A Primary Care Approach to Treating Women Without Homes

Roseanna H. Means, MD, MSc

Disclosures
In This Article

Strategies for Engagement

The following are strategies that serve to engage women in building trust with the physician and thereby improving the chances they will return.[26] These strategies are summarized in Table 6.

Build trust:

  • Offer praise, even for small steps forward such as showing up for appointments or following through with treatment.

  • Set predictable, consistent limits on inappropriate behavior.

  • In extreme cases of noncompliance, use contracts to reinforce mutual expectations.

Be predictable:

  • Be there when you say you will. (But do not create unrealistic expectations. You are not "the only one who understands," and you will not "always be there for them.")

Listen:

  • Listen to what she is asking for.

  • If you aren't sure she is homeless, ask "Where are you staying?" -- not "Where do you live?"

  • Discern whether she is sober, safe, and sheltered.

Recognize the trauma in her life:

  • Respect her psychological space.

  • Don't touch her bags or belongings without permission.

  • Try not to rush. Speak calmly and listen first. Avoid the temptation to start the exam before hearing the whole history.

  • Don't do invasive bodily exams without explaining why and getting permission.

  • Explain every step of what you are going to do before you do it.

Show concern:

  • Don't be afraid to ask when she needs to get to the shelter to get a bed.

  • Call the shelter and ask them to hold a bed if it is late in the day.

  • Ask her if she can handle her medications. Will she be able to do simple interventions such as applying ice, elevating a limb, or getting bed rest?

  • Speak to the shelter nurse if there are special instructions.

Don't try to do too much in one visit:

  • Prioritize health issues.

  • Treat the most important conditions first.

  • Empower the patient by offering options and choosing what can be accomplished together.

Simplify medical regimens:

  • Choose medicines with proven track records and minimal side effects.

  • Use once daily dosing, if possible.

Use creative solutions:

  • Combine insulin with oral agents.

  • Keep the welfare form until the lab work needed for eligibility has been completed.

  • Use meal vouchers to reward completion of therapy.

  • Use your local network of shelter nurses to give medications.

  • Consider giving homeless battered women a brief, portable health record in case they must go to multiple care sites in order to stay safe.[57]

Refer judiciously:

  • Pick colleagues sensitive to the special needs of complex patients.

  • Arrange referral dates soon after appointment dates. (Waiting increases the no-show rate.)

Arrange frequent visits:

  • Homeless people don't always have watches or calendars, so it can be hard for them to stick to long-term schedules.

  • Frequent visits provide an opportunity to show consistent concern and establish the habit of following through, and have been shown to improve outcomes.[58] (Brief once- or twice-weekly visits are especially important during vulnerable periods.)

  • Spread clinical contact among the treatment team to broaden the clients' base of support and minimize staff burnout.

Don't judge or scold for failure to follow through or to stay sober/clean:

  • Always praise the patient for showing up.

  • Acknowledge failed behavior as evidence of the many barriers that can only be overcome with the help of the treatment team.

Learn how to enroll patients in Medicaid:

  • Most homeless individuals qualify but need help with the enrollment process.

Practice comprehensive discharge planning from inpatient hospitalization:

  • Document the social, medical, and behavioral health services that will be needed by the patient[59] and communicate them to the patient's primary provider.

  • Do not discharge a patient to a shelter without shelter staff permission or without the staff understanding the degree of care and follow-up required.

Know your resources:

  • Create a file of local resources including shelters, advocacy groups, outreach workers, and public benefit agencies.

  • Know the hours of operation of your area's shelters, whether they have clinics, and what degree of follow-up care can be provided, if any.

  • Maintain a dialogue with these resources and with area emergency departments and urgent care centers so that the lines of communication stay open.

Be flexible: Encourage appointments but allow walk-ins:

  • Women who live in the unstructured society of homelessness require a flexible attitude toward office visits, because they face unique barriers to healthcare, such as:

    • The shelter may be a long distance from the office or hospital.

    • The individual may not have money for public transportation.

    • She may be physically or psychologically too impaired to get to the hospital on a regular basis.

    • She may have small children and lack day care.

    • She may be terrified of yet another bureaucratic system.

  • Flexibility in allowing walk-ins addresses the unpredictable side of healthcare for this population. If the bigger goal is establishing a connection and rebuilding a sense of community, the individual should not be turned away.

  • However, some strategies are needed to prevent this from turning into an abuse of the practitioner's time and patience. First, thank the patient for coming, and praise her for coming to you for help. Let the praise sink in. Then, inform the patient that walk-ins are okay for unavoidable situations, that you can spend only 5 or 10 minutes this time, but could give her more time in a scheduled follow-up. Make the appointment for a few days to a week hence. Some needy patients will never stick to appointments, and those have to be taken in stride. Frequent brief scheduled follow-ups help reinforce responsibility.

Although one must prioritize the health issues toward the ones that are most urgent and manageable, chemical dependency is the most life-threatening aspect of homeless persons' lives. Therefore, the practitioner must continually work with the patient on building a commitment to detoxification. This may take many visits. During this time, the patient needs support and encouragement and a commitment by the practitioner to stay connected. Challenges to anticipate include lack of insurance coverage for repeated detoxification, shelter policies that prohibit entrance of inebriated individuals, and a shortage of beds in treatment programs.

Homeless mothers with minor children who require drug or alcohol detoxification or an inpatient psychiatric program are required to arrange care for their children for that period of time. If no one is available to provide care, the children may have to go into temporary custody with the state. This decision for the mother is extremely difficult. Therefore, to maximize the experience, she needs to be as medically stable as possible in other health areas before she starts the program.

Recognition of sobriety is the number one health goal, but safety and housing stability are vital corollaries. Too often, clients undergo successful detoxification but experience no choice about what to do next. Returning to the streets or the shelters means facing the same "triggers" that perpetuate the chemical dependency. They cannot heal without safety and stability. In these cases, 6-month "halfway houses" or transitional housing programs can help.

Homeless inpatients have more than double the frequency of hospitalization and length of stay as domiciled counterparts.[14,60] Institutions that offer inpatient medical care to the homeless patient will save future costs if they offer a multidisciplinary team of social workers, outreach workers, and case managers to coordinate the housing and benefit needs of the homeless patients.

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