Homeless Patient Research Articles

Funding Health Care for People Experiencing Homelessness: An Examination of Federally Qualified Health Centers' Funding Streams and Homeless Patients Served (2014-2019).

It is estimated that three million people annually experience homelessness, with about a third of the homeless population being served by Federally Qualified Health Centers (FQHCs). Thus, FQHCs, dependent on government funding for financial viability, are vital to the infrastructure addressing the complex issues facing people experiencing homelessness. This study examines the relationship between various government funding streams and the number of homeless patients served by FQHCs. Data for this study come from three publicly available databases: the Uniform Data System (UDS), the IRS Core files, and the Area Resource File. Fixed-effects models employed examine changes across six years from 2014 to 2019. The results suggest that, on average, an additional homeless patient served increases the expenses of FQHCs more than other patients and that federal funding, specifically Health Care for the Homeless (HCH) funding, is a vital revenue source for FQHCs. We found that the number of homeless patients served is negatively associated with contemporaneous state and local funding but positively associated with substance use and anxiety disorders. Our findings have important implications for the effective management of FQHCs in the long term and for broader public policy supporting these vital elements of the social safety net.

COVID-19 vaccination uptake and receptivity among veterans enrolled in homelessness-tailored primary health care clinics: provider trust vs. misinformation

BackgroundCompared to the general population, individuals experiencing homelessness are at greater risk of excess morbidity and mortality from COVID-19 but have been vaccinated at lower rates. The U.S. Department of Veterans Affairs (VA)’s Homeless Patient Aligned Care Team (HPACT) program integrates health care and social services for Veterans experiencing homelessness to improve access to and utilization of care.MethodsThis study explores the vaccination uptake behavior and attitudes through a qualitative comparative case study of two HPACT clinics, one in California (CA) and one in North Dakota (ND). Semi-structured telephone interviews were conducted with Veterans enrolled in the two VA HPACT clinics from August to December 2021 with 20 Veterans (10 at each clinic).ResultsFour themes emerged from the interviews: (1) Vaccination uptake and timing— While half of the Veterans interviewed were vaccinated, ND Veterans were more likely to be vaccinated and got vaccinated earlier than CA Veterans; (2) Housing— Unsheltered or precariously housed Veterans were less likely to be vaccinated; (3) Health Care— Veterans reporting positive experiences with VA health care and those who trusted health providers were more likely to vaccinate than those with negative or nuanced satisfaction with health care; (4) Refusers’ Conspiracy Theories and Objectivity Claims— Veterans refusing the vaccine frequently mentioned belief in conspiracy theories while simultaneously asserting their search for objective information from unbiased sources.ConclusionsThese findings amplify the importance of improving access to population-tailored care for individuals experiencing homelessness by reducing patient loads, expanding housing program enrollment, and increasing the provider workforce to ensure personalized care. Health care providers, and housing providers, social workers, and peers, who offer information without discrediting or criticizing Veterans’ beliefs, are also key to effectively delivering vaccine messaging to this population.

Periorbital Facial Necrotizing Fasciitis in Adults: A Rare Severe Disease with Complex Diagnosis and Surgical Treatment-A New Case Report and Systematic Review.

(1) Background: Necrotizing fasciitis (NF) is a severe and aggressive pathology with a rapid progression and high mortality risk. Periocular NF is a rare condition associated with a lower mortality risk but significantly higher disabling sequelae. (2) Methods: We present the case of a 67-year-old homeless patient, a victim of assault, with multiple untreated comorbidities (diabetes mellitus, cardiac conditions, and schizophrenia) and a delayed diagnosis of periocular necrotizing fasciitis. The condition showed a cyclical evolution influenced by the existing comorbidities, and the patient underwent both surgical and medical treatment with a multidisciplinary team. Additionally, we report a systematic review of cases from the literature. (3) Results: The patient's survival outcomes were favorable; however, the sequelae were disabling, not only concerning aesthetic aspects but also due to the loss of the affected eye globe. The systematic review revealed the rarity of such cases and the peculiarities of the presented case compared to those reported in the literature up to this point. (4) Conclusions: Understanding the signs, symptoms, and predisposing factors, as well as the potential rare localizations of NF, including the periocular region, can lead to the early diagnosis and treatment with good functional and aesthetic outcomes, minimizing significant disabilities.

Identifying Predictors of Homelessness Among Adults in a Large Integrated Health System in Northern California.

