In the United States, nearly one million people are homeless at any given time, and 44% of them do not have shelter.1 It is well established that there is a high prevalence of both acute and chronic health problems among homeless populations.2 Infectious diseases are a significant source of morbidity: Homeless people suffer frequent skin infections as well as foot disorders, tuberculosis, human immunodeficiency virus (HIV), and hepatitis.3–6 Poorly controlled chronic conditions are common and include hypertension, diabetes, and high cholesterol.7 Homeless individuals are also at greater risk than the general population for physical injuries, including those sustained from acts of violence or sexual assault.8 Furthermore, the age-adjusted mortality rate of the homeless population is three to four times higher than that of the general population.9,10
Many physical health conditions that are brought on or aggravated by homelessness can be attributed to the direct effects of existential conditions, such as exposure to the elements, overcrowding in shelters, and lack of a reliable place to store medications. In contrast, mental illness may be the cause of homeless individuals’ disposition. Precipitating factors may include an inability to maintain employment, nurture supporting social relationships, or pay bills.1 Compared with the general population, a disproportionate number of homeless people suffer from mental illness. For example, estimates of mental illnesses such as schizophrenia and bipolar disorder range from 2% to 31% in the homeless population, depending on study location and methodology, versus approximately 1% in the general population.11–15 A recent meta-analysis1 confirmed the considerable heterogeneity in prevalence estimates of these disorders and highlighted the need to conduct local studies to plan mental health services.
Medical students and students in other health-related disciplines have become engaged in the direct care of homeless patients through various academic health center initiatives, including longitudinal curricula,16 elective clerkships,17,18 and department-directed clinics.19,20 Such initiatives provide homeless people with an important source of medical care and can affect medical students’ perceptions of socioeconomically disadvantaged populations.21 One example is the Houston Outreach Medicine, Education, and Social Services (HOMES) Clinic, a free clinic for the homeless managed by students from the University of Texas Medical School at Houston, Baylor College of Medicine, the University of Texas School of Public Health at Houston, and the University of Houston School of Pharmacy.22 The HOMES Clinic operates under the guidance of Healthcare for the Homeless–Houston (HHH), a local nonprofit organization and federally qualified health center dedicated to providing quality health care to Houston’s homeless population.
The HOMES Clinic operates every Sunday to serve patients who might otherwise seek care from emergency departments. The clinic provides student volunteers with opportunities for professional, social, and personal development. Students begin the day by having coffee at the adjacent day shelter with the homeless visitors. Then, during clinic hours, they work within interdisciplinary teams to obtain a detailed social and medical history for each patient. Each student team presents its findings to an attending physician, who then evaluates the team’s patients, provides feedback to students, and discusses a treatment plan with the student team and individual patients. Students and attendings meet to reflect on the day after the clinic closes. Each Sunday, there are approximately 10 to 15 student volunteers, and 4 to 8 patients are seen.
Many HOMES Clinic patients suffer from mental illness and comorbid conditions. Because the clinic has a limited budget, planning ways to provide integrated health care services that meet these patients’ needs at low cost is essential. To assist in our efforts to plan for and improve the services that the clinic offers patients, we analyzed information about clinic patients’ demographics and medical conditions. In this study, we identify the prevalence of bipolar disorder and schizophrenia among HOMES Clinic patients and compare the characteristics of patients with these mental illnesses with those of all other clinic patients. The implications of these findings for student-managed health clinics and the ways in which such clinics with limited budgets may provide care for patients with mental illness are discussed.
This study was a retrospective review of HOMES Clinic patient records from May 2007 through May 2008, inclusive. A full year of data were analyzed to avoid seasonal bias. If a patient had multiple clinic encounters during the study period, the data from the first visit were analyzed in order to report solely on the index visit of each patient.
Data on diagnoses of bipolar disorder or schizophrenia were collected from patient records; in the majority of cases, these diagnoses were preexisting per patient medical histories. To confirm self-reported medical history and clinic records, the HOMES Clinic has access to jail and county records through HHH. Axis I diagnoses made at the HOMES Clinic were done according to Diagnostic and Statistical Manual IV criteria as previously described.23 All medical diagnoses were made by an interdisciplinary team of medical, pharmacy, and public health students and were confirmed by the supervising attending physician. Several of the clinic’s psychiatrists and physicians have more than 20 years of experience working with homeless and mentally ill patients.
A standardized data collection form based on the clinic’s patient care documents was developed prior to data collection. During June to December 2008, five of the authors (K.J.W., C.B.P., R.C.F., J.D.T., S.K.M.) used this form to collect the following types of information from patients’ clinic records:
- Demographics (gender, age, race, education)
- Health risk factors (history of and current smoking, alcohol, illicit drug use)
- Social risk factors (length of homelessness, where staying, employment, income, insurance status, benefits)
- All medication use
- Chronic medical conditions (alcoholism, anemia, asthma, cancer, chronic obstructive pulmonary disease, depression, diabetes, drug abuse, hepatitis, headaches, heart disease, HIV, hypertension, kidney disease, seizures, ulcers)
For the purposes of this study, psychiatric medication use was defined as use of an antipsychotic to treat schizophrenia or use of a mood-stabilizing medication (lithium, anticonvulsants) or an antipsychotic to treat bipolar disorder. Medication use data were obtained from each patient’s history and from HHH pharmacy records.
