#216 Homeless Healthcare with Stefan Kertesz MD

May 28, 2020 | By Nora Taranto

Medicine for our most vulnerable with Stefan Kertesz MD

Learn the nuances of caring for and building relationships with patients experiencing homelessness from expert internal medicine and addiction physician Stefan Kertesz, return guest from Episode 74 on Opioids and Health Policy (highly recommend a re-listen, y’all!).  To teach us the tricks of the trade, Dr. Kertesz draws on his many years of treating the underserved and researching homelessness, housing, and addiction in Birmingham, Alabama, where he currently serves as professor at UAB and Birmingham VA Medical Center.  In the course of this episode, we discuss the challenge of creating a welcoming and useful space for individuals experiencing homelessness (this is the preferred term, per Dr. Kertesz), how to meet patients where they’re at–both physically and mentally–the challenge of managing diuretics for those without stable access to a bathroom (avoid, if possible), and how absolutely essential the foot exam is. 

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Credits

Written and Produced by Nora Taranto MD

Infographics by Nora Taranto MD

Cover Art by Kate Grant MBChB, MRCGP

Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP, Nora Taranto MD    

Editor: Carolyn Chan (written materials); Clair Morgan of nodderly.com

Guest: Stefan Kertesz MD 

Sponsor

We are excited to announce that the Curbsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out curbsiders.vcuhealth.org for and create your FREE account!.

Time Stamps

• 00:00 Intro, disclaimer, guest bio 
• 3:17 Guest one-liner
• 8:55 Picks of the Week*: Dr. Kertesz’s Book Recommendation: Saul Weiner’s On Becoming A Healer; Nora’s Pick of the week: BackStory (especially their episode on dynamite!) https://www.backstoryradio.org/ 
• 10:07 Case from Kashlak 
• 10:56 Language: How to ask where a patient lives? 
• 13:25 Terminology: Persons Experiencing Homelessness: 
• 14:35 The stats on prevalence of health and illness in the homeless population, and the importance of both medical and environmental factors
• 20:44 How to start the visit, and how to establish trust early on? 
• 27:40 Why is the mortality rate higher?  
• 35:15 Special conditions and Medication Considerations: Hypertension, Diuretics, Insulin and Food Insecurity, Substance Use Disorders, Feet, and Hepatitis C 
• 54:15 COVID and homeless healthcare
• 57:00 Care Models
• 62:30 Take Home Points and Outro

Homeless Healthcare Pearls

1. The Terminology: Dr. Kertesz prefers “individual experiencing homelessness” and “homeless person/individual” to bring it back to the individual patient in front of you. 
2. Ask patients where they have been staying the last several days. This is a concrete question, and you can build on it with further questions about their safety and the environment in which they live.
3. Ask patients about their plans, and their concerns, in the course of the visit. Align your goals with theirs.
4. The population of homeless individuals is varied, and diverse. It comprises people who live on the street, those living in shelters or with friends, and both individuals and those with families and children, to name a few of the ways to break it down.
   
5. Trauma, Substance Use, and Psychiatric Illness are all more common in the homeless population, as are chronic medical conditions compared to age-matched controls. 
   
6. Confirm contact information with patients at each visit.
   
7. Provide a team-based approach. Introduce your team to the patient each visit, and make phone calls to other providers for the patient with the patient in the room.
   
8. Examine the feet.  
   
9. Avoid diuretics, and other medications that require regular access to bathrooms (or regular lab checks).
   
10. Housing is important for health. Leverage the resources at your disposal in the system within which you work to try and get patients re-housed.

Homeless Healthcare: Clinical Pearls. Infographic 1 by Nora Taranto MD

Homeless Healthcare: Guiding Questions.  Infographic 2 by Nora Taranto MD

Homeless Healthcare: Notes

How to Ask a Patient about their Housing

Asking someone “Are You Homeless” can be tricky, in the stigmatization it can bring.  Instead, Dr. Kertesz recommends starting simply, and with specific objective questions. Try out “Where have you been staying the last few nights?” and then ask follow-up questions about whose place it is,  and do whether the patient feels safe there. Emphasize that it is important for the person’s healthcare plan to know where they are staying.  Another good question: “When’s the last time you stayed in a place that was your own and that you knew you could stay in on an ongoing basis?”

