Prioritization of other life-sustaining activities, such as finding food or shelter, may interfere with compliance with medical regimens or follow-up despite the intention to do so.14 Money may be unavailable for prescriptions. Even hospital-dispensed medications may be traded for cash or other items perceived as more essential, depending on the patient's level of despair and how well the patient understands the consequences of forgoing treatment. Some items necessary for treatment, such as insulin syringes or other medications, are valuable for illicit use and are at risk of theft. Agents such as insulin may lose their efficacy and safety when stored improperly. It may be impossible to refrigerate medications. A regular dosing medication schedule is complicated by a lifestyle devoid of daily routines.
Lack of medical insurance may cause patients to be turned away from medical care or follow-up. Negotiating eligibility for various types of state and federal medical coverage is usually complicated but may be of tremendous benefit to patients with chronic illnesses, for which poverty potentially thwarts adequate management. Patients should be referred to social workers familiar with eligibility requirements and processing. Unfortunately, even eligible patients may require several visits to social-services agencies to establish medical coverage, and this process alone may be too complex to complete.
Other barriers to care include lack of transportation or mental illness. The precarious existence of such patients must be considered with compassion, and they should be treated with a medical regimen that accommodates the limitations of their situation. For example, patients dependent on soup kitchens should have follow-up that does not compete with mealtimes. Shelter-based clinic systems may be more realistic than tightly scheduled appointments.
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