicians working in similar roles in their own cities, for help ranging from understanding a patient's history at admission to planning discharge disposition. “There's a huge network of homeless health care providers. Reach out to them, because they know these people,” Dr. Munson said.