Caring for Vulnerable Patient Populations with Limited Resources

Authors: Victoria Palmer-Smith, MD and Haig Setrakian, MD (Assistant Professors of Clinical Emergency Medicine, Indiana University School of Medicine Department of Emergency Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Stephen Alerhand, MD (@SAlerhand)

Introduction

Emergency medicine providers treat patients living under difficult circumstances every day. Patients with limited resources use the ED for emergent and non-emergent conditions because ED’s are always open, reside on a bus route, can be accessed via EMS, do not require health insurance or payment up front, and have resources that free-standing clinics may not. Failure to recognize these circumstances can lead to missed diagnoses, worsening of a patient’s condition, and failure to follow up. For the provider, meanwhile, these issues can prompt bias, dissatisfaction, and burnout. For the health care system it means repeat visits, late diagnoses, and increased costs of care.

It is thus imperative for patient, provider, and population alike to understand the complexity of these cases and address more than just the medical issues at hand. In some cases, it may even make sense to prioritize intervention for social needs over medical therapy. Addressing a patient’s homelessness, for instance, over their more chronic medical concerns, may result in better health outcomes for the patient and lower overall costs for the healthcare system [1]. Limited resources have yet to be published with regard to this topic, providing guidance and a systematic approach to this population. Here, we will discuss individual provider and department/hospital-level recommendations.

Case

Taylor is a twenty year-old transgender patient who presents to the ED after an episode of syncope on a city bus. She is hypotensive, hypovolemic, and reports having had episodes of bloody stools intermittently for months with crampy abdominal pain and weight loss. She has been seen at a local clinic and scheduled for a colonoscopy, but has missed the procedure date twice. She has presented to your ED twice this week, each time leaving before completing the visit in order to get home before dark. She did not share at previous visits that she is not housed. Having been rejected by her family, she fled on a bus and has prostituted for housing and food. She is living in a tent city, the only running water being 2 miles away. Her last meal was two days ago at a local church.

Who is at risk?

The general appearance of your patient may offer clues to their limited resources such as worn-out clothing or shoes, limited personal hygiene, or too many belongings accompanying them. However, many opportunities to intervene will go unchecked if you are looking only for the proverbial “bag-lady” as our case illustrates. Anyone without permanent housing is at risk, including the sheltered and those living as a guest [2]. Prisoner patients and arrestees, the elderly, disabled, developmentally or behaviorally challenged, new immigrants, children in the foster community or who have had to be taken in, and transgender and gender non-conforming patients all face personal hardships and societal barriers that may limit their access to sufficient nutrition, hydration and utilities, placing them in danger and prohibiting them from accessing health care and obtaining supplies and medications.

Case Continued…

The patient had presented to several medical venues, but had not felt comfortable disclosing her living situation, nor her lack of very basic daily amenities. She had coped with bloody diarrhea living in a wooded area. She had been unable to secure a safe and clean environment in which to perform a bowel prep and thus had to forgo her colonoscopy.

What could have been done differently at previous visits? How do we avoid missing this type of vital information? The following suggestions allow the patient to tell their own story and give insight into their daily lives. Through the technique “enhanced history taking”, coined by Bonin et al [3], a provider can identify non-medical factors that greatly influence the patient’s presentation.

PROVIDER APPROACH

-Assume nothing.
-Determine your patient’s level of understanding and reasoning.
-Treat all patients as if they were a relative of your best friend.
-Find a topic on which you can relate and digress a little from strictly business.
-Employ humor where appropriate and complement their achievements.
-Every patient can teach you something and enhance your understanding of their circumstances.

THE INTERVIEW

-Tell me about your current living situation…
-How do you get by?
-Walk me through a typical day for you.
-What are your big worries each day?

