Health Care for the Homeless

Homelessness is reaching epidemic proportions in the United States. The causes are complex and there is no simple solution. Lack of food, clothing, shelter and health care are problems faced by the homeless every day. Public health problems that affect the community at large, such as tuberculosis, AIDS and domestic violence, are amplified within the homeless community and contribute to the growing homelessness crisis.Medical students and other health-care providers are directly affected by homelessness. County and Veterans Administration hospitals and community health centers serve patient populations largely comprised of the homeless and medically underserved. Primary care health professionals are most often the front-line providers for this population. It is critical that health care providers are educated to the special needs of the homeless in order to understand how best to serve them.

• Who are the homeless?
• Why are they homeless?
• What are the causes of poor health among the homeless?
• What are the barriers to health care for homeless populations?
• What are the characteristics of an ideal health program to help the homeless?

STUDENT ORGANIZERS GUIDE
This Project-in-a-Box will address some of the problems of homelessness, including health and social issues. As medical students, it is our responsibility to understand the pathology of disease as well as the needs of special populations in order to provide effective care. Medical students across the country have already contributed to the homeless health care network by forming their own clinics, working with existing clinics, and starting other educational and outreach programs. Use your own ideas and the suggestions below to create a fun and informative activity focusing on health care for the homeless.

Suggestions for Planning an Activity

Host a panel of speakers: Sponsor a pizza dinner and invite a variety of speakers, including case workers, doctors who have worked in homeless clinics, and some of their homeless clients, to tell their personal stories. You can even give the event a catchy title such as, "Stories from the Front Line: Providing Health Care for the Homeless." To find speakers, contact local clinics that serve the homeless, or contact the National Coalition for the Homeless (see "For More Information" section at the end of this box).

Plan a brown bag lunch discussion series on "What It Takes To Work With the Homeless." Invite a generalist faculty physician and a faculty member from the ethics department at your school to join you and your fellow students to discuss the special skills needed in providing effective health care for homeless patients. Ask the faculty members to share their own experiences working with the homeless, and use the "Crisis of Homelessness" exercise and the Case Studies included with this box to discuss the health and social issues that homeless people face and how medical professionals can help.

Conduct an Internet search: There is good information about homeless issues on the World Wide Web, including general fact sheets on homelessness, personal testimonies, and timely legislative updates on issues affecting this population. The National Coalition for the Homeless (NCH) has a Web page that includes a national directory of homeless organizations and organizational contacts, along with a year-long calendar of NCH-sponsored activities. You can use the timeline to help you plan related activities at your school. The NCH Web site address is http://nch.ari.net/.Activity

Sample Questions to Ask Speakers

• Who makes up the homeless population that you serve in your clinic or shelter (single men, single women, children, families, etc.)?
• What are the special health problems you see? Have you noticed any trends?
• What special services do the homeless need? How do you address their total health needs, which might include needs for food, shelter, mental health counseling, and more?
• Do you work with other agencies/organizations in the community? What other support do you receive from the community?
• Do you enjoy working with the homeless? What unique skills does it require? What are the challenges?
• How have you adjusted your standard procedure for medical visits for this special population?
• How can medical students get involved?

Who Are the Homeless and Why Are They Homeless?
Homelessness has many faces. Single adults, families with children, runaway youths, all are sub-populations of the homeless. In 1987, under the Stewart B. McKinney Homeless Assistance Act (P.L. 100-77), the federal government defined a homeless person as:

(1) an individual who lacks a fixed, regular, and adequate nighttime residence; [or]

(2) an individual having a primary nighttime residence that is

a) a supervised or publicly-operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill);

b) an institution that provides a temporary residence for individuals intended to be institutionalized; or

c) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.

