Adapting Your Practice: General Recommendations for the Care of Homeless Patients (review)

This concise, clinically informative manual, developed by an advisory committee of six health and social service providers affiliated with the Health Care for the Homeless Clinicians Network, outlines general recommendations for adapting medical practices to the unique needs of homeless persons. Targeted to the audience of health care professionals, trainees, and ancillary personnel who may have little clinical experience working with the homeless, this compact guide offers basic, common-sense approaches to providing medical care to a highly vulnerable and medically underserved population.

In less than 50 pages, the authors attempt to outline the fundamental issues affecting a homeless person's life (e.g., unstable housing, limited access to nutritious food and water, lack of insurance, chronic stress) as well as to offer practical recommendations that specifically pertain to the provision of health care. The basic message is this: a patient's state of homelessness should impel the provider to modify his or her clinical approach to diagnosis, evaluation, physical examination, the ordering of relevant diagnostic tests, development of a feasible treatment plan, and the implementation of follow-up strategies.

The authors then elucidate, briefly and succinctly, recommendations for how this can be achieved on a clinical level. Some of the most valuable guidance offered concerns medication and follow-up. Keeping medication regimens to once-daily dosing when possible, dispensing small amounts on site (i.e., avoiding written prescriptions, which likely will go unfilled), discussing storage and safekeeping measures, and avoiding potential agents of abuse (e.g., inhalants, controlled substances for pain, clonidine) are all strategies aimed at increasing adherence for those living on the streets or in shelters. For those of us who provide care to the homeless on a routine basis, the issue of follow-up is also of paramount importance. This short guide suggests using case management, peer support, frequent appointments, incentives, and transportation assistance to enhance treatment retention. Woven throughout the text is an emphasis on multidisciplinary strategies because the multiple and complex needs of the homeless patient almost always greatly exceed the capacity of a single health care provider.

The strength of this manual is its hands-on, concrete approach to the clinical care of those who endure the effects of homelessness. On the positive side, it is extremely brief and user friendly. In fact, acknowledging the time limitations of most health care providers, the authors have summarized at the very beginning of the handbook the fundamental issues and the recommendations for shaping medical practices to better meet the needs of homeless individuals. They then develop these points in greater detail in the remainder of the text and proceed to flesh out the application of the treatment recommendations through the use of several clinical vignettes. The brevity of the guide, however, limits an examination of the root causes of homelessness and the systemic obstacles this population must overcome to obtain health care. However, at the conclusion of this clinically oriented handbook is a fairly extensive bibliography dedicated to a much broader social analysis of homelessness in America, which should be consulted by the health care provider to gain greater insight into the complexity of this tragic social legacy.