• Allen J, Bharel M, Brammer S, Centrone W, Morrison S, Phillips C, Rogers H, Strehlow AJ. Adapting your practice: treatment and recommendations on reproductive health care for homeless patients. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2008. 27 p. [48 references]

This is the current release of the guideline.

This guideline updates a previous version: Bonin E, Brammer S, Brehove T, Hale A, Hines L, Kline S, Kopydlowski MA, Misgen M, Obias ME, Olivet J, O'Sullivan A, Post P, Rabiner M, Reller C, Schulz B, Sherman P, Strehlow AJ, Yungman J. Adapting your practice: treatment and recommendations on reproductive health care for homeless patients. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2003. 22 p.

The following diseases/conditions in homeless patients:

• Unintended pregnancies
• Sexually transmitted diseases
• Sexual abuse/assault, post-traumatic stress disorder
• Cervical cancer

Diagnosis
Evaluation
Management
Prevention
Treatment

Family Practice
Infectious Diseases
Internal Medicine
Obstetrics and Gynecology

Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Social Workers
Students
Substance Use Disorders Treatment Providers

• To recommend simple adaptations of established guidelines to improve the reproductive health of homeless individuals regardless of gender
• To assist clinicians who provide reproductive health care and family planning services for homeless individuals

Homeless patients of reproductive age

Diagnosis/Evaluation

1. History of patient
2. Physical examination
3. Diagnostic tests

Management/Treatment/Prevention

1. Patient education and self-management
2. Dispense medications and contraceptive devices
3. Recognize and manage associated problems and complications
4. Follow-up

• Access to cancer screening: Pap smear, mammogram/breast examination, prostate examination (if indicated)
• Use of contraceptives, including barrier devices
• Access to prenatal care
• Health disparities between homeless and general U.S. populations:
  • Incidence/prevalence cancer of reproductive organs
  • Incidence/prevalence of sexually transmitted diseases
  • Complications of pregnancy

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

This guideline is adapted from five primary sources.

Expert Consensus

Not applicable

Review

A multidisciplinary group of clinicians experienced in the provision of reproductive health care to homeless individuals served on the advisory committee to review and update this guideline. Members of this advisory committee discussed the results of a comprehensive literature review and determined which reports were of particular significance for the care of individuals experiencing homelessness.

Expert Consensus

The original copy of these guidelines was developed in 2003 by primary health care providers, representing Health Care for the Homeless (HCH) projects across the United States. These 2008 guidelines reflect their original work and include revisions that suggest updates in standards of practice in reproductive health care for patients who lack stable housing. These recommendations reflect their collective experience in serving homeless adults and adolescents.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

The guideline developer's Advisory Committee identifies, in the original guideline document, the clinicians who reviewed and commented on the draft recommendations prior to publication.

Diagnosis and Evaluation

History

• Living conditions. Ask where patient lives; assess for residential stability, access to food and water.
• Sexual history. Ask about sexual identity, orientation, behaviors, number of partners pregnancies, and sexually transmitted diseases (STDs).
• Desire for contraception. Assess patient's need and desire for contraceptive services. Ask about history of contraceptive use.
• Desire for pregnancy. Assess patient's plan for future pregnancies.
• Substance abuse/mental health. Assess patient's ability to take pills daily or remember to return for follow-up.
• Medical history. Elicit history of ongoing medical problems or prior history of significant conditions such as hypertension, liver disease, or thromboembolic events.
• Contraceptive history If patient has a history of intravenous drug use (IVDU), assess exposure to hepatitis C and tailor physical evaluation and laboratory evaluation toward assessing liver function status (albumin, prothrombin time, and bilirubin).
• Smoking history. Weigh risk factors for using estrogen-containing methods with risk of pregnancy.
• Medications. Ask female patient about medications she may be taking, which may require careful regulation if taken in conjunction with birth control pills.
• Immunizations. Ask whether patient has been vaccinated against measles-mumps-rubella (MMR) and hepatitis. Patients engaging in high-risk sexual behaviors may be at risk for hepatitis A and B and should be vaccinated as necessary.
• Menstrual history. If history of irregular cycles, obtain additional information such as relationship to weight gain or loss, substance use, and galactorrhea
• Spiritual/cultural history. Ask about spiritual and cultural beliefs, values, and practices of patient and partner affecting their use of contraception.
• Domestic/interpersonal violence. Ask explicitly about history of physical/sexual abuse.
• Insurance status/resources. Assess patient's ability to pay for various contraceptive methods.

Physical Examination

• May be postponed. Communicate willingness to initiate contraception without a physical exam. Include a blood pressure evaluation even if the pelvic examination has been deferred.
• Sexual abuse. Be sensitive to concerns, fears, and safety needs of patient with a history of sexual abuse. Understand the paradigm of traumatic experience. Respect patient's physical space; ask permission to touch and to perform each exam.
• Genital exam. Recommended as part of reproductive health care for males and females. Provider should be extremely sensitive to patient with a history of sexual abuse.
• Oral health care. Oral health care should be coordinated among prenatal and oral health care providers. Delay in necessary treatment could result in significant risk to the mother and indirectly to the fetus.
• Nonjudgmental attitude. Make every effort to convey openness to patient decisions regarding sexual behavior, desire to use contraception, and plans regarding present or future childbearing.

