Care of Marginalized and Vulnerable Patients

Unlike the clinical encounters with your patients in clinic, the home visit enables you to immerse yourself in your patient’s daily environment and pinpoint possible causes of recurrent or intractable health problems. This is one of the multiple reasons an environmental assessment should be at the forefront of your first home visit with a patient.
 

Taking an Environmental History

Several ways of structuring the environmental history have been proposed (the acronym CH2OPD2 is the one shown here)

* Community : neighbourhood sources of hazard; industries; noise sources; criminality
* Home : year of construction, renovations; materials used in construction and decoration; moulds; garden and house plants; use of cleaning products, pesticides, herbicides; air quality; insalubrity
* Hobbies and leisure : exposure to chemicals, heavy metals, dusts or micro-organisms
* Occupation : current/previous occupations of household members
* Personal habits : hygiene products; smoking
* Diet : sources of food and water; cooking methods; cultural habits
*Drugs : prescription and non-prescriptions; alternative medications and health practices

What are Inadequate Housing Conditions?

Talking about the environmental history brings to mind possible issues that could be uncovered during the first visit to a patient’s home. Table 1 presents a non-exhaustive list of housing-related issues you may encounter in your home visits as a clinician. Pictures are presented on page 3. Frost’s Visual Clutter Rating is presented on page 4.

Table 1 : Housing-related issues most commonly encountered

Why Pay Attention to Housing Conditions in Home Care Settings?

On average, people spend 15-16 hours a day in their home – more so in the case of home care patients who are more often than not home-bound. Inadequate housing conditions are prevalent throughout the province.

According to a survey conducted by the Department of Public Health in Montreal in 2014, 28% of households report a sanitation problem in their dwelling. Renter households are the most affected: except for rodent infestation, renters report significantly more cockroach/bed bugs infestations, more humidity issues and more interior mould issues than owners.

Often, the most vulnerable people are the ones more affected by this issue. For example, amongst survey respondents, 40% of couples with children reported an insalubrity issue versus only 18% of single people. Fortunately, environmental health problems generally disappear when exposure ceases. However, some patterns may become chronic.

Extent, duration of exposure, and intrinsic factors may influence prognosis. That is why it is important to use the opportunity to use the home visit as a tool to assess environmental issues present in your patient’s home. A careful and complete assessment will not only help you provide optimized care to your home care patient; it can also be the first step to equip your patient with tools and resources to improve their living conditions.

One of your biggest allies as a clinician facing inadequate housing conditions is the neighbourhood’s Comité Logement. These organizations have the mandate of both helping renters uphold their individual rights, providing them with information and help, as well as advocating for their population’s right to decent and affordable housing. Contact information for Comités Logement based in most of McGill Family Medicine Units’ neighbourhoods can be found on page 6 of this document, as well as on the website of the Regroupement des comités logement et des associations de locataires du Québec.

What to Do in Case of Inadequate Housing?

For tenants

The landlord is responsible for dealing with problems in rental units such as insect pest, vermin, water damage, mould growth. 

1. Inform the tenant that he must notify the landlord verbally of the problem
2. If no process is undertaken after a verbal acknowledgement of the situation, the tenant must notify the landlord by registered mail. The letter must detail the problem and provide a reasonable timeline for resolving it.
3. If the situation is not dealt with in an adequate timeframe, the tenant can lodge a complaint to the borough (call 311 in Montréal) or municipality
4. The tenant can also lodge a complaint with the Régie du Logement du Québec.

For owners

It is much more difficult to intervene in a situation involving a dwelling owned by the affected occupant. According to the Law on Health Services and Social Services, one cannot force a person considered fit to receive services or to leave his/her home. However, if the current situation poses risks to others, the issue can be brought to court. As a clinician, you can however continue clinical management of relevant medical conditions, as well as provide medical or psychosocial follow-up as needed.

For clinicians

As a clinician, you should:

Refer to appropriate resources in the community (such as Comité Logement or the public health unit in the appropriate CIUSSS) or to a social worker

Treat relevant symptoms and medical conditions as per standard clinical management

Provide medical or psychosocial follow-up as needed

Assess for other environmental hazards (as previously described in Guide – heat vulnerability, lead exposure, neighbourhood safety, etc.)

You should also be prepared for home visits (see Home Care Environment Checklist) in order to protect yourself and decrease the risk of propagating possible infestations to other buildings. After assessing the situation, you should also reflect with your Home Care supervisor on the possibility of taking arrangements to give necessary care elsewhere if the current setting is not amenable to safe care for the resident.

In all cases, consider calling Montreal Public Health if :

• you are particularly concerned about potential health impacts, for example, in the case of vulnerable patients (dementia, functional impairment, etc.)
• there are persistent or recurrent problems
• the problem is affecting multiple dwellings
• you need advice/expertise on the situations

Ressources according to regions and UMF territories