Homelessness isn’t a disease, but it can kill. The prevalence of illness in homeless persons is as high as 55%. What’s more, the homeless are three to six times more likely to die than their housed counterparts, and their life expectancy is just 44 years on average, compared to 78 years for the general U.S. population.

The homeless experience higher rates of chronic disease than the general U.S.
population. Most homeless adults have at least one chronic disease and with age, the risk of chronic disease rises. Up to 29% have hypertension, compared to 16.5% of the general population.

The homeless are more likely to have mental health problems; up to 37% report
depression, compared to up to 10% of the general adult population. As many as 84% of homeless men and 58% of homeless women have alcohol problems, compared to just 8% in the general population.

Many homeless people become “frequent flyers” at hospitals, especially during the month before death. Providing safe care to homeless persons with a chronic disease is complicated by their high risk for comorbid conditions and lack of resources to help manage their disease after discharge.

Hospital hopping?

Some nurses feel powerless when providing care for the homeless. They believe they may be hindering rather than helping them, because many homeless patients are readmitted often and have trouble following through on discharge instructions. In a 2005 article, one author stated that the homeless “hospital hop” to obtain shelter and food.

But this may not be the case. Researchers have found that when healthcare givers spend time talking with homeless patients and hearing about their lives, patient satisfaction improves and repeat hospital visits decrease. By providing compassionate care for homeless patients and using specific strategies for their assessment and discharge planning, nurses can help homeless adults manage their chronic diseases and prevent early death.

Assessing a homeless patient

During assessment, allow time for the patient to answer your questions. Provide simple explanations and summarize the information you’ve given to help the patient understand it. Give the patient ample time to tell you about his or her situation. Elicit information about the patient’s perception of the illness. (See Eliciting the patient’s perception of illness by clicking on the PDF icon above.)

Tailor your questions to the patient’s housing and behavioral situation, physical health, and access to healthcare resources. Use simple, open-ended questions that will help you understand the patient’s unique context. (See Assessing the patient’s living situation and healthcare resources by clicking on the PDF icon above.)

Homeless adults have limited access to dental care, bathing facilities, and food, so during the physical examination, pay special attention to the patient’s teeth, skin, and feet. Check for signs and symptoms of malnutrition and infectious diseases. Other potential problems in homeless patients include hypothermia in the winter and dehydration in the summer.

Discharge planning

The Joint Commission mandates that all patients receive a safe discharge from a healthcare facility. But homelessness poses challenges to discharge planning, as the nurse must weigh the benefits and risks of recommended treatment.

For instance, if discharge planning includes prescription medication, the patient may not have resources to obtain, store, and safeguard the medication or manage side effects. Say, for example, the patient has been placed on insulin based on the diet received during hospitalization. Will the same insulin dosage be adequate on discharge? Few homeless people have the means to monitor their blood glucose levels. If they have poor access to food, maintaining the same insulin dosage may put them at increased risk for insulin shock.

The key to a successful discharge plan is to build a trusting relationship with the patient so you can develop a plan that fits within the reality of his or her daily life. Using a compassionate approach helps build trust.

Case study

Joe Seally, age 52, is an African-American who weighs 250 lb. He is admitted to the med-surg unit for observation after presenting to the emergency department (ED) with dizziness, confusion, visual disturbances, frequent headaches, and (most recently) nausea and vomiting. His admitting blood pressure is 210/110 mm Hg. The physician starts him on a diuretic and a beta blocker.

Based on information obtained from ED workers, the med-surg nurse suspects Mr. Seally may not have a regular place to live. She begins the assessment by asking if he’s homeless. He responds, “No.” When she follows up with, “Where did you sleep last night?”, he replies, “In a car.” To make sure she has the full picture, she asks, “Where do you usually sleep?” She learns he usually sleeps in an abandoned car, which he considers to be his home. During the behavioral assessment, she screens for substance use disorders and depression using commonly available tools. (See Useful screening tools by clicking on the PDF icon above.)

Physical assessment reveals Mr. Seally has a bad case of athlete’s foot and
significant tooth loss. He admits he gets most of his food by rummaging through
dumpsters behind restaurants. (The soup kitchen nearest to the car where he sleeps is too far away and he usually doesn’t feel up to the long walk.) When the nurse screens him for alcohol or drug use and depression, the results are negative.

The nurse realizes that the usual discharge instructions on diet, exercise, and medications for hypertensive patients won’t be practical for Mr. Seally. He says he has no health insurance and no idea where to obtain medications, health supplies, or primary care. And because he lives in an abandoned car, the diuretic he’s been prescribed poses a unique problem: The frequent urination it causes could cause him to be arrested if he urinates in a public place.

The discharge plan also must address other issues: With his food coming mainly from restaurant leftovers, can he maintain a low-sodium diet? Is he at risk for potassium depletion?

The nurse works with Mr. Seally, the physician, and the social worker to
develop a discharge plan that takes into account his unique situation. The social worker finds a temporary shelter that provides access to public restrooms and a soup kitchen. She contacts the soup kitchen to find out about the usual menu, and shares this information with the patient, nurse, and nutritionist to aid dietary planning. Mr. Seally is referred to a free clinic for routine foot care and blood pressure checks, as well as an agency that can help him obtain medications and dental care.

The compassionate approach taken by Mr. Seally’s nurse set the stage for a trusting relationship. Initial assessment provided the essential information on which to base a customized discharge plan. The nurse and other healthcare team members gave him hope and the tools he needs to manage his hypertension, decrease his need for readmission, and improve his ability to manage his hypertension after discharge.

Selected references

Denkens BA. Are we really helping? The problem of dual diagnoses, homelessness & hospital-hopping. J Pyschosoc Nurs Ment Health Serv. 2005;43(11):48-50.

Hahn JA, Kushel MB, Bangsberg DR, Riley E, Moss AR. Brief report: the aging of the homeless population: fourteen-year trends. J Gen Intern Med. 2006;21(7):775-778.

Hwang SW, O’Connell JJ, Lebow JM, Bierer MF, Orav EJ, Brennan TA. Health care
utilization among adults prior to death. J Health Care Poor Underserved.
2001;12(1):50-58.

Rankin SH, Stallings KD, London F. Patient Education in Health and Illness.
Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

Redelmeier DA, Molin J, Tibshirani RJ. A randomized trial of compassionate care for the homeless in an emergency department. Lancet. 1995;345(8958):1131-1134.

Christine Savage is a Professor at the University of Cincinnati College of Nursing in Cincinnati, Ohio and holds a secondary faculty appointment in the Department of Public Health Sciences at the University of Cincinnati College of Medicine. Roberta L. Lee is Assistant Professor of Clinical Nursing at the University of Cincinnati College of Nursing. Dr. Savage and Ms. Lee have worked together as coinvestigators in funded research for the homeless.