In order to understand the needs of the homeless, we must further define the sub-populations that comprise this group. In 1995, the U.S. Conference of Mayors issued its annual Status Report on Hunger and Homelessness in America's Cities. Here are statistics from that report regarding the composition of the homeless population:

• 46% single men, 14% single women, 36.5% families with children, and 3.5% unaccompanied minors; children make up 25% of the total homeless population
• 56% African-American, 29% white, 12% Hispanic, 2% Native American, and 1% Asian
• 23% are considered mentally ill
• 46% are substance abusers
• 8% have AIDS or HIV-related illness
• 21% are employed
• 22% are veterans

Causes of Homelessness
The increasing lack of affordable housing, a low minimum wage that provides inadequate support for an individual or family, and declining federal assistance to low-income groups, are all factors that have contributed to the rising number of homeless people.2 Millions of poor Americans are at extreme risk of becoming homeless. The loss of a job, a health crisis, or any unexpected expenditure could push them into homelessness. Homelessness generally is not caused by just one incident; rather, it is often the end result of a downward cycle that may involve a series of setbacks and then, in addition, the loss of the safety net that had previously prevented the individual or family from falling into homelessness. Here is a real-life example (with a positive ending) that demonstrates the cycle of homelessness:

Living in Santa Monica, Kenneth is a 44-year-old man with a history of alcoholism and unemployment due to low work skills. He became homeless after being assaulted and robbed while driving a taxi. He spent five months living on the beach in a confused and disillusioned state. Finally, he was approached by an outreach worker who recommended the Santa Monica Shelter. He has been at the shelter now for four months and is attending AA meetings in the evening at the shelter. He recently got a job as a security guard and plans to move into his own apartment in two months.1

Counting the Homeless
It is difficult to get an accurate count of how many people are homeless in the U.S., especially because the number is always fluctuating. Living in shelters, welfare hotels, shacks, cars and other substandard dwellings, or even doubled-up with other families living in low-income housing, the homeless are hard to find. For this reason, there are two recognized ways to count the homeless, the point-in-time estimate and the period prevalence count.

The point-in-time estimate attempts to count the homeless at a given point in time. It looks at the number of people in shelters and certain street locations where homeless people are usually found across the country and then the counts from all locations are added together for an estimate of the total number of homeless people. The most comprehensive point-in-time estimate was taken by the U.S. Census Bureau during the 1990 decennial census when 600,000 people were estimated to be homeless.3

The period prevalence count examines the number of homeless over a period of time. The most thorough study using this method was Link's 1990 survey in which 1,500 statistically random adults were asked if they had been homeless between 1985 and 1990. Three percent of the adults indicated being homeless at some point during those five years. The Department of Housing and Urban Development (HUD) has used this study to estimate that seven million people experienced homelessness during the years 1985 through 1990.4,5

The Rural Homeless
Information regarding the homeless is gathered in urban areas. Less is known about the rural homeless. This population tends to be homeless due to economic reasons, such as factory closings, decline in the mining and logging industries, and farm foreclosures. The rural homeless are more likely to be housed with extended family, in shacks or tents, in cars, or in the woods. This population tends to migrate to the cities and join the growing ranks of the urban homeless.6

Causes of Poor Health Among the Homeless
While poor mental or physical health can sometimes be the primary cause of homelessness, more often it is homelessness that causes or contributes to health problems. Chronic and acute health problems often result from poor living conditions and contribute to the inability of an individual or family to break the cycle of homelessness. In the struggle to survive, health care often takes second place to the more basic needs of food and shelter. This forced neglect can allow minor health problems to progress until they become life-threatening illness. The first encounter with the health-care system will occur only when the problem has finally become so bothersome that it no longer can be ignored.

Health Problems of Homeless Adults
The death rate of homeless people is almost four times greater than that of the general population.7 Harsh living conditions and constant exposure to the elements leave a homeless person more susceptible to acute illness and traumatic injuries. Frostbite and sun exposure, as well as robbery, rape and beatings are all common among the homeless. A combination of poor nutrition, poor personal hygiene, and overcrowded shelter situations have also contributed to the growing number of communicable diseases in these populations; experience with HIV/AIDS, hepatitis B, and other sexually-transmitted diseases all support this claim.8

Once thought to be a public health problem under control, tuberculosis (TB) has had a resurgence nationally, and especially in the homeless community. Among the urban homeless, 53% of the newly-reported cases of TB have been attributed to new primary infections (versus the reactivation of an old TB infection which is less contagious), as compared to 10% of the reported cases in the general population.9 The combination of the increased infectiousness of primary TB, close living quarters of the homeless, and non-compliance with recommended treatment has resulted in treatment failure, further spread of preventable illness, and the development of drug-resistant strains.