Quote by Stefan Kertesz from #216 Homeless Healthcare 

The Terminology 

Dr. Kertesz prefers the term “persons experiencing homelessness,” which reinforces the fact that this is a state that comes and goes. Other alternatives: “homeless persons” (reminds you it’s people we’re talking about), “undomiciled,” “people who don’t have a home right now”. Less used at present: “The Homeless,” since the population is not monolithic.   

“The Homeless Population”: How to break it down 

The population of individuals experiencing homelessness is not monolithic.  We often overlook folks with unstable housing who do not fit the image many have of someone panhandling in front of the hospital, or those living on the side of the street who are therefore more visible in some ways. Some individuals experience homelessness on a recurrent basis, and some experience single long episodes.   So-called “chronically homeless” individuals accounted for 18.5%  of surveyed homeless individuals (HUD Continuum of Care Homeless Assistance Program 2019 Sub-Populations Data)

Recent cross-sectional studies counted roughly 37,000 homeless veterans in a single night (2019 VA PIT Count). Cross-sectional studies of the U.S. population based on single-night surveys, known as “point-in-time (PIT) counts” in January – accounted for 568,000 homeless individuals. (2019 AHAR Report to Congress). This may be underrepresenting the problem because it may miss people living in abandoned buildings or in rural places.

Women account for up to 40% of this population, many of whom are accompanied by children (2019 AHAR Report to Congress). These family units are much less likely to be visible on the street because some resources do open up to those who are homeless with a child, including through the YWCA and local government (e.g. Massachusetts Housing Resources). It’s important to think about homeless family units, since these make up a decently sized chunk of the homeless population, and since responsibilities to family may very well affect individuals’ ability to execute their own health.

What makes health a challenge for homeless individuals? 

There are many different factors that play into the challenge of maintaining good health. From a medical perspective, many who are homeless are middle aged, with an average life-span of 42-52 years, but are medically/biologically older, and have many comorbidities and illnesses that affect those who are later in life–whether diabetes, high blood pressure, or cancer (Maness 2014).  

Moreover, many individuals will have trauma and psychiatric conditions that may destabilize their living situation and pose unique health challenges, in particular, addiction and substance use (or recovery) history.  PTSD and Schizophrenia will occur not infrequently, especially given that homelessness in and of itself is a stressful event and can precipitate exacerbations.  Based on cross-sectional data, 25% of homeless individuals have persistent and severe mental illness, with 45% having any mental illness (2015 AHAR Report to Congress).  Also common is a history of co-occurring substance use disorder or history of substance use (Tsai 2014; Gillis 2010).  A portion of those seeking medical care are early in recovery for their substance use disorders.  Chronic pain is highly prevalent in the population of unstably housed (Vogel 2017). Furthermore, among women who are homeless in particular, there is a high prevalence of childhood and recent sexual abuse (Hamilton 2011; Kushel 2003).  More often than not, there will be a history of significant physical or emotional abuse among your patients, both male and female.  

The environment in which individuals live is also important to consider. Things to ask about: Where are you sleeping? Where do you keep your medications, and at what temperature? Where are you storing your stuff? Do you feel safe where you’re sleeping? 

The social context, in particular sources of income. Many patients will be on disability or without a stable source of income.  Individuals can become homeless via different mechanisms. For some, there is one sentinel event that, with no support or resources from those around, leads to an individual becoming homeless. For others, there are many co-factors, or “strikes against them”–whether disability, difficulty with employment, mental illness or cognitive delay, or lack of education–which together contribute to a person losing stable housing over time. 

Why is mortality among homeless individuals higher? 

We know that mortality is higher among homeless individuals (Hwang 2009).  Per Hwang et al’s 2009 BMJ multi-center study, mortality ratios for drug-related deaths are estimated to be around 10 times those of age-matched cohorts, with increased mortality ratios from mental illness and suicide, as well as smoking-related disease, ischemic cardiac disease, and respiratory disease.  Even more shockingly in this study, the probability of survival to age 75 was only 32% among homeless men. 

We don’t know exactly why.  Specifically, we don’t know whether homelessness is a cause of increased mortality in and of itself or whether there are factors that predispose towards homelessness that are also risk factors for the development of disease. But rehousing people does not recreate health. The National Academy of Science, Engineering, and Medicine looked at whether housing creates health, and didn’t find compelling evidence to support this explicit hypothesis (NASEM Summary 2018; NASEM Primary Source).  That said, per Dr. Kertesz, it is hard to establish long-term effective healthcare without a home. It’s just not a simple cause-and-effect. 