HIDDEN ELEMENTS OF A PATIENT HISTORY

-Level of education
-Developmental and cognitive limitations
-Shelter and food insecurity
-Financial insecurity
-Mental Illness
-History of abuse
-Social support and transport limitations
-Criminal history

Furthermore, the efforts of individual providers are enhanced when their department implements a systematic approach to screening for unmet social needs. In a paper published by Gordon et al in 1999, a system of social triage was described that would provide a structured framework for identifying pressing social needs. This could be as simple as asking additional questions about housing status, food availability, etc… on the existing triage/assessment form, or could be as elaborate as a trained student / volunteer / social services professional to make referrals to existing community resources [4].

It is necessary to understand such hardships and priorities when considering a differential diagnosis and formulating a plan. Consider that your patient’s access to shelter, nutrition, hydration, and a place to recover and perform self-care may be limited. Their situation may place them at higher risk for injury, abuse, communicable disease, and complications of medical conditions. They may lack social support, and their activities of daily life may be criminalized as they occur in public places or on another’s private property.

DIFFERENTIAL DIAGNOSIS

-Include diseases of malnutrition and poor sanitation
-Consider diseases of exposure to the elements and communicable infections
-Screen for cognitive insufficiency, mental health disparities and substance abuse
-Inquire about homeopathic and cultural treatments

Once a differential diagnosis and or list of conditions and issues has been compiled, it is time to share this and discuss with the patient how the treatment will fit into their daily life. Determining their short and long-term goals is an important step at the onset of the discussion so that these can be prioritized. Some compromise will likely be necessary.

TREATMENT PLAN

-Agree on a list of priorities that are achievable and a timeline
-Include basic needs and services
-Discuss diet and hydration requirements
-Educate about the course of the condition, communicability & prognosis
-Discuss symptoms of complications and how to respond
-Outline clinic and emergent access
-Use the fewest pharmaceuticals that can be effective at the lowest cost
-Put plan into simple steps
-Provide supplies and a summary
-Engage support

The EM provider is limited to the resources of their department, and many of the needs of these patients outstrip routine daily medical transactions. To optimize their visit, it is essential to engage additional support such as social work, chaplainry services, and financial counseling. Community support groups that are population or disease specific may be available in person, by phone, or online. Consider involving psychiatric care when appropriate. These other providers have the potential to discover facets of patient’s lives that can impact a work up and plan and they may have more time to explore them at the ED visit than the EM provider.

Essential to the entire ED course is good documentation that communicates the patient’s needs, limitations, problem list, and treatment plan to other providers. This can be done in an electronic medical record and by phone, but also consider giving a copy to the patient themselves. Their ability to keep track of their history may be limited by cognition, sleep deprivation, and complexity and interruption of care.

All or some of this may be very effective, but is there data to support such an endeavor? A systematic review published in Annals of Emergency Medicine in 2011, showed the implementation of clinical case management in the ED clearly reduced costs and seemed to improve both clinical outcomes as well as social outcomes (such as reduction in homelessness) in frequent utilizers of the ED [5]. In a health services study performed by Raven et al in 2010, this type of approach was applied to a small cohort of high-risk patients with frequent admissions. They were carefully screened for unmet social needs and connected with community resources for housing, transportation, etc…, and care managers facilitated discharge plans and worked closely with patients in the community. This approach reduced the frequency of future hospitalization and ED visits and increased primary care visits [6].

Case Continued…

Our patient was found to be moderately anemic, dehydrated, and with electrolyte deficiencies that met criteria for a 23-hr observation stay. We coordinated care with GI to perform colonoscopy during the stay and discovered Giardia was also a factor. The patient was screened for HIV, TB, and STIs. She was allowed to clean up and chose some new clothing and personal care products from a collection of donations we routinely solicit for the ED. She began treatment, and follow-up at a local free clinic was arranged. Meds were obtained through a free program to patients who are homeless, supported by pharmaceutical companies. She was guided in signing up for state-sponsored medical assistance. We engaged a local group that delivers food and water to the homeless daily, support from the LGBTQ community, and also worked with social service entities to earn eligibility for housing and employment.

