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Guideline Summary
Guideline Title
Adapting your practice: treatment and recommendations for homeless patients with hypertension, hyperlipidemia & heart failure.
Bibliographic Source(s)
Strehlow A, Robertshaw D, Louison A, Lopez M, Colangelo B, Silver K, Post P. Adapting your practice: treatment and recommendations for homeless patients with hypertension, hyperlipidemia & heart failure. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2009 Dec 31. 53 p. [73 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Brammer S, Gee B, Hale A, Kopydlowski MA, Post P, Rabiner M, Reller C, Strehlow A. Adapting your practice: treatment and recommendations for homeless patients with cardiovascular diseases. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2004. 44 p. [33 references]

Scope

Disease/Condition(s)

Cardiovascular diseases, including:

  • Hypertension
  • Hyperlipidemia
  • Heart failure
Guideline Category
Counseling
Diagnosis
Evaluation
Management
Prevention
Treatment
Clinical Specialty
Cardiology
Emergency Medicine
Family Practice
Internal Medicine
Nursing
Nutrition
Preventive Medicine
Psychology
Intended Users
Advanced Practice Nurses
Dietitians
Emergency Medical Technicians/Paramedics
Health Care Providers
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Social Workers
Students
Substance Use Disorders Treatment Providers
Guideline Objective(s)
  • To provide helpful guidance to primary care providers serving individuals who are homeless
  • To contribute to improvements in both quality of care and quality of life for these patients
Target Population

Homeless adults with hypertension, hyperlipidemia, and/or heart failure

Interventions and Practices Considered

Diagnosis and Evaluation

  1. History including assessment of living conditions, medical status, mental health, family health, social conditions, smoking status, drug use, and activity level
  2. Physical examination including height, weight, body mass index, % body fat, abdominal girth, heart, blood pressure, lungs, thyroid, abdomen, funduscopic, peripheral pulses, dermatological assessment, oral/dental status, lung status, liver function, and lower extremities assessment
  3. Diagnostic tests including general laboratory panels, fasting lipid profile, fasting blood glucose, complete blood count, urinalysis, urine microalbumin:creatinine ratio, annual electrocardiogram, serum creatinine and potassium levels, non-fasting total cholesterol and high-density lipoprotein, direct measurement low-density lipoprotein, liver function tests, baseline chest x-ray, depression screening, and cognitive assessment

Management and Treatment

  1. Plan of care including disease management goals, encouraging patient adherence, assistance with food stamps, Social Security Disability Insurance/Supplemental Security Income, Medicaid/Medicare, and subsidized housing
  2. Education/self-management plans including self-management goals, diet/nutrition recommendations, patient instructions, written materials, portable information, exercise plans, fluids intake recommendation as needed, healthcare access assistance, harm reduction counseling, weight measurement, and education of food workers
  3. Follow-up including contact information, outreach, case management, and frequent visits
  4. Medications including information on initiation, dosing and frequency, specific information on diuretics, antihypertensives, statin therapy, immunizations, and pharmaceutical patient assistance programs
  5. Management/prevention of associated problems and complications including medication toxicity; liver disease; myopathy/rhabdomyolysis; edema; orthopnea; physical/cognitive limitations; literacy/language limitations; the presence of multiple comorbidities; chemical dependencies; assistance with lost, stolen medications; managing risks associated with transience, lack of transportation, and lack of housing and income
  6. Outreach and management strategies including outreach sites coordination, clinical team development, the importance of nonjudgmental care delivery, incentives, and patient privacy
  7. Service delivery design implementation including incorporating current standards of care, providing integrated, interdisciplinary services, flexible clinic schedules, and personal hygiene facilities
Major Outcomes Considered
  • Mortality from cardiovascular disease
  • Levels and changes in diagnostic indicators (e.g., blood pressure [BP], fasting lipid profile, body weight)
  • Frequency of clinical assessment
  • Adherence to treatment and self-management goals
  • Incidence of comorbidities and associated syndromes (e.g., type 2 diabetes, metabolic syndrome, depression, poor dental health, substance abuse)
  • Health disparities between homeless and general U.S. populations
  • Frequency of hospitalization

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The following electronic databases were searched for literature published between 2004 and 2009: MEDLINE/PubMed, Medscape, SocABS, PsycInfo, and Health Care for the Homeless Research Updates (published quarterly by the National Health Care for the Homeless Council: www.nhchc.org/researchupdates.html External Web Site Policy). References cited in this adapted clinical guideline were also identified through online searches of the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Homelessness Resource Center, the Agency for Healthcare Research and Quality's (AHRQ's) National Guideline Clearinghouse, and bibliographies of relevant reports and periodicals published by the National Health Care for the Homeless Council (www.nhchc.org/publications.html External Web Site Policy).

In order to distinguish homeless populations from the general population (or from domiciled cohorts in studies where such distinctions were possible), "homeless" was used an inclusion criterion in searching for statistical data that were cited in the Introduction.

Search terms included: homeless and (cardiovascular diseases or hypertension or high blood pressure or hyperlipidemia or high cholesterol or heart failure); homeless and (substance use disorders or substance dependence or substance abuse or alcoholism or drug addiction or smoking); periodontal disease and cardiovascular diseases; stress and cardiovascular diseases.

Number of Source Documents

This guideline is adapted from three primary sources (see the "Adaptation" field).

Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Review of Published Meta-Analyses
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Recommendations for the care of homeless adults with cardiovascular disease were initially developed in 2004 by primary care providers working in homeless health care across the United States.* A second advisory committee, convened in 2009, reviewed and revised these recommended practice adaptations to assure their consistency with current clinical standards for the diagnosis and management of cardiovascular diseases commonly seen in homeless populations, and with best practices in homeless health care.

*An Advisory Committee comprised of seven health and social service providers experienced in the care of homeless individuals with cardiovascular diseases devoted several months during 2003–2004 to development of these adapted clinical guidelines, drawing from their own experience and from that of their colleagues in Health Care for the Homeless projects across the United States. The adaptations reflect their collective experience in serving homeless people with hypertension, hyperlipidemia, and/or heart failure.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

The clinicians who reviewed and commented on the draft recommendations prior to publication are listed in the original guideline document.

Recommendations

Major Recommendations

Assessment

History

  • Living conditions – Ask at every visit: Where did you stay last night? Where do you eat and spend time during the day? Is there a place to store medicine? How can you be contacted? Are you living alone?
  • Medical – Heart/lung disease, kidney/liver problems, cardiac risk factors (high blood pressure [BP]/cholesterol, diabetes); hospitalizations; medications that may elevate blood glucose/lipid levels (newer anti-psychotics); immunizations, allergies, prescription drug coverage, other health care providers.
  • Mental health – Mental illness, head injury, problem with speech/memory/thinking/interacting with others; education completed, special education, literacy. Ever treated for anxiety or depression? Feeling anxious or depressed? Assess ability to take pills daily and remember to return for follow-up.
  • Family – High BP, heart attack, stroke?
  • Social – Cultural/ethnic heritage.
  • Diet – Control over food choice and preparation? Foods high in cholesterol, saturated fats, sodium? Beverages containing alcohol, caffeine? Add salt to foods?
  • Smoking – What do you smoke and in what form? Do you want help quitting?
  • Drug use – Alcohol, cocaine, caffeine, amphetamines, ephedra (cause/exacerbate hypertension [HTN], cardiomyopathy); injecting-drug use (IDU) (risk of cardiac infection leading to heart failure). Comprehensive assessment by alcohol and drug (A&D) counselor/social worker optimal.
  • Activity level – Usual physical activities (e.g., walking: How far in blocks?).

Physical Examination

  • Standard – Height, weight, body mass index (BMI), % body fat, abdominal girth, heart, BP (with feet flat on floor, at least 1 hour after smoking or drinking caffeine), lungs, thyroid, abdomen, funduscopic, peripheral pulses.
  • Dermatological – Acanthosis nigricans and skin tags, prevalent in metabolic syndrome.
  • Oral – Poor dentition, oral lesions (periodontal disease and abscesses linked to coronary artery disease [CAD]). Calcium channel blockers, blood thinners, meds that cause dry mouth may exacerbate gum problems.
  • Lungs – Rales (sign of heart failure); wheezes/rhonchi (with concomitant chronic obstructive lung disease [COPD], common among homeless smokers).
  • Liver – Hepatic congestion in right-sided heart failure may be difficult to differentiate from hepatomegaly due to underlying liver disease. Look for fluid waves.
  • Lower extremities – Examine with shoes removed. Differentiate swelling due to heart failure from dependent edema secondary to sleeping upright on park benches, sitting in chairs, excessive walking. Pitting vs. non-pitting edema.

Diagnostic Tests

  • Outreach settings/clinics with limited laboratory access – Finger stick glucose checks, cholesterol screens, urine dips. Use glucometer, test strips, cholesterol/lipid meter, Hemaccue, throw-away HbA1c kits. Do blood work in shelter kitchens prior to breakfast/evening meal; consider incentives. Refer abnormal results for further work-up.
  • General laboratory panels – Fasting lipid profile, fasting blood glucose, complete blood count (CBC), urinalysis, urine microalbumin:creatinine ratio annually, electrocardiogram (EKG); serum creatinine and potassium levels. If fasting is problematic, consider non-fasting glucose (100–125 for impaired fasting glucose, >200 x 2, diagnostic for diabetes mellitus type 2 [DM II]), non-fasting total cholesterol and high-density lipoprotein (HDL), direct measurement low-density lipoprotein (LDL) (if available, affordable).
  • Liver function test (LFT) – Reserve lab screening for patients meeting risk-based indications for testing. Assess for hepatitis B virus (HBV), hepatitis C virus (HCV), cirrhosis, if history of IDU/alcoholism. Monitor closely if on statins.
  • Baseline chest X-ray (CXR) and EKG – If suspected of heart failure. N.B.: cardiomegaly, prior myocardial infarction (MI), left ventricular hypertrophy (LVH), cardiac arrhythmia. (EKG may be difficult to interpret if no prior tracing for comparison.)
  • Echocardiogram – Consider stress test if symptoms/risk factors for CAD.
  • Depression screening – 9-item Patient Health Questionnaire (PHQ–9) or 2-item prescreen (PHQ-2).
  • Cognitive assessment – Mini-Mental State Examination (MMSE); assess regularly for cognitive impairment related to long-term alcohol/drug use, normal aging.
  • Test results – Community voice mail (if available) to report test results, case manager to facilitate return to clinic. Provide latest BP, creatinine, potassium, cholesterol, lipoprotein levels on wallet-sized card.

Management

Plan of Care

  • Disease management goals – Standard BP, cholesterol, triglyceride goals. Homeless patient may require initiation of drug therapy sooner, less reliance on lifestyle modification. Try to determine etiology of heart failure (alcohol/drug-related, human immunodeficiency virus [HIV], CAD, hypertension, lung disease/smoking).
  • Adherence – At every visit, discuss plan of care; ask if anything is unclear or difficult; address obstacles to adherence. Explain risk of heart attack from high cholesterol/triglycerides. Stress importance of adhering to plan of care even if you don't feel sick.
  • Benefits assistance – Assess eligibility for food stamps, Supplemental Security Income (SSI)/Social Security Disability Insurance (SSDI), Medicaid/Medicare, subsidized housing; help with applications.

Education/Self-management

  • Self-management goals – Encourage selection of own goals; discuss how to accomplish weekly visit to check BP, review meds. Offer incentive if improvement noted.
  • Diet/nutrition – Food preferences, appropriate diet, examples of healthy choices where food is obtained, portion control, preparation methods, how to interpret nutrition information on labels. Refer to nutritionist, preferably on clinical team. Advocate for more nutritious food in shelters and soup kitchens. Provide heart-healthy snacks. Help apply for food stamps.
  • Patient instruction – Simple terms, in patient's first language; interpreter if needed. Ask to repeat instructions to assess understanding.
  • Written materials – Language-appropriate, simple terms, large print, graphic illustrations. Don't presume can't read/understand just because homeless.
  • Portable information – Wallet-sized card specifying latest BP, creatinine, glucose, blood urea nitrogen (BUN), potassium levels; weight; cholesterol; lipoproteins.
  • Exercise – Benefits of aerobic exercise (may decrease swelling in legs/feet), where and how to do it. Alternatives to intensive weight-bearing for obese patients: chair exercises, leg lifts, hand weights (books, soup cans, water bottles).
  • Fluids – If fluid restriction needed, specify amount to drink each day (more fluids during hot weather); provide reusable water bottle.
  • Health insurance – If uninsured and eligibility likely, urge application/reapplication for Medicaid, SSI/SSDI—important for specialty referrals (diabetic educator, cardiologist).
  • Harm reduction – Explain risks associated with HTN/hyperlipidemia (heart attack, stroke, disability). Suggest strategies to minimize damage caused by alcohol, nicotine, other drugs. Stress importance of taking prescribed meds even while actively using. Use motivational interviewing to promote readiness for treatment/therapy; list referral resources.
  • Weight measuring – Teach how to check weight properly; allow self-checks in clinic without waiting. Explain implications of weight gain with worsening symptoms.
  • Education of food workers – About dietary needs of cardiovascular disease (CVD) patients. Encourage more nutritious food options and preparation methods, use of salt substitute; provide samples. Collaborate with senior centers/hospitals/nutrition education programs to educate staff/volunteers in shelters and soup kitchens.

Follow-up

  • Contact information – Verify at every visit: phone/cell numbers, e-mail address; ask where staying, usually sleeps, obtains meals. Request address/phone number of family member/friend/case manager with stable address to contact in an emergency.
  • Outreach, case management – To facilitate adherence, follow-up care, referrals. Provide outreach to homeless shelters; invite residents to clinic for screenings; offer incentives (meal, transportation). Provide card with clinic location, phone number, hours of operation. Find creative ways to make patient want to follow up with you.
  • Frequency – Weekly/biweekly/monthly visits to monitor weight/BP/cholesterol control, increase rapport, reinforce understanding of care plan, identify and promptly address complications/adherence problems. Encourage regular follow-up even if adherence is poor. Don't be punitive; increase adherence by decreasing barriers to care.

Treatment

Medications

  • When to start – At initial visit if unlikely to return for follow-up.
  • Diuretics – Can exacerbate dehydration; dangerous/fatal levels of hyperpyrexia triggered by anticholinergic meds (phenothiazines) with diuretics in hot, humid environments. If limited access to water/bathroom facilities or unable to return for lab tests, use alternative meds as appropriate. Advocate for easy access to potable water and restrooms for homeless persons.
  • Antihypertensives – Once daily dosing optimal. If trouble with adherence likely, use beta-blockers. Clonidine can alleviate withdrawal HTN in patients recovering from alcohol/opioid addiction who are unable to obtain inpatient detox (commonly used to enhance/prolong effects of heroin); use cautiously to avoid serious rebound HTN.
  • Statins – Continue until LFTs 2 to 3 times normal limits barring complications. Less expensive alternatives: Niacin to lower LDL cholesterol, increase HDL cholesterol; bulk laxatives (psyllium) with low-fat diet to lower serum cholesterol with mild to moderate hypercholesterolemia (difficult if limited access to appropriate liquid/toilet facilities); metformin to promote weight loss, preserve pancreatic function with DM II.
  • Simple regimen – Appropriate to diagnosis and living situation, considering availability, expense, side effects, duration of treatment. Daily dosing with evening meal, if possible. Consider combination meds (beta blockers/diuretics, angiotensin II receptor blockers [ARBs]/diuretics, calcium channel blockers [CCBs]/ARBs) available from patient assistance programs.
  • Dispensing – Consider dispensing small amounts of medications to encourage return for follow-up, reduce risk of loss/theft/misuse.
  • Dosing frequency – Pre-filled, portable medication boxes if once-daily dosing impossible. If meds are stored in shelter, explain to staff why some residents need to take them more than once a day.
  • Pharmaceutical patient assistance programs – Reduced cost meds from drug companies, retail chains, 340B Drug Pricing Program (if eligible); help with applications. Use generics, if available and medically indicated. Consider free samples until continued supply of prescribed meds is available.
  • Immunizations – Influenza vaccine annually, pneumococcal vaccine according to standard clinical guidelines.