Chronic diseases such as hypertension and diabetes can be difficult to treat properly in the general population and are almost impossible to control among the homeless. Due to the scarcity of personal resources, a homeless, insulin-dependent diabetic may face multiple problems in controlling his or her disease. Control of the diet is difficult if the only source of meals is what is served in a shelter or soup kitchen. A homeless person generally does not have regular access to a refrigerator to store insulin, and insulin needles that have not been properly cleaned can lead to infections.

In addition, homeless diabetics may carry a supply of needles that, on the streets, can put them at risk for robbery or being mistaken as an intravenous drug abuser. Diabetes may progress fairly rapidly due to poor control over the years, and those affected will develop some of the long-term effects of the disease, including numbness and poor circulation in the extremities. If the affected individual has poor fitting shoes, he or she may develop foot ulcers. Without proper care and medical attention, the lesions may become limb- and possibly life-threatening.

Mental Illness and the Homeless
It is estimated that 23% of the homeless are mentally ill.1 The most common forms of mental illness among the homeless population are schizophrenia and the affective disorders (bipolar and major depression).12 The nature of the mental illness may cause the affected person to deteriorate over time, losing the ability to function in a socially-acceptable manner. If the individual's family and larger social network can no longer support them, the person may be forced into homelessness. Over the past thirty years, there has been a trend to deinstitutionalize the mentally ill. It was determined that with the proper support and therapy, as well as the right combination of medicines, the mentally ill could function better within society and achieve an independent life.13 Although in theory this seemed the best solution, the mentally ill were released from institutions without proper support networks in place, and as a result, many have become homeless.

Substance Abuse and the Homeless
Substance abuse and alcohol abuse are prevalent among the homeless. From their own review of the literature, the National Coalition for the Homeless reports that approximately half of all "single" homeless adults have a drug or alcohol problem.13 It is often unclear whether the homeless develop drug dependencies as coping mechanisms after they become homeless, or whether the drug dependencies are part of the cause of their homelessness. Regardless of when they develop the problem, there is a severe lack of drug and alcohol treatment services available for poor or homeless people.4 Waiting lists for inpatient detoxification programs are very long, and the available treatment may be ineffective in this population if their living conditions remain inadequate. Homeless people with drug and alcohol problems require very strong support networks to help them rebuild their lives.

Causes of Homelessness 1

• Unemployment and other employment-related problems
• Lack of affordable housing
• Substance abuse and the lack of needed services
• Mental illness and the lack of needed services
• Domestic violence
• Family crisis
• Poverty or insufficient income
• High cost of living
• Inadequate welfare benefits

Federal Health Care for the Homeless Program
In 1987, the U.S. Congress passed the Stewart B. McKinney Homeless Assistance Act, which was intended to provide "urgently needed assistance to protect and improve the lives and safety of the homeless." As a result of the McKinney Act, the Federal HCH Program was established to increase access by the homeless to primary care services and substance abuse treatment services. The HCH program awarded grants to 122 community organizations, such as community and migrant health centers, local health departments, and community coalitions to help build a service network. These sites provide primary care, substance-abuse treatment, 24-hour access to emergency care services, outreach programs to let the homeless know that these services are available, and assistance with establishing eligibility for entitlement programs. The multidisciplinary care provided by this diverse network of providers is in many places the only source of comprehensive health-care services for the homeless.16

Barriers to Health Care for the Homeless
There are several reasons why it may be difficult for a homeless individual to access the medical system and receive basic health care. First, most of the homeless population do not have health insurance, and any costs associated with health care pose a significant barrier. The homeless therefore must receive care through county health facilities, emergency rooms, or low-cost or free health clinics. These clinics may be overcrowded, with few appointments available, and may be located too far away for those without reliable transportation. Also, appointments may be difficult to keep if individuals lack control over the circumstances of their daily lives. Community outreach programs are needed to educate homeless and low-income populations on the how to properly access medical care and preventive services.

