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Vulnerable Populations in Disaster: Caring for the Homeless CDR Al-Karim Dhanji M.D. USPHS Ready Responder, HRSA.

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Presentation on theme: "Vulnerable Populations in Disaster: Caring for the Homeless CDR Al-Karim Dhanji M.D. USPHS Ready Responder, HRSA."— Presentation transcript:

1 Vulnerable Populations in Disaster: Caring for the Homeless CDR Al-Karim Dhanji M.D. USPHS Ready Responder, HRSA

2 Disclaimer The contents of this presentation are solely the views of the author and do not necessarily represent the official view of HRSA, DHHS or Boston Health Care for the Homeless.

3 Overview The Homeless The Homeless Health Implications Health Implications The Challenges The Challenges Considerations for Care Considerations for Care Summary Summary

4 The Homeless Homeless people are the sum total of our dreams, policies, intentions, errors, omissions, cruelties, and kindnesses as a society. Peter Marin Sociologist

5 The US Homeless Estimated 2.3 to 3.5 million people 1 Estimated 2.3 to 3.5 million people 1 - 1% US population per year Men (77%) > Women (23%) 2 Men (77%) > Women (23%) 2 More than 760,000 people sleep on the streets or in shelters every night. 3 More than 760,000 people sleep on the streets or in shelters every night. 3 49% AA, 35% White, 13% Hispanic, 2% NA, 1% Asian 49% AA, 35% White, 13% Hispanic, 2% NA, 1% Asian 40% served in armed forces 40% served in armed forces 1 Urban Institute, US Conference of Mayors, Urban Institute, 2001

6 The US Homeless The Shelter Population: The Shelter Population: - 80% stay in shelter 1-2 nights - 10 % Episodic Users 3 weeks at a time; Young and Heavy Drug Users - 10% Chronically Homeless for years; Mentally Ill. Physically Disabled. The Stereotype

7 Health Implications First respite facility in Boston, Shattuck Hospital (picture from J. OConnell)

8 Health Implications Mortality is 3.5 times higher (NEJM, 1994) Mortality is 3.5 times higher (NEJM, 1994)Why Many problems present in advanced stages Many problems present in advanced stages Very little preventive care Very little preventive care Patient priorities are on food, shelter, clothing, safety, self-medication Patient priorities are on food, shelter, clothing, safety, self-medication Homelessness precludes good nutrition, good personal hygiene, basic first aid Homelessness precludes good nutrition, good personal hygiene, basic first aid

9 Health Implications Lifetime History 1 : Lifetime History 1 : - 62 % Alcohol Problems - 58% Drug Problems - 57% Mental Health Issues care Increase Risk Compared to Domiciled Populations 2 Increase Risk Compared to Domiciled Populations 2 - Asthma and COPD - DM, HTN, PVD - Chronic Renal and Liver Disease 1 Urban Institute Fleischman, et al.1992;Wright, 1990

10 Health Implications Hospitalization rate is 5 times higher (Hwang, CMAJ, 2001) Hospitalization rate is 5 times higher (Hwang, CMAJ, 2001) Average Age of Death in Boston 47 (Annals, 1997) vs Average National Mortality for white Male 74.5 (CDC/NCHS) Average Age of Death in Boston 47 (Annals, 1997) vs Average National Mortality for white Male 74.5 (CDC/NCHS)

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12 Health Challenges Homeless people may resist treatment or have difficulty with adherence particularly those with substance abuse and mental health disorders Homeless people may resist treatment or have difficulty with adherence particularly those with substance abuse and mental health disorders Medications are lost, stolen, diverted or abused; multi-dose regimens are especially challenging Medications are lost, stolen, diverted or abused; multi-dose regimens are especially challenging Many conditions very difficult to treat without adequate housing Many conditions very difficult to treat without adequate housing - TB, HIV, DM, HTN, addiction, mental illness

13 Health Challenges Problems secondary to exposure to the streets or outdoors: frostbite, immersion foot, hypo- and hyperthermia Problems secondary to exposure to the streets or outdoors: frostbite, immersion foot, hypo- and hyperthermia Problems secondary to exposure to the shelters: infestations, respiratory infections, TB, Problems secondary to exposure to the shelters: infestations, respiratory infections, TB, hepatitis A Greater risk of trauma resulting from muggings, rapes, beatings Greater risk of trauma resulting from muggings, rapes, beatings