Introduction Homelessness contributes to worsening health and increased health care costs. There is little published research that leverages rich electronic health record (EHR) data to predict future homelessness risk and inform interventions to address it. The authors' objective was to develop a model for predicting future homelessness using individual EHR and geographic data covariates. Methods This retrospective cohort study included 2,543,504 adult members (≥ 18 years old) from Kaiser Permanente Northern California and evaluated which covariates predicted a composite outcome of homelessness status (hospital discharge documentation of a homeless patient, medical diagnosis of homelessness, approved medical financial assistance application for homelessness, and/or "homeless/shelter" in address name). The predictors were measured in 2018-2019 and included prior diagnoses and demographic and geographic data. The outcome was measured in 2020. The cohort was split (70:30) into a derivation and validation set, and logistic regression was used to model the outcome. Results Homelessness prevalence was 0.35% in the overall sample. The final logistic regression model included 26 prior diagnoses, demographic, and geographic-level predictors. The regression model using the validation set had moderate sensitivity (80.4%) and specificity (83.2%) for predicting future cases of homelessness and achieved excellent classification properties (area under the curve of 0.891 [95% confidence interval = 0.884-0.897]). Discussion This prediction model can be used as an initial triage step to enhance screening and referral tools for identifying and addressing homelessness, which can improve health and reduce health care costs. Conclusions EHR data can be used to predict chance of homelessness at a population health level.

Ethical issues in medical treatment of homeless patients in Poland. A preliminary study

The article presents some of the most important ethical aspects in the medical care of a homeless patient. Hygiene, access to medicines and information, the problem of social discrimination are analysed. The article concludes with a short reflection on the expected ethical attitude of a doctor towards a homeless patient.

Effect of an Emergency Department Closure on Homeless Patients and Adjacent Hospitals.

IntroductionHomeless and housed patients differ on several emergency department (ED) metrics (emergency medical services [EMS] use, chief complaints, admission rates, etc.). On January 1, 2018, Memorial Hospital (MH), a safety-net hospital in Pawtucket, Rhode Island, closed. We studied the impact of this closure by analyzing homeless patient utilization of the two closest EDs before and after MH closed.MethodsA retrospective chart review compared the ED records of The Miriam Hospital (TMH), (1.8 miles from MH) and Rhode Island Hospital (RIH), (4.3 miles from MH). We analyzed visits between January 1, 2017–December 30, 2018. (MH closed on 1/1/2018). Patients were identified as homeless if their address listed was either “homeless” or a shelter/homeless service provider. All other patients were assumed to be housed. We removed from the analysis visits without an address listed or visits missing other key study variables (1.6% of the total).ResultsA total of 113,925 unique patients visited the RIH and TMH EDs in 2017, as well as 117,167 in 2018. Homeless patients accounted for 1.18% of patients seen in 2017 and 1.32% in 2018. Between 2017 and 2018, this represents an increase of individual homeless patients of 15.46% (1553-1345), while the number of unique housed patients increased by 2.69% (115,614-112,580). The closer hospital, TMH, saw a 43.72% increase in homeless visits, while RIH saw an 8% increase. Homeless patients were discharged significantly more often than housed patients (74% vs 65%) and had significantly longer time to admission (466.0 vs 304.0 minutes) and discharge (397.9 vs 263.7 minutes) compared to housed patients. Homeless patients presented with suicidality (8.61% of visits) and alcohol-related concerns (29.88% of visits) significantly more than housed patients (1.43% and 2.94%, respectively).ConclusionWhen a local ED closes, other EDs are impacted. We found visits made by homeless patients increased more than those made by housed patients and skewed significantly toward the closer hospital. We also found that homeless patients spend significantly more time in the ED and presented with behavioral health complaints more frequently. This impact of hospital closure on patterns of ED utilization by homeless patients has implications for ED management and homeless services both in the ED and the community.

