Sunday, July 11, 2010

The Homeless Patient (Elise)

Recovery following an injury is difficult for any individual—but especially for a person who is homeless. As an employee of a county hospital, I often work with individuals who are homeless with very limited resources. These patients present a challenge to the rehab team for many reasons: 1) Multiple health problems secondary to prioritizing safety, shelter and food over non-emergent health needs; 2) Addiction to drugs or alcohol; 3) Mental health conditions; 4)Variety of educational levels (especially if did not complete high school education); 5) Lack of discharge destination, especially if the individual requires physical assistance or cognitive supervision; 6) Limited access to transportation for follow-up care after discharge. Consider these characteristics and add to them age-- how many years has the individual been homeless? How is homelessness impacting the aging process?

One past patient who comes to mind is Luke. He presented to the hospital after being struck by a bicycle while walking on the sidewalk. Only 55 years old, Luke had a history of alcohol abuse, prior knee problems due to a fall a few years prior, foot pain and bilateral lower extremity neuropathy (likely due to exposure to extremes in temperature). He looked and moved like a man much older than he was. As a result of the accident, he sustained an incomplete cervical spinal cord injury affecting his ability to move both his hands and his feet. Following surgical decompression and fusion to decrease consequences of cervical stenosis, Luke presented to rehab. His goal for therapy was to “Go back to the streets and continue working to collect cans.”

As a therapist, it is my responsibility to provide patient-centered care. This involves finding ways to motivate a patient to participate in therapy and helping the patient achieve his goals. If Luke was going to be able to function on the streets, he had to be able to get up/down off of the ground, be able to bend over to pick up cans/items from the ground, and be able to cross the street in adequate time on the crosswalk. In therapy, we worked hard on walking: progressing exercises from walking on the treadmill with a harness to overground walking with a walker on level indoor surfaces to outside on gravel/sand/concrete. We practiced navigating sidewalks, crossing the street, and carrying items on his walker while on grass. We talked about the importance of following up in outpatient, however we reviewed essential exercises (and progressions) in case this was not possible.

As the therapy team continued to discuss his progress and his discharge status, we realized that he was not going to be ready to discharge to a “standard” homeless shelter. A shelter discharge requires that a person will be completely independent with physical mobility/self-care and be able to manage medications. Los Angeles has a great new program for helping individuals who are homeless integrate into stable housing following hospital discharge (due to the common lack of follow-up after ER/hospital admissions). This “recuperative care” program allows an individual to discharge to a special type of shelter which provides a wide array of services to individuals recently discharged from hospitals. The goal of the program is to provide follow-up treatment (including transportation to medical appointments), education, stable housing, and job opportunities. Luke was a perfect candidate for the program, and he was very receptive to discharging there. The rehab team (physical therapist, occupational therapist, social worker) was able to visit the facility with Luke to assess his ability to access different areas using a walker, and to provide equipment recommendations (tub bench for showering). We were very impressed with the facility’s cleanliness and commitment to each individual’s success. It was a very supportive environment. Through these types of programs, it may be possible to decrease some of the negative complications of homelessness on recovery from injury and restoration of health.

For more information about the Los Angeles Recuperative Care Program, refer to:

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