This study was approved by the University of Texas Health Science Center at Houston Committee for the Protection of Human Subjects and the Baylor College of Medicine Institutional Review Board.
The data were managed and analyzed using SAS version 9.1.3 (SAS Institute, Cary, North Carolina). Comparisons of patients with bipolar disorder or schizophrenia to patients without either mental illness were conducted by two-tailed univariate tests of association (Student t test for normally distributed variables; Wilcoxon rank sum test for continuous, nonnormally distributed variables; chi-square or Fisher’s exact test for categorical variables).
A total of 286 patients made 349 visits to the HOMES Clinic during the one-year study period. Of these patients, 25 (8.7%) had a diagnosis of schizophrenia and 45 (15.7%) had a diagnosis of bipolar disorder. Table 1 compares the characteristics of clinic patients with bipolar disorder or schizophrenia with those of other clinic patients.
Almost three-quarters of clinic patients were male (213/286; 74.5%); however, patients with bipolar disorder or schizophrenia were less likely to be male than were those without either of these mental illnesses (37/70 [52.9%] versus 176/216 [81.5%], P < .0001). Other general demographic characteristics did not differ significantly between the groups. Patients with one of these mental illnesses were more likely than other clinic patients to have slept on the street the previous night (46/70 [65.7%] versus 113/216 [52.3%], P = .05). They were also less likely than other clinic patients to be uninsured (31/70 [44.3%] versus 129/216 [59.7%], P = .02).
Types of insurance among the 286 HOMES Clinic patients were Medicare (18; 6.3%), Medicaid (21; 7.3%), veteran’s benefits (19; 6.6%), private (1; 0.4%), and the Harris County Hospital District’s (HCHD) Gold Card program (67; 23.4%), which provides health insurance to low-income individuals. The majority (160; 55.9%) had no insurance (Table 2). Patients with bipolar disorder or schizophrenia were significantly more likely than other clinic patients to have Medicare (11/70 [15.7%] versus 7/216 [3.2%], P = .0001) and were more likely to have an HCHD Gold Card (22/70 [31.4%] versus 45/216 [20.8%], P = .07).
Overall, HOMES Clinic patients had a high burden of medical conditions (Table 1). Those with bipolar disorder or schizophrenia were significantly more likely than other patients to have certain medical comorbidities, specifically a history of drug abuse, depression, cancer, kidney disease, asthma, heart disease, seizures, and headaches. The groups did not differ significantly with respect to current use of tobacco, alcohol, or illicit drugs. Of the 70 patients with bipolar disorder or schizophrenia, 45 (64.3%) were already using a psychiatric medication (Table 3).
Student-managed free clinics such as the HOMES Clinic provide health care for indigent populations while also serving as educational resources for students. Understanding the demographics and medical problems of the patients attending the HOMES Clinic might assist in improving the services provided by our clinic and similar clinics. There was a high prevalence of bipolar disorder (15.7%) and schizophrenia (8.7%) among the homeless patients attending the HOMES Clinic. Other studies have found an equally high prevalence of mental illness among low-income and homeless people in urban areas.11,14,24,25 HOMES Clinic patients with schizophrenia or bipolar disorder were significantly more likely than other clinic patients to have medical comorbidities of past illicit drug use, depression, cancer, kidney disease, asthma, heart disease, and seizures. Additionally, only 64.3% of the patients with one of these serious mental illnesses were using a psychiatric medication; this may indicate that many of these patients were not receiving adequate psychiatric care, perhaps because of a lack of access. However, the finding that patients with bipolar disorder or schizophrenia were more likely than others to be insured suggests that some of these patients may have access to care but do not use it. These patients may have poor insight into their illness and perhaps need more intensive management26 than a student-managed clinic can provide.
The results of this study have a number of implications for the more than 100 student-managed clinics across the United States that are often the only source of medical care for homeless patients.27 A nationwide survey found that the major contributors of financial assistance to medical student-managed clinics are private or community grants and student fundraising efforts, and the median annual operating budget is $12,000.27 Given limited grant opportunities (e.g., the American Psychiatric Foundation’s $5,000 Helping Hands Grant), student-managed clinics may find it difficult to fund mental health services and medications adequately. The competing priorities and comorbidities common in the homeless population require health care providers to find ways to integrate behavioral health care into primary care visits to ensure that each visit provides the broadest and most cost-effective health coverage possible.28 The proper management of psychiatric medication regimens cannot be accomplished in the span of one visit to a student-managed clinic. The adequate follow-up, end-point evaluation, dose adjustments, and, at times, polypharmacy necessary to achieve optimal therapy for mental illnesses29 are difficult to provide at a student-managed clinic because of the transient nature of the population served and the clinic’s inability to establish continuity of care. Further complicating these issues is the fact that many patients with mental illness have multiple medical comorbidities, as demonstrated by this study and others30–32 the increased difficulty of also controlling these chronic conditions33 must be taken into consideration. To address these issues, student-managed clinics should emphasize collaboration with local organizations that can provide assistance to such patients. Student clinic leaders can identify these organizations through the National Mental Health Information Center run by the U.S. Department of Health and Human Service’s Substance Abuse and Mental Health Service Administration.
