Skip to main content

Appearances can be deceiving: aging, homelessness, and acute care

 

Before reading any further, stop to think about the last older homeless adult you saw. If you are a clinician – think of the last older homeless patient you cared for – if you can remember the last time you had such an encounter in acute care settings such as the ED or hospital, even better.

Does this person you remember look anything like the gentleman pictured here?

Probably not...

...but here’s the catch: the odds are very good that you've met someone (maybe even provided clinical care for someone) who was without a home but you didn't know it because they didn't “look homeless.” In a study published this month in the Journal of Healthcare for the Poor and Underserved (JHCPU), my colleagues and I described the experience of acute care from the perspective of 100 homeless individuals seen in the ED or hospitalized over a 1 year period in New Haven, CT. We found that only 2 in 5 were ever asked about their housing status during the course of their care at the hospital. Not surprisingly, those who were asked were several times more likely to receive high-quality discharge planning based on their needs (e.g. discussions about costs of medications and transportation). Compounding the problem of using the “eyeball test” to determine who has unstable housing, many patients are hesitant to disclose their need for fear of discriminatory care or simply from embarrassment – this may be particularly true for older adults.

Our results were the result of a community-based participatory research project with Yale-New Haven Hospital and Columbus House, a robust homeless services organization that operates 2 large shelters in New Haven. Leveraging the strengths of this unique partnership, we also found that lack of coordination between the hospital and shelter was a major barrier to successful transitions for patients. As one patient explained, “miscommunication is a problem – sometimes the hospital sends you to the shelter, but you can’t get in.” Indeed almost 1 in 3 patients were discharged after dark and 1 in 10 spent their first night after discharge on the streets. Fortunately, data from this project led to a community taskforce including the hospital, shelter, city and state government to develop a respite care unit within the shelter for homeless patients requiring special care after discharge (such as daily wound care or IV antibiotics). A bill supporting this project passed the Connecticut State Legislature in Month and the respite unit will open this fall.

Many cities like New Haven are joining the movement to increase access for homeless patients to respite care after hospitalization both for reasons of quality improvement and cost reduction. In a systematic review also published this month in JHCPU by Kelly Doran, current Robert Wood Johnson Foundation Clinical Scholar at Yale and leader in the New Haven Respite Taskforce, shows that respite programs consistently reduce the length of hospital stays, hospital readmissions, and overall costs of care for homeless adults.  Despite these encouraging results, there is still work to be done. Although the mean ages of patients enrolled in the 13 studies analyzed in this review were in the mid-to-late 40s, there were no respite studies with resources specifically geared for older homeless adults.

As the homeless population continues to age, improving the quality and continuity of care for homeless adults is becoming ever more important. As my colleague Rebecca Brown points out in a study published this week in JAMA Internal Medicine, the average age of homelessness has increased from 35 to 50 over the last 20 years and older homeless adults access acute care services at extraordinarily high rates. In a cohort of 250 older homeless adults in Boston, 2 in 3 visited the ED in the last year and almost 1 in 3 visited the ED 4 or more times. The presence of geriatric syndromes such as falls and impaired executive function were powerful predictors of frequent ED use. In another study published this month in JHCPU, she also demonstrates that even the “younger” adults in this “over 50” cohort are at high risk for these geriatric syndromes.

These findings have important and unfortunate implications for these patients as well as our healthcare system – an ED clinician looking at a 55 year old man with an injury or musculoskeletal complaint might not think to ask if he is homeless and might not consider the patient’s risk for geriatric syndromes. In medicine, appearances may be deceiving but this shouldn't prevent clinicians from making a difference for this population. Patients in our community-based study recommended that clinicians take a simple, patient-centered approach to assessing housing needs: rather than ask patients who “look homeless” the usual, pointed questions of “are you homeless?” or “do you have a permanent address?” acute care providers can simply and compassionately ask all their patients, “do you have a place to stay where you feel safe?”  Personally speaking, I probably would never have guessed the gentleman pictured above – a former client at Columbus House shelter in New Haven – was homeless if I had met him in a busy Emergency Room. To provide the best possible care for this highly vulnerable population of seniors, our first and perhaps greatest challenge might just be to look past our preconceived notions to learn who these patients are.

By Ryan Greysen

Photo by Robert Lisak for Columbus House, Inc.
 

Comments

kelechukwu said…
patient is a virtue.

Popular posts from this blog

Practical Advice for the End of Life: A Podcast with BJ Miller

This week we talk with BJ Miller, hospice and palliative care physician, public speaker, and now author with Shoshana Berger of the book "A Beginner's Guide to the End."

As we note on the podcast, BJ is about as close as we get to a celebrity in Hospice and Palliative Care.  His TED Talk "What Really Matters at the End of Life" has been viewed more than 9 million times.  As we discuss on the Podcast, this has changed BJ's life, and he spends most of his working time engaged in public speaking, being the public "face" of the hospice and palliative care movement.

The book he and Berger wrote is filled to the brim with practical advice.  I mean, nuts and bolts practical advice.  Things like:
How to clean out not only your emotional house but your physical house (turns out there are services for that!)Posting about your illness on social media (should you post to Facebook)What is the difference between a funeral home and mortuaryCan I afford to die?  …

Improving Advance Care Planning for Latinos with Cancer: A Podcast with Fischer and Fink

In this week's GeriPal podcast we talk with Stacy Fischer, MD and Regina Fink, RN, PhD, both from the University of Colorado, about a lay health navigator intervention to improve advance care planning with Latinos with advanced cancer.  The issue of lay health navigators raises several issues that we discuss, including:
What is a lay health navigator?What do they do?  How are they trained?What do lay health navigators offer that specialized palliative care doesn't?  Are they replacing us?What makes the health navigator intervention particularly appropriate for Latinos and rural individuals?  For advance care planning? Eric and I had fun singing in French (yes French, not Spanish, listen to the podcast to learn why).
Enjoy! -@AlexSmithMD




You can also find us onYoutube!



Listen to GeriPal Podcasts on:
iTunes Google Play MusicSoundcloudStitcher

Transcript

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, I'm really excited about toda…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …