Leah Wonderful, PharmDCommunity-University Health Care CenterUniversity of Minnesota Ambulatory Care Residency ProgramAcademic DayMarch 11, 2016

Vita

ls • BP 127/85• HR 87• RR 20• Ht 5’6”• Wt 122 kg• BMI 43 M

edic

atio

ns • Lisinopril 40 mg daily

• Spironolactone 50 mg daily

• Amlodipine 5 mg daily

• ASA 81 mg daily• Vitamin D 1000 mg

daily• Terbinafine 250 mg

daily (not started)• Metoprolol succ.

150 mg daily

Labs • Na 140

• K 4.0• Cl 108• CO2 23• Glu 171• BUN 19• Cr 1.48• Alb 3.5• A1c 6.0• Hep C

genotype 1a or 1b

Prediabetes ObesityCKD

Stage III

HomelessHistory of latent TB Hypertension

Alcohol Dependence DepressionChronic

Hepatitis C

Homeless

A homeless individual is defined in section 330(h)(5)(A) as “an individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations, and an individual who is a resident in transitional housing.” -Section 330 of the Public Health Service Act (42 U.S.C., 254b)

Photo by Hindrik S - Creative Commons Attribution-NonCommercial-ShareAlike License https://www.flickr.com/photos/63991153@N00 Created with Haiku Deck

• Systems• Adult• Family• Youth• Domestic Violence

• Emergency• Transitional• Respite

Per

cent

repo

rting

• Lack of health insurance• Ineligibility• Gaps

• Lack of transportation• Lack of funds• Competing priorities• Follow-up/contacting patient my be

challenging

• Cognitive impairment• Literacy level• Chronic stress• Sleep deprivation

• Lack of understanding of disease state• Lack of understanding of the health care

system

• Logistics of medication storage• Lack of space• Lack of refrigeration• Potential for theft

• Disease states more common in patients in the shelter system

• Lack of restroom facilities during the daytime

• Gaps in care• Distrust of the healthcare system• Routine tests/exams may have been missed• Immunizations

• Cold• Frostbite

• Heat• Heat stroke, dehydration, cramps

• Foot care• Troubleshoot medication storage in extreme

temperatures

• Adherence• Injections• Avoid medications that cause sedation

• Chemical Dependency• Add a B complex vitamin• Naloxone• Needle exchange

• Avoid medications with street value• Benzodiazepines, gabapentin/pregabalin,

quetiapine, clonidine

• Diet• Exercise• Earlier initiation of pharmacotherapy

• Keep regimens simple• Limited storage space, no refrigeration• Lack of access to nutrition• Lack of access to restroom

Prediabetes ObesityCKD

Stage III

HomelessHistory of latent TB Hypertension

Alcohol Dependence DepressionChronic

Hepatitis C

• Engaged in care• Weekly visits

• Medication set-up• Medication delivery• Check in

June

• Lisinopril 40 mg daily

• Spironolactone 50 mg daily

• Amlodipine 5 mg

• Metoprolol succinate 150 mg daily

August

• Lisinopril 40 mg daily

• Spironolactone 50 mg daily

• Amlodipine 5 mg daily

November

• Lisinopril 40 mg daily

• Spironolactone 25 mg daily

• Amlodipine 5 mg daily

December

• Lisinopril 40 mg daily

• Spironolactone 25 mg daily

• Amlodipine 5 mg daily

• HCTZ 25 mg daily

• Avoid beta blockers • Use caution with diuretics and ACE

inhibitors, especially during extreme heat or patient lacks access to a restroom

• Prediabetes• Initiate metformin 500 mg daily

• Titrate metformin carefully if restroom access is an issue

• Use caution with medications that cause hypoglycemia

• Use caution with rapid-acting insulin• Use insulin pens and pen needles• SMBG may be unrealistic• Foot care

CKD Stage III

Homeless

Chronic Hepatitis C

• Lisinopril 40 mg daily• Spironolactone 50 mg daily• Amlodipine 5 mg• ASA 81 mg daily• Vitamin D 1000 mg daily• Terbinafine 250 mg daily • Metoprolol succinate 150 mg daily

• Lisinopril 40 mg daily• Spironolactone 50 mg daily• Amlodipine 5 mg• ASA 81 mg daily• Vitamin D 1000 mg daily• Terbinafine 250 mg daily • Metoprolol succinate 150 mg daily

HomelessHistory of latent TB

Alcohol Dependence DepressionChronic

Hepatitis C

Photo by mikecogh - Creative Commons Attribution-ShareAlike License https://www.flickr.com/photos/89165847@N00 Created with Haiku Deck

• Meds in original containers• Medication list• Contact information• Transportation• Follow-up

1. Notaro SJ, Khan M, Kim C, Nasaruddin M, Desai K. Analysis of the health status of the homeless clients utilizing a free clinic. J. Community Health 2013;38(1):172-177. doi:10.1007/s10900-012-9598-0.

2. Campbell KM, Hayes DS, Wielgos C, Theoktisto K, Taylor JR. Successful reorganization of an interdisciplinary underserved practice. J. Heal. Care Poor Underserved 2011;22(1):226-231. doi:http://dx.doi.org/10.1353/hpu.2011.0004.

3. Moczygemba LR, Goode J-VR, Gatewood SBS, et al. Integration of collaborative medication therapy management in a safety net patient-centered medical home. J. Am. Pharm. Assoc. (2003). 2011;51(2):167-72. doi:10.1331/JAPhA.2011.10191.

4. Price-Stevens L, Goode JVR. Shared Care Model in a Federally Qualified Health Care Center for the Homeless. J. Am. Board Fam. Med. 2012;25(2):253-254. doi:10.3122/jabfm.2012.02.110327.

5. Koh KA, Hoy JS, O’Connell JJ, Montgomery P. The hunger-obesity paradox: Obesity in the homeless. J. Urban Heal. 2012;89(6):952-964. doi:10.1007/s11524-012-9708-4.

6. Hauff AJ, Secor-Turner M. Homeless health needs: shelter and health service provider perspective. J. Community Health Nurs. 2014;31(2):103-17. doi:10.1080/07370016.2014.901072.

7. Stolte O, Hodgetts D. Being healthy in unhealthy places: health tactics in a homeless lifeworld. J. Health Psychol. 2015;20(2):144-53. doi:10.1177/1359105313500246.

8. Elder NC, Tubb MR. Diabetes in homeless persons: barriers and enablers to health as perceived by patients, medical, and social service providers. Soc. Work Public Health 2014;29(3):220-31. doi:10.1080/19371918.2013.776391.

9. Richards R, Smith C. The Impact of Homeless Shelters on Food Access and Choice Among Homeless Families in Minnesota. J. Nutr. Educ. Behav. 2006;38(2):96-105. doi:10.1016/j.jneb.2005.11.031.

10. Programs MR, States U, Health N, Council H. 2015 Medical Respite Program Directory: Descriptions of Medical Respite Programs in the United States. 2015:1-128. Available at: https://www.nhchc.org/wp-content/uploads/2011/10/2015-medical-respite-program-directory.pdf.

11. Maness DL, Khan M. Care of the homeless: An overview. Am. Fam. Physician 2014;89(8):634-640. doi:10.1016/S1003-6326(14)63234-9.

12. Wilder Research. Homelessness in Minnesota Findings from the 2012 statewide homeless study. Wilder Res. 20103:1-77.

13. Sheet F. Homelessness & Health : What's the Connect Ion ? Natl. Heal. Care Homeless Counc. 2011;(June):11-13.