Title: Employing charity-care services to manage cirrhosis with ascites in an adult experiencing homelessness: A case report
Authors: Danzhu Zhao, OMS III; Hannah Wilson, PA-C; Kathaleen Briggs Early, PhD, RDN, CDCES
Introduction
Low income populations face increased barriers to healthy lifestyles and living conditions, and high risk for declining health outcomes, which ultimately reduces functioning and limits self-sufficiency. In the context of these inequities, advanced alcoholic liver disease (ALD) with cirrhosis and acutely severe ascites can be especially challenging to manage. We present the case of a patient facing homelessness as a result of his ALD associated with cirrhosis complicated by ascites.
Case Description
A 53-year-old Mexican American male, facing recent homelessness due to inability to work in the agricultural fields as a result of his medical conditions, was transferred to our local free clinic (Yakima Union Gospel Mission; YUGM) for debilitating ascites from ALD that had progressed to cirrhosis. YUGM provided free temporary housing and medical care in consultation with the local gastroenterology service. The patient had been taking spironolactone and furosemide daily for ascites, and metformin daily to help control his T2DM. At YUGM, the patient was started on lactulose to reduce risk for hepatic encephalopathy and a diet that decreased fluid intake, implemented strict salt restriction, and increased protein daily to help manage the ascites.
The patient initially presented with an appreciable distended abdomen. Waist circumference measured 33 inches. Height was approximately 4 feet 10 inches; weight was 136 Ibs; with a blood pressure of 90/50. Other vital signs were within normal limits. In four months, his weight had decreased to 113 Ibs and his blood pressure had improved to 110/60. Throughout his care and stay at YUGM, he only visited the ED once due to exacerbated ascites, compared to his frequent visits previously. Within 4.5 months, the patient regained employment, and found independent housing within 7 months.
Discussion
Our patient was not only facing the health complications of cirrhosis but also unemployment and homelessness as a direct result of his health condition. Resources at YUGM helped him start his recovery in a stable environment, regain employment and housing, and build a strong patient-physician relationship in the most affordable way. As he transitioned back into independent living, maintaining an appropriate diet and regular medical care has been difficult. While living with a friend, he unfortunately has been unable to maintain the positive changes noted in this case report. While our patient is still struggling to control his ALD and associated cirrhosis with ascites, this case illustrates the value of interdisciplinary collaboration to support patients with limited resources.
I am one of the judges for your very thoughtful case. The outcome here was fantastic, how would you implement a model like this to reach a larger population (in a more urban environment) taking into consideration economic and human resources?
Thank you for reviewing our presentation and for this great question, Dr. Callan. What I adore most about YUGM and I think is crucial to its success in this rural setting, is how community-based the organization is as a whole. Working with students at PNWU, local churches, businesses, individuals, and many others in the Yakima community, YUGM is able to thrive and provide not only free medical care, but also cooked meals, recovery programs, youth programs, and others. YUGM also uses a “5-Space Model” to help individuals facing homelessness which includes outreach, gaining trust with staff at YUGM, encouraging personal change and participation in recovery programs, building financial independence, and finally helping clients enter a place in their lives where they can begin to give back to the community. This has proven to be a successful model utilized at YUGM and can easily be implemented in any rural or urban setting. When considering how we could implement this case presentation on a larger scale in the context of human resources, I think about how fortunate WA state is to now have 3 medical schools, and many residency programs. Each have students and physicians passionate about outreach and service. It would be fascinating to see if 3rd and 4th year rotating students and residents could initiate a collaborative project amongst the schools and/or residency programs to provide free medical care in larger cities. Utilizing the greater community around us like these medical programs could be helpful medical human resources.
There is a published article that has shared a similar facility model to that of YUGM in St. Paul, MN, an urban city with a population size of over 300,000. A Federally Qualified Health Center collaborated with a renovated apartment complex, repurposed for immigrants and refugees, to provide free medical care and shelter. The facility has built-in space for health care visits, community activities, and other specific services, similar to that of YUGM, so it has been and can be done in urban settings. The project was heavily funded by multiple major stakeholders. Ultimately, I believe volunteers/human resources can be found anywhere where there is heart to serve, and with the significant rise in the homeless population, there is a bigger push by many community members in larger cities like Seattle and Tacoma, WA to collaborate in finding possible ways to provide the homeless population with healthcare and housing. We need businesses, investment groups, and other donors who would be willing to help fund initiatives and facilities to make it all happen.
Thank you!
Judge: Did you identify any unanticipated communication barriers between the various stakeholders, the patient, etc? If so, what are your recommendations for mitigating these barriers to improve future patient outcomes?
Thank you for your inquiries and please let me know if this correctly addresses your question. In terms of communication barriers, language can often be a barrier in patient care but thankfully YUGM has wonderful Spanish speaking staff and providers who were able to cater to the cultural and language preferences of our patient. Some other barriers we faced included scheduling regular visits with the patient as he regained employment as a field worker and found independent housing away from YUGM. Transportation was also an issue for this patient. Something that I have noticed to be quite beneficial during my clinical rotations in the midst of a pandemic is the increased use of telemedicine. Telemedicine appointments can help remove the barriers of inconvenience like transportation and finding time to get to the clinic and back without missing too much time from work. Providing free transportation or mapping out routes with public transportation could also benefit a patient’s access to care.
Thank you!
Judge: Why do you think this patients fasting blood glucose levels went way up from admission to leaving YUGM? Does YUGM need to think about changing their dietary policies for diabetes?
Hi Dr. Novack,
Thank you for reviewing our case presentation and for pointing this out. When looking at fasting blood glucose levels, it’s important to consider what the number suggests compared to other glucose monitoring values like a hemoglobin A1c. Providers need to take into account the accuracy of how well the number truly represent the patient’s overall blood sugar levels. Fasting blood glucose is a snapshot measurement of one’s glucose level at any given time but with the assumption that the patient had fasted for at least 8 hours prior, typically before breakfast. If a patient does not properly fast, the measurement can be higher than expected and may not well represent the fasting baseline level of glucose in the blood. Fasting blood glucose level is a great tool that can be used to monitor short-term sugar levels. Hemoglobin A1c is an average of a patient’s blood sugar levels in a 3 month period and does not necessarily show the highest or lowest measurements at a given time like a fasting blood glucose level would. So this patient’s elevated fasting blood glucose level of 150 may not accurately confirm that his diabetes is necessarily worsening, but is most certainly something we need to keep our eyes on. A repeat fasting blood glucose level may have been beneficial here.
Given this patient’s acute concern of abdominal pain due to worsening ascites, the biggest priority for this patient’s care at YUGM was focusing on managing the abdominal pain and the accumulation of excess fluid in his abdomen. Therefore, the kitchen’s meals of a low-salt diet were also catered towards the priority concerns. The care team had planned to better address the patient’s diabetic management by implementing dietary/nutritional and diabetic counseling with our very own registered dietitian nutritionist and certified diabetes care and education specialist at PNWU, Dr. Early. Unfortunately scheduling has been a barrier to this, but is still something we plan to make happen.
I hope this adequately addresses your question.
Thank you!