Streptobacillus moniliformis subdural empyema in a homeless patient

• The social precariousness in which homeless persons live is a medical challenge. • A homeless man was diagnosed with empyema due to Streptobacillus moniliformis . • MALDI-ToF spectrometry and gene sequencing helps identification. Streptobacillus moniliformis, which is transmitted through rodents, is an emerging zoonotic pathogen among homeless persons. Untreated, the disease can persist for weeks or months; mortality rate ranges from 7% to 13% and can be as high as 53% in endocarditis. We report here the case of a homeless patient with a history of chronic subdural hematoma, who suffered rat’s bites on his face. He presented to our hospital with a picture of cerebral empyema due to Streptobacillus moniliformis that occurred through contiguous spread from the superinfected skin lesions due to the rat bite. Given the technical growth difficulties, S. moniliformis was identified through MALDTI-ToF mass spectrometry. The patient was successfully treated with a 6-weeks course of intravenous then oral amoxicillin. Besides the fact that cerebral empyema is an uncommon complication of S. moniliformis infection, this case highlights the usefulness of 16S RNA PCR and mass spectrometry to identify rare bacterium, as well as the possibility of using amoxicillin instead of intra muscular penicillin in S. moniliformis infections. Contact with rats in homeless patients carries a risk of transmission of Streptobacillus moniliformis . Physicians should be aware of this specific exposure and of this zoonotic disease. The microbiology laboratory has to be informed of the suspected diagnosis, given the difficulty of growth of this pathogen.

Challenging diagnosis of leprosy in a psychotic homeless patient with atypical clinical manifestations: an interesting case report

BackgroundA decision to diagnose certain skin diseases in patient undergoing psychotic break is challenging; this includes establishing the diagnosis of leprosy. Diagnosis of leprosy is established if there is at least one of the three cardinal signs of leprosy. Histopathological examination is not a gold standard, but remains useful in atypical or clinically suspicious cases.Case presentationWe report for the first time, an interesting case of leprosy with atypical clinical manifestations in a psychotic homeless male with unknown history of present illness. Upon examination, hypopigmented macules, hyperpigmented macules, and plaques were observed, with unclear sensation impairment. Peripheral nerve thickening and acid-fast bacilli from slit-skin smear were not found. Histopathological examination from hypopigmented macule on the upper right limb showed no granulomatous reaction and other histopathological features of leprosy. Although the condition did not fulfill the cardinal signs of leprosy, we found lagophthalmos, claw hands, pseudomutilation of fingers and toes. Therefore, the diagnosis of suspected leprosy was established. The patient was hospitalized and attempts to administer oral rifampicin and clofazimine were made. Several days after treatment, annular erythematous macules appeared on the patient’s face, abdomen, and back. Histopathological examination results on sample taken from erythematous macule and right sural nerve were consistent with the diagnosis of leprosy with reversal reaction.ConclusionIn certain conditions, histopathological examination of the skin and nerves are a highly rewarding test in establishing a diagnosis of leprosy.

Homeless Patients with Lung Cancer in Metropolitan Tokyo.

Background Homeless persons are those who carry out their activities of daily living in city parks and other facilities. Little is known about homeless patients with lung cancer in Japan. Therefore, we characterized the clinical features and outcomes of homeless people in metropolitan Tokyo. Methods Between January 2014 and August 2018, 2,068 homeless patients were admitted to the homeless patient care unit at Tokyo Saiseikai Central Hospital. Of these, 13 patients were treated for primary lung cancer. We retrospectively analyzed the patients' clinical characteristics, including their age, gender, treatment, and outcome, obtained from the hospital's electronic medical records. Results A total of 13 patients were treated for lung cancer. The median age was 66.2 (range, 51-77) years old. Twelve patients (92.3%) were smokers. All of the patients were men and had advanced lung cancer. Of these, four patients had adenocarcinoma, four had squamous carcinoma, and four had other histologies. Ten patients received chemotherapy, and 3 received chemoradiotherapy (carboplatin, n=8; cisplatin, n=2, immune check point inhibitor, n=2; other, n=1). Of the patients on first-line treatment, 58% discontinued treatment, with 71% doing so willfully. The median overall survival was 7.5 (1-44) months. During the study, nine patients died in the hospital, and four were lost to follow up. Conclusion It is difficult for homeless patients to continue chemotherapy, and they often quit therapy willfully. Therefore, it is necessary to develop an education and health insurance support system to ensure treatment continuity in a good social environment.