Where to Start the Visit 

As with all patients, there are always many competing–and equally important–areas on which to focus the visit. A good way to frame the visit overall, after you’ve talked about where a particular person is staying. Begin with what matters most to the patient. Ask them, what’s your first concern? Address symptomatic problems first, to build trust and rapport, by focusing on the area of most concern to the patient. Then, in quick succession, focus in on their medication lists, and ask whether there are any they’re supposed to be taking that they’re not getting right now. This will allow you to quickly identify medications that are important to continue (e.g. anticoagulation or insulin. It’s also important to ask about substance use, and to be explicit that you plan to ask them about these, because it’s important for their health.  

A framing question: What are your plans? Where are you going, and what do you see as coming up? Are you on a path to somewhere you think is the next step for you?  What are your aspirations?  If you know what the patient’s goals are, you can pivot all your healthcare goals to that context 

Tips to Ensure Continuity 

1. Make sure you verify the patient’s telephone number and how to best contact them at EVERY visit. 
2. Bring your nurses and ancillary staff in to the visit to meet the patient. Link everyone as part of a team, so that the patient knows that he/she can call the nurses or the office if you are not reachable. 
3. Give patients a physical business card. They’re easy to keep on one’s person, and also represent a physical commitment to the patient. 
4. Maintain contacts with the social services web in your community, regularly, about individual patients,  so that if someone cannot be found, you know who to call.  

Clinical Pearls, by Condition

Hypertension

Always ask what medication a patient has been on before. If it was a well-tolerated medication, we tend to steer towards those medications we’ve already used. Stick with what works. Once-a-day medications work better for patients than twice daily. Beware of diuretics given inconsistent access to bathrooms. Avoid medications that require lab checks or regular access to bathrooms over the course of the day. This leaves Calcium Channel Blockers or Ace Inhibitors/ARBs, if you already have a baseline Creatinine, as good options. 

Diabetes and Food Insecurity 

Insulin: Insulin is often stored in the fridge, but newer formulations are actually ok being kept in relatively cool temperatures, even outside the fridge. Dr. Kertesz recommends that patients store their insulin in the part of their backpack that is not facing the sun. Many of the insulin pens can be stored at room temperature for approximately 1 month. (We recommend referring to the specific manufacturer’s storage instructions)”

Avoiding the highs and lows: Avoiding hyperglycemic diets, and also low sugars with inconsistent access to food, can be quite the challenge. Individuals living in shelters have very little control over their diet, and the diets provided are often high-carb. Obesity is prevalent (though vitamin deficiencies can also abound! See Dr. Kertesz’s 2001 case report about Pellagra in 2 Homeless Men).  Food access is also an issue, so run a higher A1c goal to avoid the risk of hypoglycemia.  

How to advise about diet: Ask the patient what they’re serving at the shelter. There will probably be carb-heavy options, so it’s important to probe about non-carb sides and such–and to suggest balancing their diet with more vegetables, proteins, so that the sugars don’t vary quite so widely. Also make sure you check in once patients are re-housed, since sometimes having one’s own fridge–and control of the grocery list–can cause rapid changes in diet, especially if folks live in food deserts and have access to less healthy food options in stores. 

Substance Use Disorder

Substance use is common among individuals experiencing homelessness. Opioid use disorder is quite well managed on buprenorphine, more easily than with methadone, which requires daily visits to a methadone clinic and can be complicated by transportation challenges. The long-acting injectable form of buprenorphine is useful, but availability and cost varies by state, so the sublingual or strip formulation may be better options. 

That said, survey data suggests that the most common addiction among individuals who are homeless is alcohol use (Stringfellow 2016). It is essential to discuss alcohol–use, history of withdrawal, and history of overdose–with your patients. We do have medications such as naltrexone that can help, but treating alcohol use disorder requires a multimodal approach. Remember, it’s all about harm reduction. 

