1. Common Medical
Issues For People
Who are Homeless
Ellen M. Brown, RN, LCSW
DHHS Program Manager
Health Care for Homeless
Danielle Jacques, RN, MSN
Community Health Nurse II
Health Care for the Homeless 1

2. Introduction
Today we’ll discuss
some common
medical problems
and the issues that
arise in providing
care to people who
are homeless.
We will also review
where to refer the
homeless for primary
medical care
2 2

3. Why is this important?
 Studies show that 40% of
homeless suffer from one or more
chronic health problems
 Chronic diseases among the
homeless are typically more
severe than in people who are
housed
 The management of health
problems is more difficult in the
homeless.
3 3

4. Homeless
Homelessness can be
the cause of poor health
Poor health can lead to
homelessness
Homelessness makes
management of any
health problem more
difficult
Health
4

5. Objectives of this training:
 Be aware of the major health
problems encountered among people
who are homeless
 Gain knowledge into which clients
should go immediately to the
emergency room and which to refer
for an appointment with primary care
 Be knowledgeable of the primary care
providers for homeless clients
5 5

6. The Top Ten Medical Conditions
 1. Upper respiratory infection 2. Skin problems
 3. Dental problems 4. Hypertension
 5. Diabetes 6. Asthma
 7. Peripheral vascular disease 8. Allergies
 9. Seizures 10. Joint Pain
6 6

7. Upper Respiratory
Infection
 Prevention is
important
 Treatment is
encourage fluids,
take OTC meds,
and rest
 Need to make sure
it’s not bronchitis,
pneumonia, or
allergies
7 7

8. Common Cold vs.
Serious Respiratory Infection
Routine visit Send to clinic Send to ER
ASAPend
Runny nose, Coughing up Breathing
Dry cough or sputum rapidly
small amt Normal Has high fever
sputum breathingCoughi Sudden onset
Gradual onset ng up Skin color not
normal
8 8

9. Skin Problems
 Many kinds of skin
problems; most are
not contagious
 Treat with creams
or occasionally
need oral meds
 Watch out for lice
or scabies
9 9

10. Scabies
 Caused by a mite,
Sarcoptes scabei
burrowing under
the skin
 Causes severe
itching, especially
at night
 Transmitted by skin
to skin contact,
very contagious
 Treatment:
prescription cream
wash clothes in hot
water
10 10

11. Frostbite
 Caused when tissues freeze
and ice crystals form and
rupture causing tissue death
 3 stages
 1st redness and pain
 2nd blistering
 3rd deep red/purple, hard
 Treatment is re-warming
tissues and preventing
infection
 DO NOT Burn the skin by
trying to reheat over an open
fire
 DO NOT rub skin, this causes
further breakdown of tissues
11 11

12. Fungal Infections
Athlete's foot  Can affect any part
of the body
 Can be contagious
 Often treated with
creams or other
“topical”
medications
 Can take a long
time to resolve
 Can be recurrent
12 12

13. Bacterial infections
 Pus-filled blisters
(“pustules”) or
open wound
draining purulent
drainage
 May have
swelling, redness,
warmth
13 13

14. Is it MRSA?
Methicillin Resistant Staphylococcus Aureus
 Skin Infections
 Transmitted by skin
to skin contact
 Characterized by a
reddish rash with a
boil
 Requires
aggressive
antibiotic therapy
14 14

15. Practice
‘Universal’ Precautions
 Wash your hands often, carry
disposable hand wipes
 Protect you hands from cracking
 Wear gloves when handing
contaminated items
 Cover open wounds and change
dressings when they are wet
 Properly discard all contaminated
materials by double bagging
 Clean soiled surfaces with a 1:10
bleach solution
15 15

16. Skin Problems
Routine visit Send to clinic Send to ER
ASAP
Bleeding stopped
 Cut or sore: red Deep cut and
with pressure puffy bleeding not stopped
Human bite that with pressure
breaks skin Burn over large area
Small burn on top Itchy lesion with
layer of skin swelling, can’t breath
Itchy lesions that

Itchy lesion, wet with
don’t disturb sleep
blisters, trouble
sleeping
Open wound that is
draining
16 16

17. Dental Problems
 Refer to primary
care for
infections then
dental clinic
 May need
antibiotics
 May need pain
meds
 Need immediate
care if extra-oral
swelling occurs
17 17

18. Teeth/Mouth Problems
Routine visit Send to Clinic Send to ER
ASAP
Toothache Bleeding gums Bleeding gums and
Needs dental Tooth knocked out takes blood thinner
cleaning and doesn’t have it Tooth knocked out
Toothache with and has tooth
swelling, bleeding, Mouth sores-can’t
fever eat or drink
Swollen face, can’t
talk or can’t swallow
18 18