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Sorting Out the Parts and Wholes: Discussion of Steven Stern’s “Analytic Adoption of the Psychically Homeless”

ABSTRACT In this discussion, the author considers Steven Stern’s notion of the “analytic adoption of the psychically homeless” (p. 24–42) as a further articulation and extension of the project begun in his recent book, Needed Relationships and Psychoanalytic Healing: A Holistic Relational Perspective on the Therapeutic Process (2017). Stern is suggesting a conscious, eyes-wide-open acceptance and willingness on the part of the analytic therapist to consider, in the case of the psychically homeless patient, an extended delay, suspension, or even a conscious relinquishment of the expectation that a successful or good enough treatment will, at some point, require a termination phase, or some kind of typical ending. Stern’s concepts of psychic homelessness and mutual analytic adoption begin to give language, legitimacy, and most importantly, clinical dignity, to very long-term treatments that span years and decades. As helpful as it is to name this clinical phenomenon, this author suggests that in doing so, Stern runs the risk of giving a unique experience the quality of a speech act - a kind of declarative wholeness - that to this author’s mind, goes against the very freshness and specificity that Stern is wanting us to grant each dyad deeply involved in the process of shaping a unique meaningful needed relationship. That said, this author concludes that Stern’s bold work opens up this entire therapeutic realm for our open-minded and open-hearted future exploration.

Factors associated with homelessness referrals for an acute young adult psychiatric unit.

Homelessness is correlated with significant mental illness. Homelessness is a key psychosocial issue leading to significant use of hospital resources outside medical intervention. This study examines the characteristics, post-discharge pathway and length of stay of individuals presenting with homelessness in an acute young adult psychiatric ward. Prospective chart audit was conducted to assess the demographic information, acute presentation, clinical risk and length of stay for homelessness referrals to Social Work. Participants (N = 88) were aged 18 to 25 years old and admitted to a tertiary level psychiatric ward specifically for this age group. Acute risk presentations of all psychiatric conditions, such as Schizophrenia, Emotionally Unstable Personality Disorder, Bipolar Affective Disorder, Drug Induced Psychosis and Anorexia Nervosa, may be admitted to the unit. Descriptive statistics, one sample t-tests and Pearson's correlations were completed. No homeless patient was accommodated by local area services due to lack of availability. Change in homelessness status tended to worsen during hospitalisation, with 24% having worse accommodation upon discharge compared to 13% who improved. Length of stay was significantly longer for homeless patients compared to non-homeless patients, but not when excluding the length of time spent attempting to address homeless risk. Homeless patients presenting with an eating disorder acute presentation spent longer time in hospital, and those with psychotic acute presentations had more dynamic risk factors. Length of stay and static risk factors were positively correlated with government mental health community follow-up. Hospitalisation is not an effective intervention for homelessness and the Gold Coast Mental Health units are not resourced or linked to provide accommodation outcomes in a positive or economic manner. Future consideration should be given to health and community resources around homelessness, including health-specific housing interventions and community mental health teams incorporating homelessness risk vulnerability into their ongoing clinical risk mitigation.

Homelessness and Community Based Healthcare: A Narrative Experience in a Temporary Shelter Amidst the COVID-19 Pandemic

ABSTRACT This article serves to describe health encounters and social dynamics of 52 homeless men residing in a temporary shelter in Tshwane during the COVID-19 hard lockdown period. The purpose of this article is to explore and modify factors that influence healthcare in homeless persons, as well as to establish a homeless health profile. It also sets out to explore the help-seeking behaviour observed in this population. Common health encounters included substance use disorder, mental illness, infectious diseases, skin and soft tissue conditions and poor oral hygiene. Services were tailored to provide comprehensive on-site clinical care, making use of allied services. Barriers to healthcare were eradicated through provision of transport, delivery and on-site dispensing of medication and a patient-centred approach. The eradication of certain barriers proved that quality primary healthcare can be achieved in any setting, especially if a patient-centred approach is utilised. The provision of multiple services in a single setting would be ideal. Overall well-being improves when basic needs are met, resulting in positive health outcomes. The homeless patient specifically benefits from a multidisciplinary approach by providers who are particularly sensitive to their dynamics.

Nosocomial hepatitis A outbreak among healthcare workers and patients in a community hospital during an ongoing statewide outbreak.

