By Kaleigh Longcrier, OMS IV, Taylor Sullivan, DO and Hans Bruntmyer, DO, MPH

A Closer Look at the Medical Needs of San Antonio’s Homeless Population

By Kaleigh Longcrier, OMS IV, Taylor Sullivan, DO and Hans Bruntmyer, DO, MPH

n January 2020, there were approximately 2,932 people experiencing homelessness in the San Antonio area, which is a 2% increase from 2019.1 In the state of Texas, 27,229 people are living either sheltered or unsheltered on a single night, which is a 5% increase from 2019.2 A growing homeless population comes with an increase in demand of health needs. Lack of primary care establishment can lead to progression of chronic diseases, such as diabetes or hypertension, leading to a downward spiral of complications. This often leads to ER visits and hospital admissions.3 These visits ultimately contribute to the overall financial burden that plagues the American health care system today.4

The first step in decreasing the burden of disease and creating a holistically healthy and more cost-effective health care system begins by identifying the types and prevalence of diseases in the homeless population. Helping our community can take many forms and facets, but if the needs are unknown, our attempts would be futile. Knowing the most pressing and prevalent health conditions among the homeless in a particular region is a springboard to create programs or protocols to address these issues.

IThe motivation behind caring for San Antonio’s homeless population can be multifactorial. It can be argued that helping the homeless in Bexar County can improve overall health outcomes of the city and can decrease the financial burden of disease. Restoring the health of the homeless could create opportunities for labor intensive or physically demanding work, and thus theoretically decrease the incidence of homelessness itself.5 It can also be argued that in general, taking care of those less fortunate is an altruistic duty of society and a sacred ideal held in many religions. Christian Medical and Dental Association (CMDA) and Church Under the Bridge (CUB)6,7 are two of several organizations in San Antonio that have this layered and multifactorial motivation behind caring for the homeless population. The authors of this paper have conducted a retrospective review (University of the Incarnate Word Institutional Review Board Approval Number 21-02-004) from four free clinics provided to homeless patients by CMDA and CUB during March 2019 to January 2020. The following results were obtained on an intake form completed by patients and from history & physical elicited by students (with oversight by physicians and dentists) during the free clinics.

Results

Demographics: Fifty five percent of patients were male and 45% were female. There was a nearly even distribution of age among our patients; the majority ranged from 18-60. Nearly half listed a home address and twenty percent reported living at a shelter. Less than a third of patients reported having a primary care physician and 1/3 of patients had been hospitalized in the preceding 3 years.

Figure 1 describes the distribution of health needs during the clinics. On the dental side of the clinic, the most common intervention was extractions (46%), followed by dental hygiene (30%) and 16% of patients had dental restorative procedures. On the medical side of the clinic, the most common chief complaint was musculoskeletal, including knee, shoulder, neck, back, and foot pain, and tendonitis. Following musculoskeletal complaints, the rest of the patients did not have a specific complaint, but rather requested a physical exam (i.e., a checkup) or needed a refill for a known medical condition. Several patients had chronic medical conditions needing attention, exhibited below in Figure 2.

Of the patients with hypertension, 16% were on medication and the average systolic blood pressure reading was 136 mmHg. Nine percent of patients were on diabetic medications and the average glucometer reading was 132 mg/dL. Nearly three quarters of our patient population were overweight, obese or severely obese. Figure 3 displays body mass indices of homeless patients. Fifty six percent had a BMI greater than or equal to 30 and thirty percent with a BMI greater than or equal to 35 (classified as extremely obese).

Discussion

Table 1 displays a comparison of 2016 Bexar County prevalence rates of various health conditions to the homeless patients in our free clinics.8,9 As seen, these numbers are significantly higher amongst homeless patients than the general population. Lack of health education, financial support and access to primary care could be some of the main reasons why homeless patients’ rates are higher than county rates.

Figure 1

Figure 2

Figure 2: The most common medical problems seen at our free clinics. Hypertension, Arthritis and diabetes were the most prominent conditions seen. Figure 3: Visual representation of homeless patients’ BMI. Only 3% of our patients were underweight.

Table 1: Comparison of the most common medical conditions seen in the homeless patients compared to local rates. As seen, the prevalence is dramatically increased in the San Antonio homeless population than the general population.

Figure 3

Table 1

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Obesity was frequently encountered. Despite the common association of homelessness with underweight individuals, we found 56% of our patients to be obese or extremely obese, and this number increases to 76% when we include overweight individuals. According to a study completed by Tsai, et al. in 2013,11 57% of surveyed homeless adults across the United States were overweight or obese. This statistic is further demonstrated in another study which cited 67% of the homeless populations they surveyed were overweight or obese.12 This raises many questions about a hunger-obesity paradox, and what can be done in clinical settings to educate patients about diet and nutrition. It could also be an area further developed in public health campaigns and policy formation to increase the availability of healthy food access to this demographic.