19. Hypertension (HTN)
 HTN is elevated blood pressure
 More common in the homeless
population than in the general
population
 HTN is twice as prevalent in
alcoholics than in non-alcoholics
 HTN may have no symptoms
Found on routine examination
 HTN can be an emergency
19 19

20. Hypertension: The keys
to treatment
 Try to avoid salt
 Avoid alcohol and drugs
 Take prescribed Medications
 Monitor BP
HCTZ Verapamil
Lisinopril Atenolol
Clonidine
10/01/09 20 20

21. Heart and Circulation Problems
Routine Visit Send to Clinic Send to ER
ASAP
Running out of Shortness of Chest pain &
blood pressure breath with weakness,
pills in a few days movement or numbness
Running out of lifting Shortness of
blood thinner pills Is out of meds breath
in a few days Pale skin
Sweating
21 21

22. Diabetes
 Symptoms may include excessive
urination, excessive thirst, fatigue
 It is diagnosed through blood tests
 Complications can include peripheral
neuropathy (loss of feeling in
extremities), kidney problems, eye
problems
22 22

23. Management of Diabetes
 Clients need to monitor blood glucose with a
glucometer, primary medical provides them
 May be controlled with diet (avoid sugar)
 May need oral medication or insulin injections
 Clients need to have regular, balanced
meals. Timing is important.
 Dental and foot care is important
23 23

24. Diabetes
Routine visit Send to Clinic Send to ER
ASAP
Blood sugar less Blood sugar is Change in
than 120 and getting higher. mental status,
feels well. Is Increased with either high
taking meds urination. or low sugar
regularly. Out of meds.
Running out of
meds.
24 24

25. Asthma
 A chronic inflammatory disease of
the airways
 Prevalent in people experiencing
homelessness
 Symptoms may include wheezing,
dry cough at night, tightness in
chest, especially when exercising
25 25

26. Management of Asthma
 Inhalers
 Oral meds
 Control environment as
possible
 Flu vaccine, pneumonia
vaccine
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27. Asthma Triggers
 Tobacco
 Cold air
 Perfume, paint, cleaning fluids
 Allergens such as mites, pollen, cockroaches
 Common cold, flu, other respiratory illness
27 27

28. Asthma
Routine visit Send to Clinic Send to ER
ASAP
Can breath OK if Trouble breathing Trouble breathing
uses inhaler Increased use of and unable to
Has enough “rescue” inhaler converse
meds/inhaler and More frequent Change in skin
is taking them coughing color
28 28

29. Peripheral Vascular
Disease (PVD)
 Includes a broad group of
problems: chronic
edema, cellulitis of the
legs, phlebitis (blood
clots)
 Prevalence is 10-15 times
greater than in general
population
 High rates are related to
lifestyle: constant
walking, inability to
elevate feet during sleep
29 29

30. Cellulitis as a result of
PVD
Contributing factors:
 Malnutrition
 Lack of adequate rest
 Exposure to the
elements
 Limited access to
showers/hygiene
 Psych issues/substance
abuse
30 30

31. Treatment of
Peripheral Vascular Disease
 Elevate feet as much as possible
 May use compression stockings or ace
bandages
 Proper footwear
 Patients with ulcers may need dressing changes
 Infected wounds may need antibiotics
31 31

32. Peripheral Vascular Disease
Routine visit Send to Clinic Send to ER
ASAP
Swelling in feet Persistent Swelling of
or ankles by swelling of feet, feet, ankles,
the end of the ankles, legs legs with
day, goes shortness of
down in the AM breath or other
symptoms
32 32

33. Allergies
 There are many
types of allergies
 Possible symptoms
include sneezing,
watery eyes,
itching, skin rash or
hives, wheezing,
coughing, vomiting,
diarrhea, swelling
around the mouth…
33 33

34. Allergies
 Rarely, an allergic
reaction can become life-
threatening.
 “Anaphylaxis” may
begin with severe itching
of the eyes, and rapidly
progress to difficulty in
breathing and
swallowing, cramps, and
shock.
34 34

35. Management of Allergies
 Oral antihistamine
medications
(Benadryl, Loratadine)
 Skin creams
 Nasal sprays
 Control of
environment
35 35

36. Allergies
Routine visit Send to Clinic Send to ER
ASAP
Sneezing. Swelling of an Swelling of the
Rash but skin arm or leg face or throat
unbroken. Skin rash with Difficulty
excoriation. breathing or
Sneezing, swallowing
coughing Weakness
36 36

37. Seizures
 This is most common neurological
illness in the homeless population.
 The most common cause is alcohol
abuse, followed by head trauma.
 There are many other causes.
37 37