Hospital emergency rooms, such as those run by the county, the Veterans Administration, or academic medical centers, often are inappropriately used as primary care facilities by the homeless and other low-income populations. This route of access is inappropriate because the care is expensive, impersonal and discontinuous. Many medical schools operate mobile or stationary clinics to serve the homeless, and medical students can volunteer their time in these clinics (see "How Can Students Get More Involved" section).

Characteristics of Responsive Health Programs for the Homeless
In order to improve the delivery of health care to the homeless, the special needs of this population must be addressed. Supplemental services are often needed to make the care accessible, providers must work with other community agencies to address the comprehensive health needs of the patient, and they must administer care with a non-judgmental attitude.

Accessibility

Location -- Mobile clinics that visit shelters and other known places where the homeless gather are probably the best way to reach this population. If the clinic is not mobile, supplemental services, such as transportation and child care, should be offered.

Affordability -- Any out-of-pocket costs (especially prescriptions) are a prohibitive barrier for the homeless. Clinics serving the homeless often do not have the funds to supply endless free prescriptions and services. Providers therefore need to be realistic in the treatment programs they suggest and help the homeless to access government benefits they might be qualified to receive.

Comprehensiveness
Providers must have the ability to respond effectively to a wide variety of mental and physical illnesses.

Treatment responses must be context appropriate. Providers must take into account the patient's physical and social environments. Case management services should be provided to address the patient's overall needs, which may include shelter and housing, education and job training, managing a chronic disease, finding a substance abuse treatment program, etc. Homeless persons often qualify for government benefits, such as General Relief, Medicaid, Supplemental Social Security Income, Aid to Families with Dependent Children, and the Women, Infants and Children program, however, they need assistance to access these benefits.8

It is important to address health promotion and disease prevention issues, as many health problems of the homeless are preventable.

Non-Judgmental Attitude
Providers must have the right attitude to work with this population effectively. They must be able to listen and discuss problems and treatment without making moral judgments.

Health Concerns of Homeless Children
Homeless children, although they may be covered by Medicaid, are less likely to be seen regularly by a primary care physician.10 Some reasons include: inconvenient location of the physician's clinic, lack of transportation, inconvenient appointments, and lack of access due to the low reimbursement rate to the physician. Fewer well-child care visits mean that chronic conditions such as anemia and poor nutrition are less likely to be detected early. Homeless children are usually behind on immunizations. They often live in substandard housing with lead paint on the walls, which causes them to suffer from high lead levels. Some of the long-term effects of these chronic conditions, such as seizure disorders and learning disabilities, can be devastating and decrease their chances to break out of the cycle of homelessness.

How Can Students Get More Involved?

1. Volunteer your time in a clinic that serves the homeless. By actively participating in a clinic or program that serves the homeless, you will gain first-hand knowledge of the problems - both medical and social - that homeless people face every day. Your medical school or affiliated residency program may already have a designated night for serving the homeless. Contact your dean of student affairs to find out if your school already has an affiliation. If there is no program at your school, you can probably find one nearby by contacting the National Coalition for the Homeless or by using their Online Directory of Local Homeless Organizations (see "For More Information" section). If there is no clinic night at your school, start one! Many medical students have done it.
2. Start an educational outreach program to teach the homeless in your community how to access health care and other community services. Take the initiative and start a project at your school.
3. Join the Health Care for the Homeless (HCH) Clinicians Network. This is a national organization of clinicians dedicated to combating and preventing homelessness and improving the health and overall quality of life for homeless people. By joining the network, you can form links with health care providers concerned about serving the homeless, get information on current issues and legislation for the homeless, and learn about research opportunities. The student membership fee is $15 per year. Call the HCH Network at (615) 226-2292, or write to P.O. Box 68019, Nashville, TN 37206-8019 for more information.