Integration of behavioral health and medical services is an optimal strategy that has been successfully implemented in a variety of settings,34–36 but it is difficult to achieve in practice. Nonetheless, there are a number of strategies that student-managed clinics, as well as other community clinics, can undertake to provide care for patients with mental illness and other medical comorbidities. Many coordinated community interventions for the psychiatric care of homeless individuals are based on the program for assertive community treatment (ACT),37 in which the patient is assigned to a team consisting of a clinical case manager (with a case load of 10–12 patients), an attending psychiatrist, and a consumer advocate, all of whom are available 24 hours a day.38 These programs have been shown to increase medication compliance rates,39 be cost-effective, and reduce homelessness.40 The success of ACT programs depends on their integration with other local resources, which vary. Other integrated programs have been reviewed in detail.41
Such integrated models may be difficult for student-managed clinics to implement because of a lack of funding. Identifying local ACT programs that target homeless individuals with mental illness would allow student volunteers to make appointments (not just provide referrals) for patients who visit their clinics. In cases where patients are experiencing acute psychotic episodes, HOMES student volunteers (under the supervision of an attending physician) call the Mental Health Mental Retardation Authority of Harris County to inquire about the availability of beds in the inpatient psychiatric emergency unit and to arrange for possible emergency evaluation and treatment.
In addition, street medicine is emerging as a method of directly engaging with homeless individuals where they reside.42 Given the environmental limitations that lead to informal clinical settings, proposed outcome measures for this nascent field include patients’ engagement and their self-reported well-being.43 Student-managed clinics with a large volunteer base could assemble mobile teams of students and supervising clinicians to reach out to homeless individuals on the street. These teams would focus on assessing patients’ mental health and could refer individuals with medical conditions to the clinic at its physical location. Although this method is not ideal, its limitations should not preclude student-managed clinics from forming such offshoots. However, it would be important to assess the reproducibility and effect of such interventions, even in terms of short-term outcomes. According to Lam and Rosenheck,44 “Street outreach to homeless persons with serious mental illness is justified as these clients are more severely impaired, have more basic service needs, are less motivated to seek treatment, and take longer to engage than those contacted in other settings.”
There are additionally a variety of other social services and systems of health care delivery that are directed toward homeless individuals with mental illness. These include shelter-based interventions,45 24-hour psychiatric outreach services,46 outpatient or community mental health centers,47 street medicine,48 and multicomponent programs such as the Choices program,49 which provides outreach and engagement, a center with resources (e.g., food, showers), respite housing, and rehabilitation services to help individuals find housing. The HOMES Clinic is similar to the Choices program in that it is located next to the Beacon, a day shelter open Fridays through Mondays where homeless individuals can be indoors, sit around tables to socialize, receive food, do laundry, and shower. However, the HOMES Clinic does not employ an ACT-like integrated delivery of social services; rather, it uses a teaching model to educate student volunteers.22 To address such needs, student-managed clinics could maintain updated databases of social services offered at the city, county, state, and federal levels, which would empower student volunteers to contact these organizations on their patients’ behalf. Social work students could also be encouraged to participate in student-managed clinics. At the HOMES Clinic, social work students serve as the clinic managers who triage patients and connect them with social work and other community resources. In the Houston area, certain other clinics use dedicated psychiatric social workers to assist low-income patients with mental illness to get appropriate care.
This study has limitations, including its retrospective design and focus on a single clinical site. Other serious mental illnesses, such as depression, likely play a role in homelessness but were not examined in this study because of the difficulty in assessing severity retrospectively.50 Also, the HOMES Clinic operates only on Sundays; it is possible that the homeless patients who attend this clinic on Sundays may differ from those who attend clinics offered elsewhere during the week.
We found a high prevalence of psychiatric and medical comorbidity among the homeless patients served by our student-managed free clinic. Patients with such complicated issues raise a number of management concerns for student-run clinics, which often operate on a limited budget. Student leaders and faculty advisors of clinics for underserved populations may be able to make use of our findings in their efforts to leverage and improve clinic resources. These findings provide a framework for future studies designed to understand factors associated with homelessness in patients with mental illness and show the need for increased funding for the care of such patients in student-managed and community clinics.
Acknowledgments: The authors would like to thank the HOMES Clinic’s sponsoring organization, Healthcare for the Homeless–Houston (HHH), the Change Committee–HHH’s consumer advisory board, and the volunteers who make the clinic possible.
Other disclosures: None.
Ethical approval: This study was approved by the University of Texas Health Science Center at Houston Committee for the Protection of Human Subjects (HSC-MS-08-019) and the Baylor College of Medicine Institutional Review Board (H-23439).
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