Introduction
The increasing health disparities have created vulnerable groups that lack access to care of optimal quality and quantity (Pauly & Pagán, 2007). Thus, patients from these populations may not receive adequate medical attention during hospitalization, which exposes them to co-morbidities and complications. Vulnerability is a product of a complex interplay of unrelated factors, including immigrant status, lack of insurance and chronic illness, among others (Rasmor, Kooienga, Brown, & Probst, 2014). Patient advocacy is required when treating such vulnerable individuals. This paper is a personal reflection of clinical experiences with homeless drug users lacking optimal medical care compared to other populations.
Vulnerable Patients versus another Group
Homeless injection-drug abusers are a medically vulnerable group predisposed to high morbidity and limited access to high-quality care compared to non-drug users. Their complex medical and psychosocial needs mean that most providers are ill-equipped to care for them. For example, Boutin-Foster et al. (2013) note that people served by community health centers require access to social service resources to improve specific determinants of health. Injection-drug abusers are a medically underserved group that is more prone to chronic conditions than non-drug users are. They are “powerless to fix” health disparities such as “child abuse, domestic violence, or homelessness” on their own (Jones, 2010, p. 49). Most of them are uninsured and poor. Consequently, they delay treatment or fail to use preventive services, which results in frequent ED visits. In contrast, non-drug users have access to screening tests and early interventions.
Provider’s Management of Patient Needs
From my observation, homeless injection-drug users’ needs were not met in traditional care settings I have worked. Besides medical intervention (screening for hepatitis C), this group requires cognitive-behavioral therapy (CBT) that address multiple issues to encourage behavior change. Examples of key focus areas include patient attitude and knowledge (intrapersonal), provider collaboration, and provider-patient interaction (interpersonal) (Boutin-Foster et al., 2013). What I observed was that injection-drug users could not access integrated care, for example, hospital-based services (assessment and screening services), preventive care and follow-ups, and CBT, during clinical visits because of their vulnerable status (lack of health insurance) (Timmermans, Orrico, & Smith, 2014). As such, they are at risk of poor health outcomes with potential spillover effects on the insured population and social organizations.
An Example from My Clinical Practice
Vulnerable persons often present with complex health needs due to unaddressed determinants of health, such as housing, insurance, and diet, among others. One particular case involving a Hispanic man who was an alcoholic and used injection drugs exemplifies the challenges that vulnerable people face when seeking medical care. His primary diagnosis was hepatitis C. The patient worked as a casual laborer and was homeless. He relied on a community soup kitchen for his nutrition. He visited the facility for urgent issues only. His poor experiences with hospital care owing to his profile (uninsured, homeless, and drug addict) discouraged him from seeking specialized care. He could not keep up with his appointments for hepatitis C evaluation, predisposing him to other comorbidities.
How the Experience Affected Me
The above clinical experience with a vulnerable patient exposed me to the challenges that minority groups with complex needs go through. It changed my attitudes and perceptions of the homeless injection-drug users. I now understand that vulnerability can limit one’s access to quality primary care. It made me realize that people may be vulnerable because of circumstances beyond their control. For example, unemployment may have occasioned the above patient’s homeless status and related social risk of injection-drug use that caused hepatitis C. This clinical experience made me commit to patient advocacy through outreach programs in vulnerable community settings.
Practice Changes based on this Experience
Following my experience with the above patient, I made visits to his community to understand his living conditions and challenges he experienced in accessing healthcare. Through this outreach initiative, I gained trust from him. As a result, the patient agreed to visit the clinic for an evaluation before commencing hepatitis C therapy. Going forward, I will organize meet vulnerable patients in their community after the first encounter as a practice change to build effective therapeutic relationships.
Patient’s Feelings
During the first encounter at the hospital, the patient revealed his bad experiences with medical care. He felt that communication with the medical staff was a problem. He intimated that he only needed a quick relief for his abdominal pain. He did not understand the link between injection-drug use and his condition. He also felt that the liver-function tests and psychotherapy were an unnecessary expense given his uninsured status.
Follow-up Conversation
I made a follow-up conversation with the patient when I met him at the community soup kitchen. Through this visit, I was able to know his concerns and barriers to accessing quality care. I also a follow-up with the healthcare provider and an integrated treatment team (nurses, social worker, and a physician) to arrange for the patient’s interferon dose and manage any adverse effects. I also contacted his family members who helped offer emotional support during his recovery.
Management’s Handling of the Situation
The management was aware of this case. Their response involved establishing a mobile medical unit to reach out to homeless drug users with complex health needs in community settings. Through this outreach program and partnerships with local health centers, vulnerable people at risk of chronic conditions received preventive care. The management also undertook to support continuing education for clinicians to enable them to provide culturally competent care.
Conclusion
Vulnerable groups are at risk of poor health outcomes because of socioeconomic disadvantages. Homeless injection-drug users required integrated care to improve specific determinants of health. Healthcare providers, through outreach programs, can help this population receive optimal care and reduce disparities in access.
References
Boutin-Foster, C., Scott, E., Melendez, J., Rodriguez, A., Ramos, R., Kanna, B., Michelen, W. (2013). Ethical considerations for conducting health disparities research in community health centers: A social-ecological perspective. American Journal of Public Health, 103(12), 2179-2184. Web.
Jones, C. M. (2010). The moral problem of health disparities. American Journal of Public Health, 100(1), S47-S51. Web.
Pauly, M. V., & Pagán, J. A. (2007). Spillovers and vulnerability: The case of community uninsurance. Health Affairs, 26(5), 1304-1314. Web.
Rasmor, M., Kooienga, S., Brown, C., & Probst, T. M. (2014). United States nurse practitioner students’ attitudes, perceptions, and beliefs working with the uninsured. Nurse Education in Practice, 14, 591-597. Web.
Timmermans, S., Orrico, L. A., & Smith, J. (2014). Spillover effects of an uninsured population. Journal of Health and Social Behavior, 55(3), 360-374. Web.