The Homeless Patient

Rama B. Rao Lewis R. Goldfrank

Carea.nd Evaluation speciaLMedicaioonsiderations Lower, Extremity, „Diseases infections Compliance

Special„Populations Women„and„Children



Psychiatric, „Evaluation

Emergency „Depa.rtment„„Treatmenf Chapter, References

Homelessness is a social problem of epidemic proportions worldwide.1 In the United States alone, estimates of the homeless population range between 3 to 13.5 million. As much as 7.4 percent of the general population will experience homelessness in their lifetime. 2 Homelessness affects a diverse population of all ethnic groups and includes both urban and rural families, the elderly, children, veterans, migrant farm workers, mentally ill persons, and persons with substance abuse disorders. Minority groups are overrepresented in this population, most likely due to disparities in economic opportunities. Causes of homelessness are related to divorce or separation, domestic violence, pregnancy, adolescent runaways, substance abuse, eviction, acute or chronic unemployment, and the deinstitutionalization of persons with mental illness. A disparity between the need for low-income housing and its availability has also contributed to the epidemic of homelessness.

Homelessness has been defined in a variety of ways, including living on the "street," in shelters that provide temporary residence, or in single-room occupancy hotels with shared bathrooms. The consequences of homelessness are profound. A study of homeless adults in Philadelphia found that their age-adjusted mortality rate was nearly four times higher than that of the general population. 3 The median age of death of homeless adults in Atlanta was 44.4 Infant mortality rates are more than twice those for nonpoor, domiciled mothers and 50 percent higher than those for poor domiciled mothers. The effects of homelessness on children may be profound and are discussed below. Other risks important to homeless populations include communicable diseases, environmental exposures to extreme heat or cold, and traumatic injury due to violent encounters, foraging for food, and seeking shelter.5 These factors contribute greatly to acute medical illness in the homeless. Some of the increased risks are associated with poverty, and others are specific to undomiciled patients. Chronic illnesses, such as hypertension and diabetes, are neglected or poorly managed due to desperate living circumstances. Homeless individuals often delay care of minor medical problems until they become severe or unbearable.

The emergency department is often used as a primary source of medical care for acute and nonacute illnesses of the homeless.67 Outpatient community- and shelter-based clinics provide medical care in a limited fashion and can lead to ED referral for more extensive evaluation and management. In some cities, homeless patients may arrive by police or emergency medical services because of extreme weather emergencies or other health and safety mandates. All of these factors make knowledge of this population important to emergency physicians. The management of the homeless patient is complex, and similarities to the domiciled layperson are limited. Medical evaluation and care, homeless health issues, and special conditions and populations are reviewed in this chapter.

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