The Homeless Outreach Project
The Homeless Outreach Project was created in 1994 by joining together the Homeless Clinics Project at Hahnemann University and the Outreach Project at the Medical College of Pennsylvania. It is a student-run organization that provides access to basic health services for the underserved in Philadelphia.

The project focuses on continuity of care by providing a network of free clinics at four area shelters and a street outreach site that together serve 2,200 patients each year. A core group of medical and physician assistant students in conjunction with two physician faculty advisors administer the project, and each year over 300 students volunteer as clinic staff.

A social service component of the project is operated by undergraduate and graduate students who conduct health information workshops and organize creative expression activities for children. Students benefit by gaining early exposure to a primary care setting while learning about both the medical and social needs of the underserved population.

A specialized database was developed to analyze data compiled from clinic sites since 1989, and from this data it was estimated that the Homeless Outreach Project saved the Hahnemann Emergency Department over $40,000 in a one year period. Driven by energy from student and clinician volunteers, in-kind support from university and corporate sponsors, and additional grant support, this project works to provide continuous and comprehensive care to the underserved while at the same time teaching them the best ways to access mainstream health care.

For More Information

Health Care for the Homeless Information Resource Center
Policy Research Associates, Inc. 345 Delaware Avenue, Delmar, NY 12054
Phone: 888.439.3300, ext. 243 / Fax: 518.439.7612

National Health Care for the Homeless Council (NHCHC), (615) 226-2292, is an association of 25 Health Care for the Homeless projects in 23 cities. NHCHC advocates for federal policy with regard to issues of health care for the homeless, coordinates the staffing of an HCH clinicians network, and provides support to local projects.

National Resource Center on Homelessness and Mental Illness, (800) 444-7415, has annotated bibliographies and other information on mental health and homelessness.

National Coalition for the Homeless (NCH), (202) 775-1322, has extensive literature on the homeless. They can find information in your local area. 1612 K Street NW #1004, Washington, DC 20006.

Interagency Council on the Homeless, Department of Housing and Urban Development, (800) 998-9999, has free information they will mail to you. Write to American Communities, P.O. Box 7189, Gaithersburg, MD 20898.

For More Information on Starting Up a Program to Serve the Homeless Contact:

1. Sarah Hamilton, Box 825, 4614 Fifth Ave, Pittsburgh, PA, 15213; (412) 683-4297; sbhst7@cis.pitt.edu. (Sarah works with The Birmingham Clinic, the homeless clinic at the University of Pittsburgh School of Medicine.)
2. Michelle Mikol, Clinic/Home Visit Supervisor, The Homeless and Indigent Population Health Outreach Project (HIPHOP), c/o Department of Environmental and Community Medicine, Rm. N-107, 675 Hoes Lane, Piscataway, NJ 08854; (908)235-4198. This project is operated out of the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School.

