ࡱ> y{x` (bjbj CQ DB,g2zkgmgmgmgmgmgmg$jhlgs"ggkgkg^fn $/.a.kgg0gbFm]FmfFmfgg g  Asthma Care for Homeless Adults: Summary of Recommended Practice Adaptations Health Care for the Homeless Clinicians Network DIAGNOSIS & EVALUATION History Living conditions Elicit a description of where the patient sleeps, where medications and inhalers are stored, rules for medication use/storage if living in a shelter. Assess allergen exposure. Working conditions Ask about occupational exposures that may contribute to asthma. Symptoms Ask what causes / worsens asthma symptoms, if treatment is effective, if patient is awakened by dry cough, about frequency of inhaler use. Functional impairment Determine patients activity level and relationship of activity to symptoms. Prior diagnosis, treatment Ask when patient was diagnosed with asthma, number of ER visits, hospitalizations. Ask about adherence to prior treatment and what patient does to relieve asthma symptoms. Inhaled substances Specify substances inhaled: tobacco, marijuana, cocaine, glue, heroin. Treatment during incarceration If patient was recently incarcerated, ask about treatment during incarceration and if medications were returned on release. Medical/ mental health history Ask about history of mental illness, tuberculosis, and HIV. Prior providers Ask about other health care providers and where prescriptions were filled. Assess patient mobility and the likelihood of remaining in one place to work on asthma control. Health insurance Ask whether patient has prescription drug coverage. Literacy Assess patients ability to read instructions in English or their primary language. Reliability Consider possibility that patient may give unreliable information about a history of asthma to obtain inhalers to sell or to enhance illicit drug effects. Complexity Recognize that homeless patients' complex health and social conditions complicate history taking, diagnosis, and treatment. ER/ acute care visits Ask how and when patient uses emergency rooms, outreach sites, and other health care facilities to assess symptom control, treatment adequacy, and potential for primary care. Physical examination Nasal exam Assess for nasal inflammation or signs of chronic sinusitis secondary to drug inhalation, which may complicate asthma control. Mental health status Assess for cognitive deficits, delusions, hallucinations, and signs and symptoms of psychoactive substance use that complicate treatment adherence. Diagnostic tests Spirometry Access to spirometry may be limited; history, physical examination, and peak flow measurement may be the only available options for diagnosis. Tuberculin testing and chest X-ray Maintain a high index of suspicion for tuberculosis as an alternative or co-existing condition. Screen for tuberculosis with purified protein derivative testing; consider chest X-ray in immunosuppressed or symptomatic patients. HIV test Offer where facilities, expertise, and support are available to provide HIV care. Serologies or sputum cultures Consider other respiratory infections (histoplasmosis, coccidiomycosis) that cause chronic cough. Be alert to infections in region(s) where patient has lived. PLAN & MANAGEMENT Education, Self-Management Inhaler use Ask patient to demonstrate at every visit. Demonstrate/explain correct use. Spacers Toilet paper rolls, respiratory tubing, or plastic water bottles with a hole cut in the bottom may be used with inhalers as spacers. Nebulizers Recognize that patients without health insurance usually cannot get nebulizers. Those who have nebulizers and live in shelters need designated space for storage and use. Cleaning nebulizers & spacers Teach patient how to clean equipment with vinegar and water; provide vinegar. Smoking Encourage cessation. Investigate providing pharmacologic aid through manufacturers' patient assistance programs. If patient is not ready to quit, use harm reduction approach of decreasing number of daily cigarettes. Shelter staff Educate shelter staff about reducing asthma triggers such as mold, dust, chemicals, and secondhand smoke. Patient goals Encourage patient to set own treatment goals. Asthma action plan Use a symptom-based action plan if patient is unable to carry or use a peak flow meter. Provide a wallet-size written action plan appropriate to literacy level. Assessment of understanding and ability to adhere Ask, Was anything discussed today unclear? Will anything in this plan of care be difficult for you to do? Medications Choice of Rx Use the simplest medical regimen available to patient. Inhaled corticosteroids Discuss importance of controller medications at each visit, but realize homeless clients may value quick relief over prevention and may not use ICS. Short-acting beta agonists Recognize potential for misuse and monitor number of inhalers used. Recognize that patients may be obtaining additional inhalers at emergency rooms, outreach sites, or other facilities. Long-acting beta agonists Assess patient's ability to use these correctly; prescribe cautiously or not at all if they may be used for quick relief. Dispensing inhalers Recognize that patients may not fill prescriptions; dispensing them on site is more effective. Medication reconciliation Have patients bring their medications to each visit to identify drugs provided by other clinicians that may exacerbate asthma. Associated problems, complications Lost, stolen, abused medications Be aware that albuterol is used to enhance effects of cocaine and has high street value. Financial barriers Help uninsured patients apply for SSI/ Medicaid or obtain medications through pharmaceutical discount programs (340B, manufacturer-sponsored patient assistance programs). Transience Recognize that patients may seek care from more than one source and may not remain in one area, or may be intermittently incarcerated. Functional impairments Evaluate for cognitive deficits secondary to substance use, mental illness, trauma, and/or developmental disability that complicate treatment. Literacy/ language barriers Assess literacy tactfully; obtain or create educational materials appropriate to literacy levels and primary language, and assess understanding. Misdiagnosis Recognize that patients may have been misdiagnosed with asthma during emergency room visits or by other care providers. Follow-up Regular follow-up Explain importance of regular care, explore barriers, and provide incentives to return. Contact information Identify ways to contact the patient (case managers, cell phones, shelters, e-mail, voicemail services, outreach workers). Medication control Identify ways patient can obtain medication refills before inhalers run out. Outreach, case management Coordinate a plan of care with outreach workers and case managers. Shelters Work with shelter staff to facilitate rescue care, store nebulizers, remind clients to take medication, provide smoke-free spaces, and decrease asthma triggers. What Is Homelessness? A homeless person is an individual without permanent housing who may live on the streets; stay in a shelter, mission, single room occupancy facility, abandoned building or vehicle; or in any other unstable or non-permanent situation. An individual may be considered to be homeless if that person is doubled up, a term that refers to a situation where individuals are unable to maintain their housing situation and are forced to stay with a series of friends and/or extended family members. In addition, previously homeless individuals who are to be released from a prison or a hospital may be considered homeless if they do not have a stable housing situation to which they can return. Recognition of the instability of an individual's living arrangement is critical to the definition of homelessness. Principles of Practice: A Clinical Resource Guide for Health Care for the Homeless Programs, Bureau of Primary Health Care/HRSA/HHS, March1999; PAL 9912. 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