In 2004, the National Guidelines Clearinghouse placed eight guidelines from the National Health Care for the Homeless Council on its Web site. Seven of the guidelines are on specific disease processes and one is on general care. In addition to straightforward clinical decision making, the guidelines contain medical information specific to patients who are homeless. These guidelines have been endorsed by dozens of physicians who spend a large part of their clinical time caring for some of the millions of adults and children who find themselves homeless each year in the United States. In one guideline, physicians are prompted to keep in mind that someone living on the street does not always have access to water for taking medication. Another guideline points out the difficulty of eating a special diet when the patient depends on what the local shelter serves. As the number of homeless families and individuals increases, family physicians need to become aware of medically related information specific to this population. This can help ensure that physicians continue to offer patient-centered care with minimal adherence barriers.

Each day in the United States, at least 800,000 persons are homeless. This includes 200,000 children in homeless families. (1) As of the beginning of the 21st century, 2.3 to 3.5 million persons were homeless at some time during an average year. (2) Approximately 33 percent of these are families with children, and another 3 percent are unaccompanied minors. (3) Two percent of children in the United States are homeless in the course of a year. (4) Figure 1 (3) shows the composition of the homeless population in the United States.

The Federal Bureau of Primary Health Care defines homelessness using the following descriptors (5):

* An individual without permanent housing who may live on the streets; stay in a shelter, mission, single-room occupancy facility, abandoned building or vehicle; or in any other unstable or nonpermanent situation.

* An individual may be considered homeless if that person is “doubled-up”, a term referring to a situation in which individuals are unable to maintain their housing situation and are forced to stay with a series of friends or extended family members.

* Previously homeless individuals who are to be released from prison or a hospital may be considered homeless if they do not have a stable housing situation to return to.

* Recognition of the instability of an individual’s living arrangement is critical to the definition of homelessness.

State, city, or private definitions (e.g., ones used for grants or to receive certain subsidies) may differ from this.

At the beginning of this century, clinicians from the National Health Care for the Homeless Council (NHCHC) began to adapt clinical practice guidelines for patients who are homeless. In 2004, the National Guidelines Clearinghouse placed eight NHCHC guidelines on its Web site, including seven relating to specific disease processes and one on general care (online Table A). Well-researched evidence that differentiates care for the homeless population from the general population is almost nonexistent. Therefore, the method used to assess the quality and strength of the evidence for those criteria and to formulate recommendations was based almost entirely on expert consensus.

This article summarizes some of the NHCHC guidelines that apply to a variety of conditions that pertain to persons who are homeless. Although some of this information is duplicated in other NHCHC guidelines, most of it comes from the NHCHC’s general recommendations, 6 except when noted otherwise. In addition, some relevant information from more recent literature on the topic is included.

Overcoming Barriers to Care

Millions of persons in the United States with minimal health care access experience barriers to care, but persons who are homeless face additional unique obstacles. Difficulties can arise when a physician tries to build trusting relationships in a population where histories of mental illness and abuse are often the norm. Even when trust is won, finding the appropriate prescribing patterns and education techniques to help ensure adherence can be a challenge for any physician, particularly when food and housing concerns often outweigh those for ongoing health care. Ideally, physicians should develop individualized care plans that incorporate the meeting of basic daily needs.

Unrealistic expectations by physicians are a key cause of patient nonadherence. (5) When adherence is a problem, the physician should reassess goals with the patient. Knowing some of the issues that affect adherence for persons who are homeless may help clarify any unrealistic expectations (Tables 1 and 2 (6-10)).

Building Trust

A full-body, unclothed, comprehensive examination of an adult who is homeless is rarely possible before patient-physician trust and engagement is achieved. Approximately 25 percent of these patients have at some time experienced severe mental disorders such as schizophrenia, major depression, or bipolar disorder, and many are survivors of physical or sexual abuse and/or assault. (11-14) In addition, many have experienced negative interactions with authority figures, and because anxiety is highly prevalent in the homeless population, these patients may be averse to the private aspects of the physical examination.