Care of the Homeless: An Overview



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Homelessness affects men, women, and children of all races and ethnicities. On any given night, more than 610,000 persons in the United States are homeless; a little more than one-third of these are families. Homeless persons are more likely to become ill, have greater hospitalization rates, and are more likely to die at a younger age than the general population. The average life span for a homeless person is between 42 and 52 years. Homeless children are much sicker and have more academic and behavioral problems. Insufficient personal income and the lack of affordable housing are the major reasons for homelessness. Complex, advanced medical problems and psychiatric illnesses, exacerbated by drug and alcohol abuse, in combination with the economic and social issues (such as the lack of housing and proper transportation) make this subset of the population a unique challenge for the health care system, local communities, and the government. An integrated, multidisciplinary health care team with an outreach focus, along with involvement of local and state agencies, seems best suited to address the components needed to ensure quality of care, to help make these patients self-sufficient, and to help them succeed. Family physicians are well suited to manage the needs of the homeless patient, provide continuity of care, and lead these multidisciplinary teams.

Homeless persons are individuals without permanent housing who may live on the streets; may stay in a shelter, mission, single room occupancy facility, abandoned building, or vehicle; or who are in any other unstable or nonpermanent situation. Persons may be considered homeless if circumstances force them to stay with a series of friends or extended family members, or if they have been released from prison or the hospital and do not have a stable housing situation to which they can return.1

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

For homeless patients, meeting standard blood pressure, cholesterol, and diabetes mellitus goals may require earlier initiation of drug therapy. Lifestyle modification usually does not work.

C

26, 2831

All homeless patients should receive the influenza vaccine annually and be immunized against pneumococcus according to standard clinical guidelines. For homeless adults, hepatitis A and B vaccines should be provided and tetanus (tetanus and diphtheria toxoids; or tetanus, diphtheria, and acellular pertussis) vaccines updated if the patient's last immunization was more than 10 years ago.

C

28


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

For homeless patients, meeting standard blood pressure, cholesterol, and diabetes mellitus goals may require earlier initiation of drug therapy. Lifestyle modification usually does not work.

C

26, 2831

All homeless patients should receive the influenza vaccine annually and be immunized against pneumococcus according to standard clinical guidelines. For homeless adults, hepatitis A and B vaccines should be provided and tetanus (tetanus and diphtheria toxoids; or tetanus, diphtheria, and acellular pertussis) vaccines updated if the patient's last immunization was more than 10 years ago.

C

28


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Demographics

Homelessness affects men, women, and children of all races and ethnicities. In the United States, approximately 3 million persons, 1% of the population, are homeless in a given year. On any given night in 2013, more than 610,000 persons were homeless; approximately 36% were families and 35% were unsheltered.2 Most homeless persons' experiences are temporary, lasting a few days to several weeks.

Over the past 30 years, the increase in poverty and the growing shortage of affordable housing are the trends largely responsible for the increase in homelessness.3 In 2009, 14.3% of individuals and 10.5% of families had incomes below the poverty level, putting approximately 46.2 million Americans at risk of homelessness if they experience a single catastrophic financial or medical event.4 Economic

The Authors

DAVID L. MANESS, DO, MSS, FAAFP, is a professor and the chair of the Department of Family Medicine at the University of Tennessee Health Science Center in Memphis.

MUNEEZA KHAN, MD, is an assistant professor and the program director at the UT-Saint Francis Family Medicine Residency Program at the University of Tennessee Health Science Center.

Address correspondence to David L. Maness, DO, MSS, FAAFP, University of Tennessee Health Science Center, 1301 Primacy Parkway, Memphis, TN 38119 (e-mail: dmaness@uthsc.edu). Reprints are not available from the authors.

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