14 1 Institutional Challenges: Disaster Paradigms 1 Traditional Mass Care – –Top Down Command - Injuries and Infections – –Survival of the Fittest – –Compliance Dependent – –Externally Supported 1 Jones, U. Albany, Grand Rounds Mokdad et al,Prev Chronic Disease Special Needs Care –Community Based –Internally Supported –Chronic Diseases 2 –Flexible –Support the Weakest Link –Longer Term Commitment

15 Institutional Challenges: The Provider 1 Our Unrealistic Expectations=Their Non Adherence: Understand their Issues 1 Personal vs Societal Responsibility 2 Practicing In Vertical Silos 2 1 National Health Care for the Homeless 2 Soskin, MPP Thesis JFK School- Harvard

16 Institutional Challenges: The Provider 1 Our Values and Judgements the Issue of Compassion 1 –Canadian Study Looking at Stable Homeless comparing usual care with usual care plus personal contact –Cut the rate of average return visits per month by about a third 2 If we tell them to, they will do it 2 –Inspiration? Action? Results? –Does information=Inspiration? Action? Results? 1 Redelmer, the Lancet, Redelmer, the Lancet, Jones, U. Albany, Grand Rounds Jones, U. Albany, Grand Rounds 2006

17 The team approach to care… The care of homeless people is so complex, that to put that burden on one person would be impossible. What is impossible in a traditional system is a joy in a system where the care is shared by the team. I cant imagine practicing as a physician without the whole team. I dont think I could do it, nor could I deliver good care. Jim OConnell, MD President, Boston Health Care for the Homeless Program

18 Organizational Considerations Balancing traditional with special care Community based approach: – –Build on pre-established local networks for care delivery – –Greater understanding of the needs of vulnerable clients – –Promote Cultural Competency – –Better access to Local Communities outreach to sites

19 Cultural Considerations Realize that there is a culture to be understood Using Person-Centered Values: – –Empowered and Educated to make choices – –Dignity and Respect our language – –Creating Hope to combat despair and helplessness Integrating into Therapeutic Relationship where relationship is valued as much as expertise Build the Trust

20 Clinical Considerations

21 Enquire about Medical Conditions: – –At risk for: Asthma, Anemia, DM, CVD,TB,HIV,STI – Alcohol Abuse, Opiates, HIV, Arrhythmias, Liver Disease, Frostbite, Renal disease, Hypothermia, Trench Foot 1 –At risk for Death: Alcohol Abuse, Opiates, HIV, Arrhythmias, Liver Disease, Frostbite, Renal disease, Hypothermia, Trench Foot 1 Normalize Discussion of Mental Health or Cognitive Deficits – 1 Hwang,, Archives 1998 –Feeling down, difficulty focusing, sleep issues, keeping track of things 1 Hwang,, Archives 1998

22 Clinical Considerations Alcohol/Drug Use: – –Engage the Patient What is good or not so good about using? – –At risk for detoxing Physical Examination – –Ask permission before each part of the exam – –Do you have their trust?

23 Homelessness and TB Homeless individual are at increased risk: malnutrition, substance abuse, living conditions/shelters Homeless individual are at increased risk: malnutrition, substance abuse, living conditions/shelters In 2002, Six percent of TB cases were Homeless in preceding twelve months in the US In 2002, Six percent of TB cases were Homeless in preceding twelve months in the US Always have a high index of suspicion Always have a high index of suspicion DOT may be beneficial for active disease DOT may be beneficial for active disease

24 Homelessness and Diabetes Most have limited control over their diet Most have limited control over their diet - shelter food tends to be high fat, salt, sugar Liver dysfunction is common in those living outside which affects med choice/regimen Liver dysfunction is common in those living outside which affects med choice/regimen Avoid hypoglycemia Harm Reduction Avoid hypoglycemia Harm Reduction If using insulin, have a plan for how someone will give it to self, store it If using insulin, have a plan for how someone will give it to self, store it - consider using Lantus, once-daily dosing Ask about potential SE and how pt will deal with it (e.g. diarrhea and metformin) Ask about potential SE and how pt will deal with it (e.g. diarrhea and metformin)

