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Am Fam Physician. 2023;108(2):118

Author disclosure: No relevant financial relationships.

To the Editor: I read the article by Dr. Lanham and colleagues with interest.1 I commend the authors for their cogent overview of medical care for people experiencing homelessness, which represents a growing crisis within the United States health care system.

I would like to underscore the importance of the authors' specific considerations for simplifying medication regimens in this population whenever possible. My colleagues and I conducted a qualitative study of individuals with heart failure experiencing homelessness in one U.S. city, examining participants' interactions with the health care system.2 Heart failure is a common condition involving intensive self-management behaviors, especially adherence to medications. New evidence-based treatments for heart failure continue to emerge, and the medication regimens have become increasingly complex.3 Complex regimens are a known barrier to medication adherence in patients with heart failure.4

For participants in our study, homelessness engendered a pervasive sense of instability and a lack of routine. Routine plays a central role in the successful self-management of many chronic conditions such as heart failure.5 Individuals in our sample expressed difficulty establishing a routine involving heart failure medications. One participant said, “It's hard to take the medication when you're out there… I take 12 different types of medications…the only ones I would take is the torsemide and spironolactone so I can get [fluid] off of me.”

This presents an opportunity for primary care clinicians and specialists caring for individuals with heart failure who are homeless. Simplifying medication regimens is associated with improved medication adherence in heart failure.6 Such an approach, when applied to patients with heart failure who are experiencing homelessness, may reduce the burden on this vulnerable population.

As a cardiologist in a safety-net clinic treating patients experiencing homelessness, I try to incorporate these considerations into my clinical practice. I often preferentially prescribe once-daily metoprolol succinate instead of twice-daily carvedilol (Coreg). Also, I instruct patients to take loop diuretics only when they have reliable access to restrooms.

These are small interventions and do little to address the structural foundations of the housing crisis in the United States, but they are important in the day-to-day care of patients who find themselves marginalized and stigmatized by broader society.

Editor's Note: This letter was sent to the authors of “Care of People Experiencing Homelessness,” who declined to reply.

Email letter submissions to Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Letters may be edited to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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