COMMUNITY RESOURCES

-Free or low cost medical and dental clinics
-Faith based organizations
-Disease specific support and activism groups
-County Trustee Office
-Mayoral / Governor’s Offices
-Food and clothing banks
-Pro Bono Legal Care
-Shelters
-Low cost med lists at local pharmacies
-Partner with local agencies to provide supplies as a tax deductible donation

The current political climate has ushered in welfare reform that has proven to be detrimental to support systems for the most needy of our society. Only Emergency Departments remain to offer resources to all, regardless of the severity of need or time of day and without requiring prequalification. The infrastructure to provide services is already in place with convenient access, and thus it would seem only logical to use the opportunity to determine the spectrum of a community’s needs and for emergency medicine providers “to become leaders in the design and implementation of integrated sociomedical systems of care” [4]. Most physicians have had experience in advocacy at some point in their personal or professional lives, and there is a wealth of wisdom and compassion to be applied to the dilemma of how best to deliver care to the most vulnerable of our patients.

Special thanks to the Indiana University Department of Emergency Medicine faculty who selflessly serve a highly vulnerable population night and day and generously shared their wisdom with the authors, and to the vulnerable patients whose bravery in sharing their stories has led to a greater understanding and compassion for all of our patients.

References/Further Reading
  1. Montauk, Susan Louisa. “The homeless in America: adapting your practice.” Am Fam Physician 74.7 (2006): 1132-8.
  2. Doran KM, Misa EJ, Shah NR. Housing as health care—New York’s boundary-crossing experiment. N Engl J Med. 2013;369: 2374-2377.
  3. Bonin E, Brehove T, Carlson C, Downing M, Hoeft J, Kalinowski A, Solomon-Bame J, Post P. Adapting Your Practice: General Recommendations for the Care of Homeless Patients. Nashville: Health Care for the Homeless Clinicians’ Network, National Health Care for the Homeless Council, Inc., 2010.
  4. Gordon, James A. “The hospital emergency department as a social welfare institution.” Annals of emergency medicine 33.3 (1999): 321-325.
  5. Althaus, Fabrice, et al. “Effectiveness of interventions targeting frequent users of emergency departments: a systematic review.” Annals of Emergency Medicine 58.1 (2011): 41-52.
  6. Raven, Maria C., et al. “An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study.” BMC health services research 11.1 (2011): 270.

National Health Care for the Homeless Council (http://www.nhchc.org/)
HCH Clinicians’ Network (phone: 615-226-2292, e-mail: network@nhchc.org)
Bureau of Primary Health Care Patient Assistance Programs (http://www.hrsa.gov)
Society of Health-System Pharmacists Patient Assistance Program Resource Center (http://www.ashp.org)
Bureau of Primary Health Care – HCH Information Resource Center (http://www.bphc.hrsa.gov/hchirc/)

More Ideas

Indiana University Department of Emergency Medicine has developed a Vulnerable Patient Resident Lecture Series. We invite patients and their caregivers to panel discussions on topics often overlooked in formal education curricula. Recent topics have included living with addiction, caring for the homeless, unique needs of the incarcerated population, and considerations when caring for patients on the autism spectrum.

The Indiana School of Medicine Student Outreach Collective runs a multidisciplinary health clinic at a local church on Saturday mornings staffed by volunteer faculty and students from medicine, social work, pharmacy, nursing and dentistry.

Our county hospital ED partnered with a clothing company that donates items with minor flaws but cannot be sold at retail.

Each winter we hold a sock drive to collect new undergarments to give away to those in need and have developed an inclement weather policy with nearby shelters.

During a remodeling, we installed a washing machine and dryer. If a patient can be treated and discharged but their clothes are wet or dirty, we can launder them during their work up.

Create a resource folder where copies of maps, transportation options, free clinics, local pharmacies, shelters, advocacy groups and other community resources can be collected for distribution.

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