25 Homelessness and Dermatological Problems Diseases: Venous Stasis Venous Stasis Cellulitis and Ulcers Cellulitis and Ulcers Immersion/Trench Foot Immersion/Trench Foot Infestations InfestationsCauses: Chronically on their feet Chronically on their feet Ill-fitting shoes/clothes Ill-fitting shoes/clothes Wet and cold Conditions Wet and cold Conditions Poor Hygiene Poor Hygiene Use of infested blankets/clothes Use of infested blankets/clothes

26 Venous Stasis -Predisposes patients to ulcers and cellulitis -Interferes with patients ability to ambulate during the day -Treatment difficulties include lack of BR if give diuretics Photo from J. OConnell

27 Cellulitis and Ulcers Can be complication of venous stasis Can be complication of venous stasis Predisposing factors: tinea, onychomycosis, calluses, immersion foot, inadequate shoes, wet conditions Predisposing factors: tinea, onychomycosis, calluses, immersion foot, inadequate shoes, wet conditions Ulcers common even without co-morbid conditions, like PVD or DM Ulcers common even without co-morbid conditions, like PVD or DM Photo from M. Bharel

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29 Immersion Foot AKA Trench Foot b/c it was common among soldiers in WWI who stood in water-logged trenches for long periods at a time. AKA Trench Foot b/c it was common among soldiers in WWI who stood in water-logged trenches for long periods at a time. Occurs when feet are subjected to cold and wet conditions for prolonged periods of time, without freezing of tissue. Occurs when feet are subjected to cold and wet conditions for prolonged periods of time, without freezing of tissue. Conditions create damage to skin, nerves and muscle. Conditions create damage to skin, nerves and muscle. Contributing factors: malnutrition, PVD, improper clothing, wind, inactivity. Contributing factors: malnutrition, PVD, improper clothing, wind, inactivity.

30 Immersion Foot Symptoms: Symptoms: Initially – tingling, numbness, itching, pain. Signs: edema, pale, clammy, macerated skin Initially – tingling, numbness, itching, pain. Signs: edema, pale, clammy, macerated skin Late – anesthesia to touch, walking on blocks of wood Late – anesthesia to touch, walking on blocks of wood Re-warming – burning or throbbing pain, swelling Re-warming – burning or throbbing pain, swelling Can have symptoms of hypersensitivity, sweat gland dysfunction, and pain for months to permanently Can have symptoms of hypersensitivity, sweat gland dysfunction, and pain for months to permanently Can be complicated by infection Can be complicated by infection

31 Immersion Foot Treatment: Dry feet, Dry socks, Dry Shoes Dry feet, Dry socks, Dry Shoes Slow re-warming Slow re-warming Avoid weight-bearing or trauma Avoid weight-bearing or trauma Prophylactic topical or oral antibiotics, antifungals Prophylactic topical or oral antibiotics, antifungals Treat pain Treat pain

32 Immersion Foot

33 Lice

34 Lice Homeless People Suffer Infestations Three times general adult population 1 Homeless People Suffer Infestations Three times general adult population 1 Pediculus humanus – head lice (corporis) and body lice (capitis) Pediculus humanus – head lice (corporis) and body lice (capitis) Serve as vectors for other infectious diseases like epidemic typhus, trench fever and relapsing fever Serve as vectors for other infectious diseases like epidemic typhus, trench fever and relapsing fever 1 Healing Hands Newsletter, Feb 2005

35 Scabies Pimple-like irritations, burrows or rash of the skin, especially in skin folds or webbing between the skin (i.e. fingers) Pimple-like irritations, burrows or rash of the skin, especially in skin folds or webbing between the skin (i.e. fingers) Intense itching Intense itching Sores on body caused by scratching Sores on body caused by scratching Acquired by direct, prolonged, skin-to-skin contact Acquired by direct, prolonged, skin-to-skin contact Symptoms may take 4-6 wks if never had scabies before. If exposed in past, may take just a few days Symptoms may take 4-6 wks if never had scabies before. If exposed in past, may take just a few days Symptoms may persist for 2-3 wks after treatment Symptoms may persist for 2-3 wks after treatment

36 Scabies Diffuse the Shame!

37 In Conclusion Be aware of the risk homelessness itself imparts on a patients overall health and risk of death Be aware of the risk homelessness itself imparts on a patients overall health and risk of death There is a cultural competency centered around compassion, hope and relationship There is a cultural competency centered around compassion, hope and relationship Appreciate the challenging congruence of medical conditions in this vulnerable population Appreciate the challenging congruence of medical conditions in this vulnerable population

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