“Ultimately I want to continue to care for someone who’s alive in their life. I may harbor a goal for them, and I may hope that I can see them achieve that abstinence. But at the end I want someone who’s alive. And it may be that if we reduce the number of hard liquor benders to one every 3 months from 1 a month, they will be better able to be alive.” –Dr. Kertesz 

Feet 

Patients experiencing homelessness are on their feet a lot. Moreover, they may be overweight or have other medical illnesses such as diabetes and limited access to hygiene resources that, together with long periods of time on foot and upright, create a perfect storm for foot infections and foot pain. Cross sectional samples of homeless individuals estimate that anywhere from 9-65% have chronic foot problems, whether calluses, corns, or nail infections (To, 2016).  Maintaining good footwear and foot care is therefore essential. 

Ways to mitigate this: Provide socks and shoes in your clinic, and insoles, if you can provide them. Provide access to showers and hygiene sites in clinic. Teach patients to do daily foot soaks (with or without acetyl salicylic acid topical formulations) and slow filing, over time, for those with chronic calluses. 

Always look: It is essential to do a foot exam on the patients you see. There is a lot of perceived stigmatization and judgment about smell and cleanliness among patients experiencing homelessness. So it is a gesture of humility, and can also guide medical care, to lower your head below a patient’s head to look at a patient’s feet. Of course, always ask permission to do so before you examine. 

The Liver: Hepatitis C and Cirrhosis  

Hep C: We can provide oral therapy for Hepatitis C to attain sustained viral remission with reasonable success (Barokas, 2018). It’s important to remind patients that reinfection is a possibility, even after cure. 

Cirrhosis: Managing cirrhosis is very challenging in the homeless population because of the intense diuretic regimen required. The best thing for the cirrhotic patient, per Dr. Kertesz, is to advocate for the patient to be rehoused as soon as possible on the basis of their medical illness, since it will be very difficult for the patient to maintain their health unless we find them housing. 

COVID-19

Shelters and congregate living situations are particularly vulnerable to outbreaks of COVID-19, especially given the likely prevalence of asymptomatic or pre-symptomatic carriers of the virus. When there has been a cluster in a particular city [Boston], universal testing of an adult homeless shelter  revealed 36% positivity of COVID (Baggett 2020). 

Furthermore, the public health advice regarding safety during the pandemic, including social distancing and self-quarantining of symptomatic individuals, poses unique challenges for homeless individuals without control over housing.  Check out the CDC’s interim guide on Homelessness and COVID-19 for the most up-to-date recommendations.

Care Models: What Works, and What doesn’t 

There are two variables worth considering, both the funding streams and the model of service. Regarding funding streams, one common resource is via Federally Qualified Health Center Homeless Grants, which are relatively small but theoretically enable these FQHCs to serve homeless individuals. This can be a great strength in particular if the FQHC also has medicaid resources (i.e. is in a medicaid expanded state). 

Regarding the service model, one appealing option is that of “tailored primary care,” in which decisions made by management focus on the unique needs of the population the clinic is serving. For clinics serving homeless individuals, that includes allowing for specific training, extra time for visits, shower, clothes closets, and social workers networked and linked to existing services in the community. Existing data on homeless services suggests better experiences (and better longitudinal relationships) with tailored care models, though data on outcomes is not yet available (Kertesz 2013).

Shelter-Embedded Clinics: Going to shelters means discovering patients who can’t get in the doors of clinics, even those with grant money to serve them. You can meet people in shelter-based clinics and then ease their way to a larger, more resourced environment. It can be particularly useful to phone the staff in larger clinics in advance, while the patient is with you, to show that you’re engaging in communication on the patient’s behalf. (Yet again, all about the relationship-building). 

What about Street Medicine, you ask? Street medicine is an up-and-coming approach in which health providers meet their patients where they’re at, outside of the clinic. Mostly anecdotal success with it, without robust evidence at this point (it would be hard to randomize and study this). But it seems like a useful model of care for some of our most vulnerable and most challenging patients, who are no longer welcome at shelters and who have been abandoned by most of society–to meet them where they’re at.  

For post-hospital care, look for homeless medical respite programs. These programs are for people too sick to return to the streets or to a busy shelter but who are too well to remain in acute-care hospitals.  There are more than 50 programs like this around the country (see the National Healthcare for the Homeless Council’s Site for resources). N.b. if you work in a community without one, consider starting one (especially if in a medicaid-expansion state).