Associated Problems, Complications

  • Medication toxicity – Nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, CCBs (especially diltiazem and verapamil), and diabetes medications (metformin, thiazolidinediones) may exacerbate heart failure.
  • Liver disease – Hepatitis B/C, alcoholic cirrhosis. Monitor liver function at baseline and 1 to 3 months following initiation of statin therapy.
  • Myopathy/rhabdomyolysis – From alcohol/drug abuse, hepatitis, uncontrolled seizures; side effect of nefazodone, some HIV meds. Symptoms: muscle aches, soreness, weakness (may also be related to exertion, trauma, comorbidities). Monitor creatine kinase (CK) levels.
  • Edema – Dependent edema may mask/exacerbate edema due to heart failure. If no place to elevate feet during day, sit on ground to decrease swelling; if living in car, lie down with legs elevated on back of seat.
  • Orthopnea – Educate shelter providers about need of persons with heart failure to sleep with head slightly elevated. Provide pillows if unavailable in shelters.
  • Physical/cognitive limitations – Secondary to substance abuse/trauma/mental illness. Tailor plan of care to patient needs and capacities.
  • Literacy/language limitations – Can lead to serious complications, loss to follow-up. Ask if patient has "trouble reading"; provide interpreter if English proficiency limited.
  • Multiple comorbidities – MI, cerebrovascular accident (CVA), organ damage from uncontrolled CVD and comorbidities (emphysema, alcoholic cirrhosis, hepatitis, diabetes, HIV, psychiatric disorders). Cardiology referral for older patients with hyperlipidemia/metabolic syndrome/tobacco abuse/family history of CAD.
  • Chemical dependencies – Nicotine, alcohol, cocaine, amphetamines, ephedra contribute to cardiac arrhythmia, acute HTN, stroke, heart attack, cardiomyopathy, heart failure. Motivational interviewing to promote readiness for concurrent treatment of substance abuse and CVD.
  • Lost, stolen medications – Public insurance may not cover replacement. Dispensing one-week supply can reduce risk of loss, improve adherence, allow for closer follow-up.
  • Transience – Increases risk of discontinuous, episodic, crisis care. Use incentives (food, coupons) to encourage follow-up. Provide pocket card listing latest test results, vital signs, current meds to document medical history for other providers.
  • Lack of transportation – Provide carfare. Assess for mobility impairment; provide documentation to help impaired persons get mobility pass. Use outreach teams/fire departments/other agencies to monitor BP in the field.
  • Lifestyle limitations – Limited food choice, physical impairments, lack of safe place to exercise, inappropriate footwear. Educate about Dietary Approaches to Stop Hypertension (DASH) diet and importance of limiting sodium intake; discuss feasible exercise alternatives.
  • Lack of housing and income – Explore availability of low-barrier permanent housing with optional supportive services or convalescent care for patients with severe illness/impairments. Document medical conditions and functional status with cognizance of disability criteria for SSI/SSDI eligibility.

Model of Care

Outreach and Management

  • Outreach sites – Wherever homeless people congregate or receive services. Teach non-medical staff to measure BP; provide written notes to shelters requesting leg elevation privileges for persons with edema.
  • Clinical team – Outreach workers, case managers, mental health professionals, substance abuse counselors, nutritionist, medical and social service providers proficient in languages used by populations served. Involve patient in care planning and coordination to facilitate engagement, diagnosis, treatment, follow-up. Train clients as health promoters.
  • Nonjudgmental care – Essential for successful engagement in trusting therapeutic relationship, instrumental in motivating adherence to plan of care.
  • Incentives – Food and drink/vouchers, hygiene products (toothpaste, hotel soaps/toiletries, brushes, socks), subway/bus cards/tokens—to promote engagement
  • Patient privacy – Be sensitive to self-consciousness about poor hygiene, possible history of interpersonal violence/sexual abuse; bring homeless patients to examining room as soon as possible.