The Tennessee Department of Health (TDH) investigated a hepatitis A virus (HAV) outbreak to identify risk factors for infection and make prevention recommendations. Case series. Community hospital. Healthcare workers (HCWs) or patients with laboratory-confirmed acute HAV infection during October 1, 2018-January 10, 2019. HCWs with suspected or confirmed hepatitis A infections were interviewed to assess their exposures and activities. Patient medical records and hospital administrative records were reviewed to identify common exposures. We conducted a site investigation to assess knowledge of infection control practices among HCWs. Serum specimens from ill persons were tested for HAV RNA by polymerase chain reaction (PCR) and genotyped. We identified 6 HCWs and 2 patients with laboratory-confirmed HAV infection. All cases likely resulted from exposure to a homeless patient with a history of recreational substance use and undiagnosed HAV infection. Breaches in hand hygiene and use of standard precautions were identified. HAV RNA was detected in 7 serum specimens and all belonged to an identical strain of HAV genotype 1b. A hepatitis A outbreak among hospital patients and HCWs resulted from exposure to a single patient with undiagnosed HAV infection. Breakdowns in infection control practices contributed to the outbreak. The likelihood of nosocomial transmission can be reduced with proper hand hygiene, standard precautions, and routine disinfection. During community outbreaks, medical providers can better prevent ongoing transmission by including hepatitis A in the differential diagnosis among patients with a history of recreational substance use and homelessness.

Mortality Outcomes in People Experiencing Homelessness Across England: a population-based study

Abstract Introduction The number of people experiencing homelessness in England has increased since 2010 and a recent systematic review and meta-analysis demonstrated high levels of mortality in this group across high-income countries. In this study we examine the death rates in people experiencing homelessness after discharge from hospital. Methods This is a study of linked hospital admission records and mortality data for two groups. First, a “Homeless group”: people seen by 17 specialist homeless discharge schemes between 1 November 2013 and 30 November 2016. Second, an “IMD5 group”: A matched group of patients who live in deprived areas and have the same age and sex, and were discharged from the same hospital in the same year as the homeless patient. Our analysis entailed calculating mortality rates across each group and by the number of comorbidities. Results The mortality rate for the IMD5 group was 1,935 deaths per 100,000 person years, compared with 5,691 for the homeless group, giving a rate ratio of 2.9 (95% CI 2.5-3.5). The mortality risk increased with the number of comorbidities. Individuals in the IMD5 group with zero comorbidities had a death rate of 831 per 100,000 person-years, compared with the homeless group for which the corresponding figure was 2,598 and or those with 4+ comorbidities were 7,324 (IMD5) and 12,714 (homeless). This suggests a 'super-additive' interaction in which the effect of morbidity on mortality risk after discharge is greater for homeless patients. Survival at 5 years for the homelessness group was for men 80% (95% CI 77-85) and women 85 (95% CI 81-87). Conclusions This study shows that the well-established inequity in mortality for people experiencing homelessness exists after discharge from hospital and is greatest for the most unwell patients. Our results suggest a need for greater emphasis on prevention of homelessness, early healthcare interventions and improved hospital discharge arrangements for this population. Key messages The well-established inequity in mortality for people experiencing homelessness exists after discharge from hospital and is greatest for the most unwell patients. Our results suggest a need for greater emphasis on prevention of homelessness, early healthcare interventions and improved hospital discharge arrangements for this population.

Social and Economic Challenges to Implementing the Ketogenic Diet: A Case Series

AbstractThe ketogenic diet (KD) is a powerful therapeutic tool that can reduce seizure activity in patients with refractory epilepsy. However, dietary implementation can be difficult for patients and families due to the time and resource intensive nature of the diet. These challenges are particularly pronounced in economically disadvantaged or socially unstable patient populations. The first case of this series describes the successful implementation of KD in a low-income, homeless patient through the use of innovative KD recipes and access to social programs offered through Boston Medical Center. The second case illustrates the importance of consistent parental support to the success of KD and describes mechanisms used to improve familial support within a nonunified household. Collectively, these cases demonstrate ways by which health care providers can make this powerful dietary treatment accessible to low-resource patients.

Disparities in triage and management of the homeless and the elderly trauma patient