The most prevalent chronic diseases we came across during our clinics were obesity, diabetes and their complications (i.e., self-reported nephropathy, neuropathy, Charcot foot). These remain more of a challenge to treat, as medical treatments require pharmacologic intervention and necessitate follow up. Having regular, frequent clinics (i.e., monthly rather than quarterly), even if hosted by other ministries, could provide consistent care.

The most common chief complaint we encountered was musculoskeletal pain. University of the Incarnate Word School of Osteopathic Medicine medical students performed osteopathic manipulative treatment10 on several of the patients’ complaints, including back pain, foot pain and neck pain. Additional interventions included cupping, counseling on ergonomics, home therapy and occasionally prescribed anti-inflammatories. We encouraged regular attendance at our clinic for subsequent OMT treatments.

Future Considerations

According to 2020 Point in Time Count, 21% of individuals experiencing homelessness are suffering from some form of mental illness in Bexar County.1 However only 4% of our patients disclosed as much during the clinics. Including mental health on our intake form could prompt the interviewer to elicit a psychological history. Additionally, future collaboration could include psychology and therapy students from local universities to participate in our clinics and provide counseling to this marginalized population.

Presenting the most common conditions from our clinics was the first step in our pursuit to highlight and bring care to San Antonio’s homeless patients. We intend to follow these patients over many clinics once they start back up again (currently halted due to the COVID19 pandemic) to determine if our interventions are making a positive benefit to this population.

Acknowledgements

The authors would like to thank Scott Philips and Mitzi Roberts of CMDA San Antonio, Diane Talbert of Church Under the Bridge San Antonio and Dr. Arunabh Bhattacharya of UIWSOM for their support and assistance on this project.

References: 1. South Alamo Regional Alliance for the Homeless (Ed.). (2020). 2020 Point-in-Time Count Report San Antonio and Bexar

County. SARAH Homeless. https://www.sarahomeless.org/wpcontent/uploads/2020/05/2020-PIT-Report-_5.14.pdf 2. 2020 Annual Report. Texas Homeless Network. (2020, December 17). https://www.thn.org/2020-annual-report/ 3. Garrett, D. G. (2012, January). The business case for ending homelessness: having a home improves health, reduces healthcare utilization and costs. American health & drug benefits. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046466/ 4. Hwang, S. W., Weaver, J., Aubry, T., & Hoch, J. S. (2011). Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services. Medical care, 49(4), 350–354. https://doi.org/10.1097/MLR.0b013e318206c50d 5. Integrate Health Care. Integrate Health Care | United States Interagency Council on Homelessness (USICH). (n.d.). https://www.usich.gov/solutions/health-care 6. Christian Medical & Dental Associations. (2020, July 23).

Healthcare for the Poor. Christian Medical & Dental Associations. https://cmda.org/healthcare-for-the-poor/ 7. San Antonio Help for the Homeless. CUB Church Under the bridge. (n.d.). https://cub-sa.org/ 8. City of San Antonio Metropolitan Health District (2016). Bexar

County Data Report https://www.sanantonio.gov/Portals/ 0/Files/health/News/Reports/BRFSSReport2016_5-3118.pdf?ver=2018-06-04-155732-877 9. Centers for Disease Control and Prevention. (2020, December 8). PLACES: Local Data for Better Health. Centers for Disease

Control and Prevention. https://www.cdc.gov/places/ 10. American Osteopathic Association. (n.d.). OMT: Osteopathic

Manipulative Treatment. American Osteopathic Association. https://osteopathic.org/what-is-osteopathic-medicine/osteopathic-manipulative-treatment/ 11. Tsai, J., Rosenheck, R. (2013) Obesity among Chronically homeless adults: Is it a problem? Public Health Reports. https://pubmed.ncbi.nlm.nih.gov/23277657/ 12. Koh, K.A., Hoy, J.S., O’Connell, J.J., Montgomery, P. Hungerobesity paradox: Obesity in the Homeless. Journal of Urban Health. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3531350/

Kaleigh Longcrier is a fourth-year medical student at UIWSOM applying to Family Medicine residency. She is also CMDA’s Texas Student Leader Representative and Student Trustee to the Board of National Trustees.

Taylor Sullivan, DO is graduate of the inaugural class at UIWSOM, current General Surgery resident at UTHSCSA and member of Bexar County Medical Society Publications

Committee.

Hans Bruntmyer, DO, MPH graduated from Texas College of Osteopathic Medicine in 1994. After completing residencies in emergency and aerospace medicine, Dr. Bruntmyer retired from the U.S. Air Force in 2015. His current medical practice consists of providing Osteopathic Manipulative Medicine (OMM) and general health care at a free clinic for the marginalized in his community. He is a member of the Bexar County Medical Society.