A Primary Care Approach to Treating Women Without Homes

Roseanna H. Means, MD, MSc

Disclosures
In This Article

Measuring Success

Successful care of the homeless woman patient is measured by the steps taken toward higher functioning as well as improved personal safety and better health. As medical practitioners, we are taught to look for quantifiable measurable outcomes. What we at times overlook are the measures of success that pertain to the context of our patients' lives. Women who survive months and years without homes have had to face daunting challenges that we can only imagine. Simply showing up for an appointment, following through on a test, or taking one's medicine on time and with consistency are sometimes accomplished through extraordinary efforts. When those successes are embraced with acknowledgment and praise, it can lead to improved self-esteem.

It is also important to know how long the patient has been homeless. "Newly" homeless (< 6 months) in general have been exposed to the trauma of street life for a shorter time and therefore have stronger psychological stamina for moving forward from homelessness. These women need an early and aggressive search for housing before they get dragged down emotionally by their circumstances. Elderly homeless women also need aggressive intervention, being at higher risk for cardiovascular disease, osteoporosis, cancer, and Alzheimer's disease. "Success" for the newly homeless means preventing them from becoming chronically homeless.

The longer one is homeless, the harder it is to reintegrate back into mainstream society. When homelessness becomes the norm or the challenges of homelessness lead to entrenched psychological changes, behaviors and attitudes can result that make it very difficult to handle the responsibility of a rental unit. Many government-subsidized housing units screen for drug and alcohol dependence before offering the subsidy.

Nevertheless, some addicted persons manage to get the apartments, then fail to pay their share of the rent or violate the rules by allowing friends or relatives to stay. If they get evicted, the cycle of personal failure as the cause of homelessness is played out all over again. Homeless women who have sought refuge from their traumatic symptoms in chemicals have to face their dependency before they can successfully live on their own. Some shelters offer transitional living programs (supervised residences) that gradually build responsibility and independence. "Success" for these women may mean keeping regular appointments, staying sober, and taking medicines as prescribed, but it might not mean having a home.

The following are examples of goals that women without homes can aim for with the help of appropriate primary care:

  • sobriety and a commitment to a sober and clean lifestyle, when applicable

  • finding housing or actively searching for housing, using social services, shelter counselors, government agencies, or any other resources

  • engagement and compliance built on a foundation of trust of the clinician and recognition and naming of the traumatic milieu

  • attention to personal hygiene

  • willingness to take prescribed medicines and advice on a long-term basis

  • willingness to accept referrals for in-depth psychological counseling and supportive therapy from professionals trained in working with traumatized individuals

  • seeking ongoing care, with greater intervals between appointments

The steps to successful care of the homeless woman patient require time, patience, and improved communications between the "homeless world" and medical facilities. Sobriety, safety, trust, and continuity of care are paramount factors. Without sobriety, her health cannot improve. Without safety, her terror cannot be eradicated. Without trust, her relationship with her clinician cannot grow. Without that relationship, she will get fragmented care -- which means her health is not likely to improve, and she will be at risk for serious illness and premature death.

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