38. What does a seizure look like?
Any of these:
 Sudden falling
 Passing out
 Drooling, frothing at mouth
 Grunting, snorting
 Breathing stops temporarily
 Uncontrollable muscle
spasms
 Teeth clenching
 Eye movements
 Unusual behavior
 Staring
38 38

39. Management of Seizures
 Requires good relationship with a
primary medical care provider
 Compliance with Medications
 Controlling environmental factors
39 39

40. What to do if someone has a
seizure
 Don’t panic
 Keep him from hurting himself by easing
to the ground or positioning him safely
 If possible, try to gently turn him on his
side
 Tell someone to call 911
 Note how long the seizure lasts
 Don’t try to put anything in his mouth
 When it’s over, have him rest
comfortably. Don’t try to move him right
away.
40 40

41. Seizures
Routine visit Send to Clinic Send to ER
ASAP
Takes seizure Is out of meds. Witnessed
meds but has Reports having seizure, esp. if
had no seizures. seizure for first time.
Prolonged
seizure.
41 41

42. Joint Pain
 Back pain, hip pain, leg pain
very common
 Made worse by walking,
sleeping on an uncomfortable
bed
 May be a sign of more serious
disease
42 42

43. Joint Pain
Routine visit Send to Clinic Send to ER
ASAP
Past injury New injury that New injury.
causing is bruised, Bone is sticking out
discomfort; still swollen, and No feeling
has feeling, joint painful; still has Can’t move part of
can be used feeling, joint can body
be used Change in skin color
43 43

44. Flu!
44 44

45. Flu Symptoms
 Sudden onset of illness
 Fever higher than 100.4
 Chills
 Cough
 Headache
 Sore throat
 Stuffy nose
 Muscle aches
 Feeling of weakness and fatigue
 Diarrhea, vomiting, stomach pain, esp in
children
45 45

46. “High Risk” Medical
Conditions Susceptible to
Flu
 Pregnancy
 Diabetes
 Heart problems
 Kidney Disease
 Immunosuppression
 Age over 65
 Chronic lung disease
46 46

47. Is it flu or a common cold?
Influenza Common cold
 Sudden fever, lasts 3-4  Fever is rare
days
 Headache is common,  Headache is rare
can be severe
 Aches and pains are  Aches and pains are rare
common and can be
severe
 Fatigue is common and
 Sometimes mild fatigue
can be severe
47 47

48. Is it flu or a common cold?
Influenza Common cold
 Nausea, vomiting,  Nausea,vomiting,
diarrhea in children, esp diarrhea are rare
< 5 years old
 Watery eyes rare  Watery eyes is common
 Sneezing rare in early  Sneezing is common
stage
 Stuffy nose rare  Stuffy nose is common
 Chest discomfort  Chest discomfort rare
common and can be
severe
48 48

49. Is it flu or a common cold?
Influenza Common Cold
 Complications:  Complications: Earache,
respiratory failure, congestion
worsening of chronic
conditions
 Not fatal
 Can be fatal
49 49

50. What to do for flu
 Prevent spread of flu to others:
 Wash hands
 Dispose of tissues properly
 Clean counters/surfaces with usual
products
 Get a Flu Shot
 If you get sick, rest, drink fluids,
and treat symptoms
50 50

51. Influenza
Routine visit Send to Clinic Send to ER
ASAP
Needs vaccine Underlying Shortness of
medical condition breath
Has had Poor color
symptoms for 5
days and no
better
51 51

52. Primary Medical Providers for
Homeless
Community Clinic Inc.
 Serves uninsured men, women and children
 Contracted with HHS for uninsured homeless adults
 Participates with MA, PAC and Medicare
 3 locations:
 Gaithersburg Clinic
200 Girard St. Gaithersburg
301-216-0880 /Ride On #61
 Silver Spring (Progress Place)
8210 Dixon St. Silver Spring
301-585-1250 / one block from SS Metro
 Takoma Park
7676 New Hampshire Ave.
301-431-2972 / Ride On # 15, 16, 17, 18
52

53. Primary Medical Providers for
Homeless
Kaseman Clinic Inc.
 Serves uninsured men and women
 Contracted with HHS for uninsured homeless
women
 Does not participate with any insurance
 Kaseman Clinic
8 West Middle Lane, Rockville, MD
301-917-6800 /Ride On # 46
53

54. When you need help…
 Call DHHS Health Care for the Homeless
 Danielle Jacques, RN, MSN
240-777-3104 office
240-277-1003 cell
 Ellen M. Brown, RN, LCSW-C
240-777-3963 office
240-380-7717 cell
 The National Health Care for the Homeless Council
website: www.nhchc.org
54 54