References

1. Waxman LD, Peterson K, McClure, M. A Status Report on Hunger and Homelessness in America's Cities: 1995. U.S. Conference of Mayors. Washington D.C.; 1995.
2. Shapiro I, Greenstein R. Cited by: National Coalition for the Homeless. Why Are People Homeless Fact Sheet. Washington D.C.; 1996.
3. U.S. Bureau of the Census. 1990 Census Results. Washington D.C.; 1990.
4. Link BG, Susser E, Stueve A, Phelan J, Moore RE, Struening E. Lifetime and five-year prevalence of homelessness in the united states. American Journal of Public Health. 1994;84:1907-1912.
5. National Coalition for the Homeless. How Many People are Homeless in the U.S.? Homelessness Information Exchange. Washington D.C.; 1994.
6. Committee on Health Care for Homeless People. Homelessness, Health, and Human Needs. Institute of Medicine. National Academy Press, Washington D.C.; 1988.
7. Hibbs J, et.al. Mortality in a cohort of homeless adults in philadelphia. NEJM. 1994;331;5:304-309.
8. Usatine RP, Gelberg L, Smith MH, Lesser J. Health care for the homeless: A family medicine perspective. American Family Physician. 1994;49;1:139-146.
9. Barnes P, et.al. Transmission of tuberculosis among the urban homeless. JAMA. 1996;275;4:305-307.
10. National Coalition for the Homeless. Mental Illness and Homelessness Fact Sheet. Washington D.C.; 1996.
11. Federal Task Force on Homelessness and Severe Mental Illness. Outcasts on Main Street: A Report of the Federal Task Force on Homelessness and Severe Mental Illness. Rockville, MD: National Institute of Mental Health; 1992.
12. Fischer P, Breakey W. Homelessness and mental health: an overview. International Journal of Mental Health. 1986;14:6-41.
13. National Coaliton for the Homeless. Chemical Dependency and Homelessness Fact Sheet. Washington D.C.; 1996.
14. National Health Care for the Homeless Council. The Rationale for Targeted Funding To Provide Health Care for Homeless People. Nashville, TN; 1993.
15. Cousineau MR, Wittenberg E, Pollatsek J. Executive Summary: A Study of the Health Care for the Homeless Program. Bethesda, MD: Bureau of Primary Health Care, Health Resources and Services Administration; 1995.
16. BPHC Fact Sheet: Health Care for the Homeless Program. Rockville, MD: Bureau of Primary Health Care, Division of Programs for Special Populations; February 1996.

The Crisis of Homelessness Exercise
This exercise, intended to help sensitize people to the problems of the homeless, is adapted from a workshop created by Homeless Health Care of Los Angeles in 1990.

Introduction (for facilitator to give to the group)
The support network we have established through our family and friends, jobs, and economic stability is vitally important to helping us feel secure in our everyday lives. While we all have different ways of handling setbacks, it may be difficult to appreciate the situation of others who have lost most or all of their support network. Imagine how you would feel if you had no one to rely on for help. Homelessness is usually the result of a series of setbacks or losses from which a person eventually cannot recover, neither emotionally nor financially. For example, it could start with the loss of a family member, followed by a serious health problem, loss of a job, financial difficulties, then divorce as the final straw. This exercise is about loss and is intended to offer some insight into the feelings and perceptions of people who have lost much more than just their home.

Important Note
Explain to the participants that this is an exercise focusing on loss. If anyone in the group has recently experienced a personal loss, give them the opportunity to excuse themselves.

Resources Needed

• paper and pen/pencil for each member of the group
• two thick black markers
• enough facilitators to break into discussion groups of five to seven people

The Exercise (instructions for the facilitator)

1. On a blank piece of paper, ask each member of the group to list three people/things in each of the following categories (they should write the names of the categories above each section):
   A. Role models that are important to you (colleague, teacher, parent)
   B. Individuals who are important to you (wife, mother, son, pet)
   C. Activities that are important to you (jogging, swimming, reading, eating)
   D. Material possessions that hold value for you (house, car, photo album, jewelry)
2. Once everyone has completed their lists, tell them they must choose one item to give up and cross it off the list with a single line.
3. Next, ask them to cross off (again with a single line) one of the items on the list of the person to their left.
4. Now, you (the facilitator) should randomly cross off three items from each person's list with a thick black marker, making sure to cross off at least one item from categories A and B.

Discussion Groups
Split the large group into smaller discussion groups of five to seven people. Each group should have a facilitator who is familiar with homeless issues. The facilitator should ask the following questions and allow each person in the group to respond.

1. Knowing that you have lost the people and things that were crossed off your list, how are you feeling right now?
2. How did it feel when you had to choose what to give up on your list? What about when someone else chose what to take away?
3. How would you begin to cope with these losses in your life?
4. What does homelessness mean to you? When you see someone who is homeless, what is your initial reaction? Do you ever think about what brought them to that point in their lives?

