N.E.
You are working with the inpatient medicine/cardiology service at your hospital and are tasked with completing the discharge planning for patient N.E. N.E. is a 48 year old man who was admitted four days previously with a non-ST elevation myocardial infarction (NSTEMI). He presented to the emergency department with acute onset chest pain, leading to this diagnosis.
Prior to this visit, N.E. last saw a physician approximately fifteen years ago. His past medical history is significant for 30 pack years of smoking and a remote history of depression. On this admission, he is noted to have hypercholesterolemia and hypertension.
N.E. was on no medications at the time of admission to hospital. His current medications include: Aspirin, Metoprolol, Ramipril, Hydrochlorothiazide, and Atorvastatin. In accordance with the American Heart Association Guidelines, discharge planning also includes smoking cessation, a low-fat diet, and cardiac rehabilitation.
While discussing discharge planning, N.E. discloses that he has been staying at a homeless shelter for the past month. Prior to that time, he was working occasionally as a handyman and staying with a friend, who has since moved out of the city.
At this point, both the patient N.E and the care provider (you) are feeling overwhelmed by the complexity of his discharge planning.
Prior to this visit, N.E. last saw a physician approximately fifteen years ago. His past medical history is significant for 30 pack years of smoking and a remote history of depression. On this admission, he is noted to have hypercholesterolemia and hypertension.
N.E. was on no medications at the time of admission to hospital. His current medications include: Aspirin, Metoprolol, Ramipril, Hydrochlorothiazide, and Atorvastatin. In accordance with the American Heart Association Guidelines, discharge planning also includes smoking cessation, a low-fat diet, and cardiac rehabilitation.
While discussing discharge planning, N.E. discloses that he has been staying at a homeless shelter for the past month. Prior to that time, he was working occasionally as a handyman and staying with a friend, who has since moved out of the city.
At this point, both the patient N.E and the care provider (you) are feeling overwhelmed by the complexity of his discharge planning.
Question 1: How comfortable are you assessing housing status during discharge planning? Do you regularly incorporate it into care planning for patients? How might earlier knowledge regarding N.E.'s housing status have been helpful?
Unless otherwise noted, discussion points below are from Greysen SR et. al. Improving the Quality of Discharge Care for the Homeless: A Patient-Centered Approach. J of Health Care for the Poor and Underserved, May 2013; 24(3):444-455.
One paper describes the use of a pneumonic to better plan for discharge of the homeless inpatient. Framing the discussion around "A SAFE DC" may be an easy way to ensure that critical components of discharge planning are not missed. See Best JA and A Young. A SAFE DC: A conceptual framework for care of the homeless inpatient. J of Hospital Medicine 2009;4:375-381.
A = Assess housing status
S = Screening and prevention
A = Address primary care issues
F = Follow-up care
E = End of life discussions
D = Discharge instructions, simple and realistic
C = Communication method after discharge
Unless otherwise noted, discussion points below are from Greysen SR et. al. Improving the Quality of Discharge Care for the Homeless: A Patient-Centered Approach. J of Health Care for the Poor and Underserved, May 2013; 24(3):444-455.
- In a survey of 98 homeless persons in New Haven, 56% reported that they had not been asked about housing status on their most recent hospital visit. Patients reported that they feared discrimination if they reported their housing status, as healthcare providers might assume they were seeking shelter rather than care for a medical condition.
- Investigators in the above study asked participants how healthcare providers could better approach discussions around housing with patients. Participants recommended approaching the topic with concern for the patient's well-being and safety. For example, Greysen et. al. suggest asking "Do you have a place to stay where you feel safe?" rather than directly asking patients "Are you homeless?"
- When housing status was addressed, patients were more likely to report discussion of medication cost, primary care follow-up, physical activity, diet, transportation, and mental health follow-up
One paper describes the use of a pneumonic to better plan for discharge of the homeless inpatient. Framing the discussion around "A SAFE DC" may be an easy way to ensure that critical components of discharge planning are not missed. See Best JA and A Young. A SAFE DC: A conceptual framework for care of the homeless inpatient. J of Hospital Medicine 2009;4:375-381.
A = Assess housing status
S = Screening and prevention
A = Address primary care issues
F = Follow-up care
E = End of life discussions
D = Discharge instructions, simple and realistic
C = Communication method after discharge
Question 2: How common is smoking amongst persons experiencing homelessness? What unique barriers do you anticipate N.E. may encounter in trying to quit smoking? What special considerations might you take in your approach to discussing smoking cessation with N.E?
Discussion points below are from Baggett T, Tobey M, Rigotti N. Tobacco Use among Homeless People - Addressing the Neglected Addiction. N Engl J Med, 2013 Jul 18; 369(3):201-4 unless otherwise noted.
Discussion points below are from Baggett T, Tobey M, Rigotti N. Tobacco Use among Homeless People - Addressing the Neglected Addiction. N Engl J Med, 2013 Jul 18; 369(3):201-4 unless otherwise noted.
- Approximately three quarters of homeless adults smoke cigarettes; a prevalence 4 times the general population and more than double that of other impoverished adults (US Data)
- Smoking-related deaths occur at double the rate of stably housed people
- Barriers to quitting include: lack of private drug plan limits access to smoking cessation therapy, nicotine use may ease psychiatric symptoms (especially from schizophrenia, see Silva 2013), smoking around shelters remains commonplace, there may be an expectation of premature death that diminishes perceived benefits of smoking cessation
- Baggett states: "The daily stressors of homelessness foster a present-oriented outlook that values immediacy over delay". He suggests focusing on short-term gains from smoking cessation in persons experiencing homelessness, such as fewer smoking-related symptoms and money saved from not purchasing cigarettes.
Question 3: What barriers might N.E. encounter in acquiring and taking his medications? How might you overcome some of these barriers?
Health Care for the Homeless Clinician's Network provides clinical practice guidelines for a number of conditions, including hypertension, hyperlipidemia, and heart failure. While an American resource, they can be tremendously valuable in preparing a care plan for a patient experiencing homelessness. Additional information about screening for homelessness is also provided.
- Challenges in paying for medications - N.E. may qualify for provincial social assistance (e.g. Ontario Works), which would help to cover his medication costs. Prescribers should ensure that all medications prescribed are on the provincial formulary; this can be checked by searching your provincial e-formulary. Ontario's is here: https://www.healthinfo.moh.gov.on.ca/formulary/index.jsp (active link below)
- Challenges adhering to a complex medication regimen - if possible, prescribe drugs with once daily rather than BID or TID dosing. Some combination therapies (eg. Ramipril/Hydrochlorothiazide) may be available on the provincial formulary and can also simplify the drug regimen. Providing simple tools, such as a pillbox, may also help with adherence
- Recognize that patients staying in shelters may have medications lost or stolen, therefore may require additional refills or prescriptions for reasons that are out of their control
Health Care for the Homeless Clinician's Network provides clinical practice guidelines for a number of conditions, including hypertension, hyperlipidemia, and heart failure. While an American resource, they can be tremendously valuable in preparing a care plan for a patient experiencing homelessness. Additional information about screening for homelessness is also provided.