Challenges of caring for homeless patients with rheumatic and musculoskeletal disorders in Los Angeles

Homelessness is a public health crisis. Homeless individuals have significantly worse health outcomes than the general population. We have begun examining challenges of caring for homeless patients with rheumatic and musculoskeletal diseases. Difficulties include physical environment, food and financial insecurity, access to healthcare, low health literacy, and comorbid mental illness, and substance abuse. Based on known prevalences of rheumatic and musculoskeletal diseases (RMSDs), we extrapolate that there are thousands of homeless with rheumatoid arthritis (RA), systemic lupus erythematosus, psoriatic arthritis, gout, and osteoarthritis. We present preliminary observations of disparities in the care of homeless patients with RA seen at the Los Angeles County Medical Center of the Keck School of Medicine of the University of Southern California. They tended to be African American males, missed appointments, utilized emergency services frequently, tended not to be on medications, and exhibited severe disease. We reviewed the available literature on homelessness and homeless healthcare to consider what further studies might be helpful and what interventions might improve the care of patients with RMSDs. We identified several aspirational and practical recommendations. These include ensuring access to healthcare for the homeless (indeed for all); reducing disparities through policy, tailored care, and enhanced social services; and recognizing and treating disease early. Developing better approaches for the care of these homeless has obvious and important implications for other underserved populations needing rheumatologic care, patients with early arthritis, or situations where rheumatologists are unavailable. We believe that physicians have a special responsibility to mitigate inequities in this particularly disadvantaged population.