Take Home Points 

1. Ask in specific terms how people are living and where they’re going. It’s essential to understand the details of where someone stays, where they store their stuff, and where they think they’ll be next week. 
2. Tailor your care to patients. Just ask the patient whether they think the treatment you’re thinking of would work. They will tell you if they don’t, for whatever logistical or other reason.  
3. The patients we take care of have a history of being poorly served both because individual clinicians have gotten angry and upset at their lack of engagement, and because these patients have observed that we are terrible at communicating with each other. There are two solutions to this. 

• • First, when we learn patient stories and take the time to genuinely get to know them, we will get far less angry and frustrated. 
  • Second, we can pick up the phone when the patient is with us, and have face to face discussions with their multiple providers. This mitigates communication failures by getting the team on the same page in the same moment, and by demonstrating to the patient that we’re focusing on the piece of the doctor patient relationship that so often is a challenge in healthcare, which can help to build trust.

Links*

1. Dr. Kertesz’s Book Recommendation: Saul Weiner’s On Becoming A Healer 
2. Nora’s Pick of the week: BackStory (especially their episode on dynamite!) https://www.backstoryradio.org/
3. HUD 2019 Sub-Populations Data: https://files.hudexchange.info/reports/published/CoC_PopSub_NatlTerrDC_2019.pdf
4. VA PIT Count: https://www.va.gov/HOMELESS/pit_count.asp 
5. 2019 AHAR Report to Congress: https://files.hudexchange.info/resources/documents/2019-AHAR-Part-1.pdf
6. Massachusetts Housing Resources: https://blog.mass.gov/blog/living-in-massachusetts/housing-resources-for-massachusetts-homeless/
7. Maness, 2014: https://www.aafp.org/afp/2014/0415/p634.html#afp20140415p634-b29
8. Tsai, 2014: https://www.sciencedirect.com/science/article/abs/pii/S0306460313000415
9. Gillis, 2010: https://pdfs.semanticscholar.org/7892/e9853815c90c1ab01e9367238b2e200c3a19.pdf
10. Vogel 2017: https://academic.oup.com/painmedicine/article/18/12/2280/2977712
11. Hamilton, 2011: https://www.sciencedirect.com/science/article/abs/pii/S1049386711000909
12. Kushel, 2003: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/216287
13. Hwang, 2009: https://pubmed.ncbi.nlm.nih.gov/19858533/?from_single_result=19858533&expanded_search_query=19858533
14. NASEM 2018 press release: https://www.nationalacademies.org/news/2018/07/permanent-supportive-housing-holds-potential-for-improving-health-of-people-experiencing-homelessness-but-further-research-on-effectiveness-is-needed-including-studies-on-housing-sensitive-health-conditions
15. NASEM report: https://www.nap.edu/read/25133/chapter/1
16. Kertesz, 2001: https://www.mayoclinicproceedings.org/article/S0025-6196(11)62894-2/fulltext
17. Stringfellow, 2016: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4999348/
18. To, 2016: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5147925/
19. Baggett, 2020: https://jamanetwork.com/journals/jama/fullarticle/2765378
20. CDC COVID Guidelines: https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/unsheltered-homelessness.html
21. Kertesz, 2013: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3969114/
22. NHCHC Respite Information: https://nhchc.org/clinical-practice/medical-respite-care/

Supplementary Reading: 

1. Weinreb 1998: Health Characteristics and Medical Service Use Patterns of Sheltered Homeless and Low-Income Housed Mothers
2. Liu 2020: Communicable Disease Among People Experiencing Homelessness in California
3. O’Toole 2015: Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial 
4. Klein 2015: Care for the Homeless Patient 

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra

Goal

Listeners will learn the unique health challenges posed to individuals who are experiencing homelessness, and the best practices for addressing these challenges. 

Learning objectives

After listening to this episode listeners will…

1. Screen for and identify patients experiencing homelessness
2. Identify the unique challenges facing this population 
3. Identify best practices in caring for this population
4. Differentiate between different structures of healthcare delivery, and their advantages and disadvantages for the homeless population. 

Disclosures

Dr. Kertesz reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

Kertesz S, Taranto NT, Williams PN, Brigham SK, Chan, Caroyn, Watto MF. “#216: Homeless Healthcare with Stefan Kertesz MD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. May 28,2020.