Service Delivery Design

  • Standard of care – Elimination of health disparities between homeless and general population should be clinical goal.
  • Multiple sites – Offer BP checks wherever homeless people receive services. Consider use of electronic medical records to promote continuity of care across service sites.
  • Integrated, interdisciplinary services – Coordinate medical and psychosocial services across multiple disciplines and delivery systems, optimally accessible at same location. Resolution of homelessness should be a central goal of health care team.
  • Flexible clinic schedules – Provide walk-in clinics/designated slots or providers for walk-in patients so appointments aren't necessary. Allow self-checking of BP in clinic on walk-in basis; patients with elevated BP should always be seen by a provider.
  • Early appointments – If fasting, schedule for early clinic appointment. To make fasting easier, offer healthy snacks in clinic after diagnostic testing.
  • Hygiene – Provide shower facilities at clinics and personal hygiene kits, where possible.

Note: All recommendations for the treatment of homeless patients with heart failure presuppose use of the Model of Care described in the "Description of the Implementation Strategy" field.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Use of this guideline will increase opportunities for homeless patients to receive the optimum standard of care and ultimately reduce mortality as a result of uncontrolled cardiovascular disease.

Potential Harms
  • Diuretics can exacerbate dehydration, particularly in warmer climates, for persons with limited access to water.
  • Dangerous (even fatal) levels of hyperpyrexia can be triggered by anticholinergic medications in combinations with diuretics in hot, humid environments without adequate hydration.
  • Beta-blockers and clonidine should be prescribed with caution, since discontinuing these medications suddenly can result in serious rebound hypertension.
  • At initiation, beta-blockers can exacerbate depression.
  • Clonidine can be misused by persons with chemical dependencies to prolong effects of heroin and other opioids.
  • Statins may worsen health outcomes in persons with chronic transaminase elevations secondary to hepatitis B or C or in chronic alcohol users.
  • Nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, calcium channel blocker (especially diltiazem and verapamil), and diabetes medications (metformin, thiazolidinediones) may exacerbate heart failure.

Contraindications

Contraindications

Ask if the patient drinks alcohol, and if so, how much and how often. This may affect the decision to prescribe statin medications, which may be contraindicated by altered liver function tests.

Qualifying Statements

Qualifying Statements
  • The information and opinions expressed in the guideline are those of the Advisory Committee on Adapting Clinical Guidelines for Homeless Patients with Cardiovascular Diseases, not necessarily the views of the U.S. Department of Health and Human Services, the Health Resources and Services Administration, or the National Health Care for the Homeless Council, Inc.
  • Recommendations found in the source standard clinical guidelines are not restated in this document except to clarify a particular adaptation for homeless patients or to identify higher health risks for homeless populations. The recommended practice adaptations are intended to supplement—not to supplant—the standard clinical guidelines listed in the "Adaptation" field.

Implementation of the Guideline

Description of Implementation Strategy

All recommendations for the treatment of homeless patients presuppose use of the following model of care.

Model of Care

Outreach and Engagement

Outreach sites – Conduct outreach on the streets, in soup kitchens, in shelters and other places where homeless people receive services. Teach non-medical staff to measure blood pressure at outreach sites. Educate outreach workers to look for swelling of lower extremities and encourage persons with edema to seek care. Instruct regarding proper cuff sizes, arm positioning. Reliable portable electric BP measurement equipment can be transported to outreach shelters. Remember to calibrate frequently. Monitor non-medical staff until you feel comfortable with their skills. Teaching vital signs measurement to non-medical personnel can be very useful. Educate outreach workers to look for swelling of lower extremities and encourage persons with edema to elevate legs whenever possible and to seek further medical care. Consider providing written notes to shelters requesting leg elevation privileges for persons with edema.