Closing Discussion
Bring everyone back together as a large group and discuss how this exercise might help them to empathize with the homeless and how that empathy can enhance their ability to work more effectively with homeless people.

Case Studies of Homeless Patients

Case 1: Thelma
You work in a volunteer medical clinic in Los Angeles county. Your first patient is Thelma, a 32 year-old black Hispanic female who presents with a two-month history of "having no periods," fatigue, weight loss, and night sweats. From the medical record, you learn that she has recently entered a drug addiction outpatient-rehabilitation program because of a history of cocaine and alcohol abuse. She tells you during the interview that she currently has a boyfriend, has two other children by previous partners (now in foster homes), has no health insurance, has been a resident in a local shelter for battered women for several months, and is currently unemployed and receiving supplemental security income (SSI).

During the exam and subsequent follow-up visits, you identify the following health problems: active tuberculosis; positive HIV test; anemia; and malnutrition. You also discover that she is pregnant, at 20-weeks gestation. Subsequently, she is admitted to an in-patient ward at the county hospital where she is placed in respiratory isolation and started on appropriate therapy for her HIV and TB. Her pregnancy is being monitored.

Questions

1. How do this patient's multiple medical problems relate to her homelessness? Her drug addiction?
2. What are the ethical and practical issues involved in Direct Observed Therapy (DOT) for this patient with regard to her TB? Focus on the issue of maintaining contact with a patient who has no phone or permanent address.
3. AZT treatment has been shown to dramatically reduce the risk of maternal-fetal transmission of HIV. How does this patient's lack of insurance affect availability of treatment for the unborn child? Consider this in terms of cost vs. benefit, short-term vs. long-term, etc.
4. How can the hospital and physician in charge of Thelma's case best assist her? Can treatment of the medical conditions be realistically accomplished without addressing this patient's social and financial situations? At what point do providers have to "draw the line" when confronted with issues like homelessness and joblessness? What is the role of the community with regard to both protecting the public health and providing for its needy citizens?

Adapted from case studies created by Homeless Health Care of Los Angeles, CA, 1995.

Case 2: JP
You work in an urgent-care clinic in a small town in the California Central Valley. You are called by the triage nurse to see "JP", a 22 year-old itinerant farmworker who was brought in after work by several of his co-workers. He appears exhausted, dehydrated (the afternoon temperatur reaches 101 F), and slightly disoriented. The one co-worker who speaks English fluently tells you that the patient has been complaining of thirst for days, and over the past two weeks, has been having to get up several times at night to urinate. On your exam, you note JP is generally cachetic, has tacky mucous membranes, two large, annular, scaly lesions on his scalp, and a fruity odor on his breath. He appears to be healthy otherwise. On mental status exam, he is oriented to person, place and time, but is too somnolent to participate further with more extensive questioning. Fingerstick glucose is recorded at 473.

After initiating appropriate therapy for his mild diabetic ketoacidosis (DKA), you return to talk to JP's companion. He appears nervous and asks if it will be long before JP can leave the clinic. After explaining to him that JP has diabetes and will need to be admitted to the hospital, the companion tells you that JP is in the country illegally.

Questions

1. How will this patient's homelessness affect diabetic teaching and self-care for JP? (e.g., how can an itinerant farmworker keep their insulin cold?). How can society coordinate long-term care for a migrant population?
2. What should the role of public health and social workers be in this case? Would home-health visits be helpful, or even possible? What should a society do to assist people without a permanent address when the majority of government services are budgeted on a county or state basis?
3. Because he is an undocumented alien, JP is not eligible for Medicaid coverage. While the hospital is required by law to provide emergency care for the gravely ill, they have no obligation to provide other services. After two days on the ward, and with the hospital utilization review nurse pressuring you to release JP, you visit your patient. He informs you he has managed to save $50, but has no other possessions other than his truck, some camping gear, and a few clothes. What is your role as a physician in this case? If JP cannot afford to pay for his medicines, what can you do to help him? What if you cannot get enough funding together to allow him to purchase insulin and needles?