Clinical Management of the Homeless Patient : Social, Psychiatric, and Medical Issues

This volume highlights the socioeconomic concerns related to medical care for homeless patients and places them at the interface of common psychiatric and medical problems clinicians encounter. Written by experts in psychiatry and other medical specialties, this volume is a concise, yet comprehensive overview of the homeless crisis, its costs, and ultimately, best practices for improved outcomes. The text begins by examining the scope and epidemiology of the problem and discusses its costs. It then examines the best practices for both physical and psychiatric care before concluding with a section on working with special populations that have unique concerns across the country including LGBTQ, women, children, veterans, and aging adults. As the first medical book on homelessness, it is designed to cover a broad range of concerns in a concise, practical fashion for all clinicians working with homeless patients. Clinical Management of the Homeless Patient is written by and for psychiatrists, general internists, geriatricians, pediatricians, addiction medicine physicians, VA physicians, and all others who may encounter this crisis in their work. Preface References Contents Contributors Part I: The Big Picture—Social and Medical Issues Chapter 1: Framing the Issue: An Introduction Introduction Background Chapter 2: Frontline Work Taking Care of Homeless Veterans Mr. P Mr. D Mr. R Mr. M and Mr. O The Shelters Mrs. S Mr. L Mr. V Unhoused The Strength of Community Chapter 3: Medical Care for Homeless Persons Background General Strategies Diabetes Mellitus Hypertension Cardiovascular Disease (CVD) Smoking Cessation HIV and Sexually Transmitted Illnesses Hepatitis B and C Vaccines Tuberculosis Skin Diseases Cold Weather Injury Osteoarthritis Pharmacological Treatment Considerations Use of Assistive Devices Conclusion References Chapter 4: Chronic Pain Management in the Homeless Population Introduction The Pathophysiology of Pain Special Populations Chronic Pain and Mental Health Chronic Pain and Substance Use Disorder Chronic Pain in the Veteran Population General Approach to the Diagnosis of Chronic Pain Pain Assessment Physical Exam Mental Health Assessment Treatment of Chronic Pain Pharmacological Approach Opioids Opioid-Associated Morbidity and Mortality Opioid Screening Opioid Side Effects Central Nervous System Neuroendocrine Effects Gastrointestinal (GI) System Cardiovascular System Others Special Situations When Prescribing Opioids Distinguishing Between Medication Tolerance, Physical Dependence, and Opioid Use Disorder (OUD) and Pseudoaddiction Cannabinoids and Pain Conclusion References Chapter 5: Comprehensive Management of the Lower Extremity in the Homeless Patient Introduction Hyperkeratosis Onychocryptosis/Retronychia Tinea Pedis/Dermatophytosis Bacterial Infections of the Lower Extremity Erythrasma Cellulitis Gas Gangrene Puncture Wounds/Foreign Bodies Osteomyelitis Common Foot Disorders Bunion Deformity Hammertoe Deformities Plantar Fasciitis Trauma/Burns Peripheral Neuropathy and Ulceration Frostbite Gout Treatment, Prognosis, and Prevention Footwear Transportation Lack of Insurance Follow-Up Challenges Discussion References Chapter 6: Reproductive and Other Related Health Concerns Among Women Experiencing Homelessness Background: Women and Homelessness Risk Factors Associated with Homelessness Among Women Pregnant Women and Homelessness Obstetric and Neonatal Complications Among Homeless Women Gynecologic Conditions Gender-Specific Cancer Screening Gender-Specific Cancers Strategies to Address Gender-Specific Cancers Infectious Diseases Strategies to Address Infectious Diseases Strategies, Resources, and Opportunities for Advocacy Conclusion References Chapter 7: Clinical Management of the Homeless Patient with Traumatic Brain Injury and Cognitive Impairment Traumatic Brain Injury Introduction Definition Epidemiology Pathophysiology Acute Management Cognitive Impairment Introduction Late Seizures Substance Abuse Depression Sleep Disorders Headaches Treatment of Cognitive Impairment Summary References Chapter 8: I’m Old and on the Street: How Did this Happen and Now What Do I Do? Introduction How Homelessness Occurs Among Seniors: Chronic Recurrent Versus Onset In Later Life Dimensions of Homelessness Among Older Adults Social Dimensions of Homelessness Predisposing Vulnerabilities: Poverty and Social Isolation Structural Factor: Lack of Affordable Housing Lack of a Safety Net Physical Dimensions of Homelessness Psychological Dimensions of Homelessness Treatment Implications: Geriatric-Specific Models of Housing and Care Long-Term Care End-of-Life Care: Advanced Care Planning Conclusion References Chapter 9: Hospital Discharge Challenges of the Homeless Patient Introduction Specific Issues for Discharging the Homeless Mental Health and Substance Abuse Solutions Education Entrance to Lower Level Facilities Additional Resources Automatic Mental Health Referral Recuperative Beds Transportation Conclusion References Part II: Psychiatric Issues and Treatment Chapter 10: Why Persons with Serious Mental Illness End Up Homeless Introduction American Deinstitutionalization: Impact on Homeless and SMI Prevalence of Serious Mental Illness (SMI) among Homeless Stigma, Vulnerabilities, and Barriers to Care Stigma Unique Vulnerabilities of Homeless Persons with SMI Barriers to Care Models of Care and Outcomes Housing First Enhanced Permanent Supportive Housing Mental Health Models of Care Conclusion References Chapter 11: Nonadherence and Mental Health Treatment in Homeless Populations Introduction Risk Factors for Nonadherence Barriers to Adherence