Clinical team – Include both medical and social service providers on the clinical team. Hire staff proficient in languages used by the populations you serve. Use outreach workers and case managers to promote initial engagement with the patient. Involvement of all team members—outreach workers, case managers, mental health professionals, substance abuse counselors, and a nutritionist—in care planning and coordination is important to facilitate engagement, diagnosis, treatment, and follow-up of persons experiencing homelessness. Consider training clients as health promoters; help highly motivated individuals find a Medical Assistant course.

Nonjudgmental care – Nonjudgmental and supportive patient interactions with members of the clinical team are essential for successful engagement in a trusting therapeutic relationship, which is instrumental in motivating adherence to plan of care. Work with the patient to meet basic human needs including food, clothing, and shelter.

Incentives – Offer incentives to promote engagement—e.g., food and drink (or vouchers for same), hygiene products (toothpaste, brushes, socks), subway/bus cards or tokens. If possible, provide hygiene supplies, such as hotel soaps and toiletries (body wash, shampoo, lotion).

Patient privacy – Bring homeless patients to examining rooms as soon as possible. Be sensitive to self-consciousness about poor hygiene, over which people experiencing homelessness may have little control. Recognize that many homeless individuals have experienced interpersonal violence and/or sexual abuse, and may not feel safe waiting for extended periods in public settings. Differentiate patients who are experiencing emotional problems from those who simply don't have access to showers, and provide appropriate interventions accordingly.

Service Delivery Design

Standard of care – Health care providers are challenged to provide the same evidence-based standard of care to patients who are homeless as to those who have more resources. Although meeting desired outcomes can be more challenging with homeless patients, elimination of health disparities between these patients and the general population should be clinical goal.

Multiple sites – Provide primary care at multiple points of service (e.g., clinics, drop-in centers, outreach sites), as feasible. Offer blood pressure checks at all sites where homeless people receive services. Have a scale available for patients to weigh themselves. Consider use of electronic medical records, if feasible, to promote continuity of care among multiple service sites.

Integrated, interdisciplinary services – Coordinate medical and psychosocial services across multiple disciplines and delivery systems, including provision of food, housing, and transportation to service sites. Optimally, medical and psychosocial services should be easily accessible at the same location; fragmented service systems do not work well for homeless people. Resolution of the patient's homelessness is prerequisite to resolution of numerous health problems, and should be a central goal of health care team.

Flexible clinic schedules – Appointments are frequently missed by homeless patients. Provide walk-in clinics or designated slots for walk-in patients at every primary care clinic, so that appointments aren't necessary. Designate one or two walk-in providers during each clinic session to see new patients or returning patients who may have missed a primary care appointment. Allow patients to check their blood pressure in the clinic on a walk-in basis; those with elevated blood pressure should always be seen by a provider.

Early appointments – Allow homeless patients easy access to early clinic appointments, especially if they are fasting. (Some soup kitchens serve meals early; requiring homeless patients to fast may prevent them from getting something to eat until many hours later.) Offer healthy snacks in clinic to make it easier for homeless patients to agree to fast before diagnostic tests are done.

Hygiene – Provide shower facilities at clinics and personal hygiene kits, where possible.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Strehlow A, Robertshaw D, Louison A, Lopez M, Colangelo B, Silver K, Post P. Adapting your practice: treatment and recommendations for homeless patients with hypertension, hyperlipidemia & heart failure. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2009 Dec 31. 53 p. [73 references]
Adaptation

This guideline was adapted from the following sources:

  • National Heart, Lung, and Blood Institute/National Institutes of Health/US Department of Health and Human Services. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), May 2003: www.nhlbi.nih.gov/guidelines/hypertension/index.htm External Web Site Policy.
  • National Heart, Lung, and Blood Institute/National Institutes of Health/US Department of Health and Human Services. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), May 2001: www.nhlbi.nih.gov/guidelines/cholesterol/atp_iii.htm External Web Site Policy.
  • American College of Cardiology/American Heart Association. 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults, March 2009. http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.11.013 External Web Site Policy.
Date Released
2004 (revised 2009 Dec)
Guideline Developer(s)
Health Care for the Homeless (HCH) Clinician's Network - Medical Specialty Society
National Health Care for the Homeless Council, Inc. - Nonprofit Organization
Source(s) of Funding

The Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services

Guideline Committee

Advisory Committee on Adapting Clinical Guidelines for Homeless Patients with Cardiovascular Diseases

Composition of Group That Authored the Guideline

2009 Committee Members: Aaron J. Strehlow, PhD, FNP-C, RN, UCLA School of Nursing Health Center at the Union Rescue Mission Los Angeles, California; Danielle C. Robertshaw, MD, Health Care for the Homeless, Baltimore, Maryland; Anita Louison, PA-C, Swope Health Services, Kansas City, Missouri; Manuela Lopez, RN, Health Care for the Homeless, Austin Resource Center for the Homeless, Austin, Texas; Brian Colangelo, LCSW, Project H.O.P.E. (Homeless Outreach Program Enrichment), Camden, New Jersey; Kelvin Silver, Med, LCADC, CRC, LPC, Health Care for the Homeless, Baltimore, Maryland; Patricia Post, MPA (Editor), HCH Clinicians' Network, National Health Care for the Homeless Council, Nashville, Tennessee

2004 Committee Members: Sharon W. Brammer, FNP, Franklin Primary Health Center, Mobile, Alabama; Betsy L. Gee, BS, Southwest Community Health Center, McKinney Health Care for the Homeless, Bridgeport, Connecticut; Abby Hale, PA-C, Community Health Center of Burlington Homeless Health Program, Burlington, Vermont; Mary Ann Kopydlowski, BSN, RN, Boston Health Care for the Homeless Program, Jamaica Plain, Massachusetts; Mark Rabiner, MD, Saint Vincent's Catholic Medical Centers, Saint Vincents Manhattan, New York, New York; Christine Reller, MSN, RN, Hennepin County Community Health Department, Health Care for the Homeless Project, Minneapolis, Minnesota; Aaron Strehlow, PhD, FNP-C, RN, UCLA School of Nursing Health Center at the Union Rescue Mission, Los Angeles, California; Patricia Post, MPA (Editor); HCH Clinicians' Network, National Health; Care for the Homeless Council; Nashville, Tennessee

Financial Disclosures/Conflicts of Interest

The Heath Care for the Homeless (HCH) Clinicians' Network has a stated policy concerning conflict of interest. First, that all transactions will be conducted in a manner to avoid any conflict of interest. Secondly, should situations arise where a member is involved in activities, practices, or other acts which conflict with the interests of the Network and its Membership, the member is required to disclose such conflicts of interest, and excuse him- or herself from particular decisions where such conflicts of interest exist.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Brammer S, Gee B, Hale A, Kopydlowski MA, Post P, Rabiner M, Reller C, Strehlow A. Adapting your practice: treatment and recommendations for homeless patients with cardiovascular diseases. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2004. 44 p. [33 references]

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the National Health Care for the Homeless Council, Inc. Web site External Web Site Policy.

Print copies: Available from the National Health Care for the Homeless Council, Inc., P.O. Box 60427, Nashville, TN 37206-0427; Phone: (615) 226-2292

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on May 24, 2004. The information was verified by the guideline developer on June 24, 2004. This summary was updated by ECRI Institute on June 30, 2010. This summary was updated by ECRI Institute on June 27, 2011 following the U.S. Food and Drug Administration advisory on Zocor (simvastatin). This summary was updated by ECRI Institute on April 13, 2012 following the U.S. Food and Drug Administration advisories on Statin Drugs and Statins and HIV or Hepatitis C drugs.

Copyright Statement

All material in this document is in the public domain and may be used and reprinted without special permission. Citation as to source, however, is appreciated. Suggested citation:

Strehlow A, Robertshaw D, Louison A, Lopez M, Colangelo B, Silver K, Post P. Adapting Your Practice: Treatment and Recommendations for Homeless Patients with Hypertension, Hyperlipidemia & Heart Failure, 53 pages. Nashville: Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc., 2009.

Disclaimer

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