Balancing Act

This paper describes special adaptations to clinical practice necessary for addressing the most common health problems of homeless individuals and families. A case is made for the integration of primary care, mental health and substance abuse services as the preferred approach to care for this population, based on the complexity of multiple interrelated health problems that are seen. These problems are examined in a section on the epidemiology of health problems common to people without homes. Homeless people face numerous barriers to access which can be overcome by adaptations to the structure of the delivery system, including extensive outreach, mobile sites and flexibility in policies and procedures. The nature of the homeless condition also calls for special adaptations to clinical practice in the areas of intake and assessment, clinical preventive services, diagnosis, follow-up to assure continuity of care, referrals to specialty care and linkages to other services. Specific adaptations for treatment of physical and mental illnesses are presented, with discussion of primary care, treatment services for substance use disorders, treatment services for serious and persistent mental illnesses, and special services for homeless people with dual diagnoses. The paper concludes with comments on how to address the threats that challenge successful continuation of the unique approach to homeless health care that has evolved, including: inadequate funding to fully implement the integrated approach to homeless health care; impact of market-driven managed care; lack of funding for accessible and appropriate substance abuse treatment; limited cost and outcome data; the disconnect between research and practice; and the scarcity of skilled practitioners willing to serve this population. increased demand for services, decreased capacity and limited resources, the effects of Medicaid managed care, and the need for more qualified practitioners in this field.