Provider Attitudes and Behaviors Patient Attitudes and Behaviors Treatment Setting Limitations The Consequences of Nonadherence Impact on Patients Impact on Healthcare Systems Strategies to Improve Adherence Provider Practices and Attitudes Patient Attitudes and Practices Treatment Setting Factors Conclusion References Chapter 12: Homelessness and Substance Use Disorders Introduction Prevalence of Substance Use and Abuse Among Homeless Outcomes Associated with Homelessness and SUD Two-Way Relationship Between SUD and Homelessness Comorbid Psychiatric Disorders in Homelessness and SUD Treatment Considerations The Chronic Care Model Outreach Screening and Assessment of SUD Behavioral Interventions Medications for Substance Use Disorders Settings of Care Conclusion References Chapter 13: Management of Homeless Suicidal and Aggressive Patients in the ED Background Factors to Consider for Admission to the Psychiatric Ward Composite Case Examples Conclusion References Suggested Readings Readings for Frequent ED Utilization and Malingering Readings for Concepts of Compassion Fatigue Readings for Assaults in ED and how to De-Escalate Patients and Enhance Safety Chapter 14: Clinical Management of Homeless LGBTQ+ Patients: Overcoming a History of Discrimination and Invisibility and Improving Care Through Education, Training, and Advocacy Introduction Prevalence and Risk Factors for Homelessness Among LGBTQ+ Individuals Prevalence of Homelessness Among LGBTQ+ People Risk Factors for Homelessness Among LGBTQ+ Communities Systemic Approaches to Addressing Homelessness Within LGBTQ+ Communities National Efforts and Interventions Systematic Approaches on a Regional and Local Level Increased Funding More Homeless Shelters Welcoming of LGBTQ+ Individuals Improved Preparation for Life After Foster Care Education and Training Efforts Homeless Shelter Staff Members, First Responders and Healthcare Providers Education for Family Members, Faith Leaders, and Educators Homeless Communities Clinical Approaches Assessing Sexual and Gender Identities Distinguishing Identity from Behavior Promoting an Affirming Environment Intersectional Approaches to Cultural Responsiveness Patient-Centered and Trauma-Informed Care Integrated Psychosocial Assessments: A Harm Reduction Approach Transgender-Specific Care and Resources Summary References Chapter 15: Ethnicity, Mental Illness, and Homelessness Demographics African Americans Latino Americans Asian Americans American Indians/Alaskan Natives Precipitating/Perpetuating Factors Socioeconomic Factors Criminal Justice History Racial Discrimination Substance Use Disorders Barriers to Culturally Informed Mental Healthcare Strategies to Improve Culturally Sensitive Mental Health Care Healthcare Providers Homeless Individuals Limitations References Part III: Other Issues Chapter 16: Sex Trafficking Introduction The Problem Statistics Advances in Legislation Advocacy Victimization Risk Factors Identifying the Victim Victims’ Characteristics Perpetrators’ Characteristics Challenges in Engaging the Victim Health Effects and Healthcare Community Reintegration Barriers and Proposed Solutions Conclusion References Chapter 17: More Than Hunger: Nutrition and Food Issues Introduction Review of Social Determinants of Health Defining Food Insecurity Quantifying Food Insecurity Prevention and Nutrition Screening Nutrition Care Process Nutrition Diagnosis Nutrition Interventions Nutrition Monitoring/Evaluation Discharge Planning Resources and Social Interventions Interdisciplinary Teamwork and Summary References Chapter 18: Efforts to Reduce Justice Reinvolvement: Jail Diversion, Justice Outreach, and Justice Reentry Introduction Background/Discussion of Problem Important Definitions Statistics Incarceration By the Numbers Mortality in Corrections Costs Standards of Care in Correctional Facilities Diversion Programs Law Enforcement Training Specialized Courts Reentry Outreach Programs Sequential Intercept The Future Conclusion References Part IV: Best Practices Chapter 19: Housing First Introduction Homelessness: A National Issue What Does It Mean to Be “Homeless”? Who Are the Homeless? Viewpoints on the Causes of Homelessness Lack of Affordable Housing Low or Unstable Income and Poverty Health, Mental Health, and Substance Use Disorder Domestic Violence Homeless Assistance Approaches Permanent Supportive Housing Housing First Implementing Housing First in the Department of Veterans Affairs (VA) Conclusion References Chapter 20: VA Clinical Services: The Key to Achieving Stability and Sustainment for Homeless Veterans Introduction Services for Homeless Veterans Are a Core Component of the VA Healthcare System Housing First Model Outreach Programs Justice-Involved Veterans Biopsychosocial Services Homeless Patient-Aligned Care Teams (H-PACT) Residential Rehabilitation Treatment Programs (RRTP) Mental Health Treatment for Homeless Veterans Evidence-Based Psychotherapies Suicide Prevention Suicide Prevention Teams Veterans Crisis Line Vocational Services Compensated Work Therapy Compensated Work Therapy-Transitional Work (CWT-TW) CWT-Supported Employment (CWT-SE) Compensated Work Therapy-Transitional Residence (CWT-TR) Homeless Veterans Community Employment Services (HVCES) Summary References Chapter 21: Medical Respite for the Homeless: Moving from the Present to the Future Introduction What Post-Hospital Care of Previously Homeless Individuals Has Looked Like in Most Big Cities Until Recently Why the Status Quo Is Now Ethically Unacceptable How Medical Respite for Those Previously Experiencing Homelessness Can Be a Win-Win for Patients and Hospitals Alike Moving from the Present to the Future Conclusion: Next Steps References Index