BackgroundTrauma systems are designed to provide specialized treatment for the most severely injured. As populations change, it is imperative for trauma centers to remain dynamic to provide the best care to all members of the community.MethodsA retrospective review of all trauma patients treated at one Level II trauma center in Southern CA over 5 years. Three cohorts of patients were studied: geriatric (> 65 years), the homeless, and all other trauma patients. Triage, hospitalization, and outcomes were collected and analyzed.ResultsOf 8431 patients treated, 30% were geriatric, 3% homeless and 67% comprised all other patients. Trauma activation criteria was met for 84% of all other trauma patients, yet only 61% of homeless and geriatric patients combined. Injury mechanism for homeless included falls (38%), pedestrian/bicycle related (27%) and assaults (24%), often while under the influence of alcohol and drugs. Average length of hospital stay (LOS) was greater for homeless and geriatric patients and frequently attributed to discharge planning challenges. Both the homeless and geriatric groups demonstrated increased complications, comorbidities, and death rates.ConclusionsHomeless trauma patients reflect similar challenges in care as with the elderly, requiring additional resources and more complex case management. It is prudent to identify and understand the issues surrounding patients transported to our trauma center requiring a higher level of care yet are under-triaged upon arrival to the Emergency Department. Although a monthly review is done for all under-triaged patients, and geriatric patients are acknowledged to be a cohort continually having delays, the homeless cohort continues to be under-triaged. The admitted homeless trauma patient has similar complex case management issues as the elderly related to pre-existing health issues and challenges with discharge planning, both which can add to longer lengths of hospital stay as compared to other trauma patients. Given the lack of social support that is endemic to both populations, these cohorts represent a unique challenge to trauma centers. Further research into specialized care is required to determine best practices to address disparities evident in the homeless and elderly, and to promote health equity in marginalized populations.

Establishing a pharmacist-managed outreach clinic at a day shelter for homeless veterans.

IntroductionThe US Department of Veterans Affairs (VA) has developed a homeless patient aligned care team (H-PACT) model to provide clinical outreach to homeless veterans. This model has not been implemented by the VA Sierra Nevada Health Care System; however, a day shelter for homeless veterans does exist. Currently, clinical staff at the shelter consists of licensed clinical social workers.MethodsA half day per week pharmacy clinic was established and managed by a postgraduate year-2 psychiatric pharmacy resident. Data regarding provider and emergency department (ED) visits, psychotropic medication adherence, and interventions made during visits were collected and analyzed to provide support for need of additional clinical staff and the establishment of an H-PACT at the Reno VA.ResultsOver 5 months, 52 veterans were seen, including some over multiple visits, with a total of 77 encounters. There were an average of 4 visits per clinic day. Total interventions equaled 205 and included medication review, patient education, and adverse drug reaction detection among other interventions. Provider visits and psychotropic medication possession prior to and following clinic visits were tracked.DiscussionThis pharmacist-managed outpatient clinic provided a comfortable walk-in environment for homeless veterans. The difference in provider visits, medication possession, and ED visits before and after walk-in clinic visits provided clinical significance with 205 documented interventions, and the clinic was well received by veterans.

Unusual subdural empyema in a homeless patient diagnosed by molecular approach: a case report

BackgroundWe report a case of subdural empyema in a homeless patient caused by Bartonella quintana. B. quintana is a facultative intracellular bacteria for which bacterial growth is fastidious. The molecular biology approach has been a real help in establishing the diagnosis.Case reportA 59-years old homeless patient, with a history of chronic alcohol abuse, was brought to the emergency department with a massive subdural empyema. Extensive microbiological evaluation didn’t reveal any pathogen in the pus collected before antibiotic treatment. B. quintana was detected in the pus from the empyema using a 16S rRNA-based PCR. Histology of intraoperative samples was consistent with the diagnosis and a serological assay was positive. The patient responded well to a treatment that included craniectomy with drainage of the loculated pus, total removal of the infected capsule and a combination of antibiotics.ConclusionThis unique case of B. quintana-related empyema illustrates the risk of secondary infection of subdural hematoma with B. quintana since such infections have recently reemerged, predominantly among the homeless populations. Patients with subdural empyema in at-risk populations should be systematically evaluated for B. quintana with an appropriate diagnostic approach involving molecular biology.

Discharge policies for homeless people and immigrants: Compromising professional ethics.

Discharging a homeless patient from hospital raises ethical issues which are compounded when the patient is from outside the United Kingdom. This article begins with an extended case study of a 30-year-old homeless man from Lithuania describing his complex medical and social needs. It is best practice for all homeless patients to have their housing needs planned for prior to discharge, but this is made more difficult by the United Kingdom's 'hostile environment' policy which creates a subclass of homeless people who are not eligible for support. This means healthcare professionals discharge patients back to homelessness, even when this is likely to adversely affect their health and dignity both directly and indirectly through impairing access to care for chronic conditions. Policies in health and social care which compel professionals to treat some patients with second-class care undermine the ethics of healthcare professions.