Diagnostic Tests

• Sexually transmitted disease (STD) screening. Concurrently assess for and treat sexually transmitted diseases. Test for gonorrhea, chlamydia, syphilis, HIV (following local regulations regarding patient consent), hepatitis B antigen, trichomonas, bacterial vaginosis, and monilia. Don't neglect possibility of infection of multiple orifices in men and women, considering sexual practices. For patients with a history of hepatitis C or chronic hepatitis B infection include completed blood count (CBC) with differentials, liver function and bilirubin testing.
• Pregnancy test. Urine pregnancy test (urinary chorionic gonadotropin [UCG])
• Routine health care maintenance. For female: annual Pap smear with reflex human papillomavirus (HPV) testing beginning within three years of sexual debut or at age 21 or older. Mammogram if indicated. For male: periodic testicular self-examination and instruction and clinician examination as appropriate; discussion on prostate cancer screening.
• Tests for other concurrent conditions. Anemia screening if at risk, urinalysis if symptomatic.

Plan and Management

Education, Self-Management

• Hygiene. Assist client in finding ways to keep clean, given limited access to bathing facilities, menstrual hygiene items, and/or clean underwear.
• Contraceptive methods. Describe each method in a way that is understandable to patient. Give simple instructions for contraceptive method selected. Ask if there is any barrier to complying with the plan of care and if anything about it is unclear.
• Side effects. During every visit, reinforce education about medication/contraceptive side effects.
• STD protection. Explain that many contraceptives (including birth control pills) do not protect against sexually transmitted diseases. Recommend condom use even with other contraceptive method.
• Risk reduction. Counsel at-risk clients to adopt safer sexual behaviors. Use interactive counseling that focuses on preventing unwanted pregnancy and transmission of disease.
• Smoking cessation. Use opportunity to encourage smoking cessation; assess readiness to change.
• Partner education. If possible, include partner in discussion of contraceptive alternatives.
• Preconception counseling. Discuss nutrition, mental health, and substance abuse. Explain risks of pregnancy for patient and fetus related to alcohol, drug, and nicotine use. Encourage folate-containing vitamin supplements. Educate client desiring pregnancy about advantages of and contraindications to breast feeding.
• Health care maintenance. Encourage regular breast/testicular self-exam.
• Storage/expiration of condoms, birth control pills. Educate patient about proper storage of condoms and birth control pills.
• Co-existing medical conditions. Educate patient about possible effects of pregnancy on chronic medical conditions.

Medications/Contraceptive Devices

• Dispense on site if possible, instead of giving patient a prescription or referring elsewhere. Recommend contraceptive methods that are easiest to use.
• Injections. Consider injectable contraception if patient cannot adhere to daily regimen.
• Birth control pills. Determine number of pill packs to prescribe at one time based on patient's access to medications and ability to adhere to prescribed regimen.
• Transdermal methods offer the advantage of convenience for some homeless clients. Consider patient's occupation when prescribing contraceptive patches.
• Female condom. Easy to use and as effective as the male condom, this method may offer homeless clients another alternative for birth control.
• IUD (intrauterine devices) provide a contraception option for women unable to use hormonal options in the presence of an elevated liver function status. World Health Organization (WHO) guidelines should be followed.
• Implanon is an easy method of long-term birth control which can be inserted in a clinic or medical van.
• NuvaRing. The NuvaRing is a one month method of birth control that is inserted vaginally and remains for the month.
• Emergency contraception. Emergency contraception available under the brand name, Plan B, can be administered up to five days after unprotected intercourse to prevent pregnancy. Plan B or alternate method of emergency contraception should be offered to women with a history of rape or unprotected intercourse within the last five days.
• Initiation of contraception. After discussion of contraceptive alternatives, patient may wish to sign consent and begin contraceptive method immediately.
• Vitamins. Prescribe folate supplement to all women of childbearing age. Recommend calcium supplement.
• Contraindications. Estrogen-containing methods are not recommended for women 35 years of age or older who smoke. IUDs are contraindicated for women with high STD risk.
• Anti-seizure medication. Careful regulation of anti-seizure medication required if taken in conjunction with birth control pills. IUD should be considered as a safe contraceptive option for women taking anti-seizure medications if all other contraindications are absent.

Associated Problems/Complications

• Pregnancy. Counsel patient on medical and personal risks of pregnancy. Help patient to understand risks of pregnancy related to irregular menses, drug and alcohol abuse.
• Housing problems. Recognize that lack of housing may be even more of a problem once client becomes pregnant.
• Post-traumatic stress disorder (PTSD). Recognize that many homeless women and men are survivors of physical/sexual assault, with associated risks of psychological trauma and sexually transmitted disease (STD).
• Financial barriers. Limited resources for medications and lack of affordable health insurance for impoverished adults unaccompanied by children may present barriers to reproductive health care for both women and men.
• Lack of safe storage place. Store contraceptive devices and medications for patient and provide ready access to them.

Follow-Up

• Frequent follow-up is recommended to deal with any side effects of prescribed contraceptive method.
• Reminders. Appointment cards are useful to remind patient when to return to clinic for next prescription or injection.
• Positive reinforcement. Thank patient for showing up, even if late, and for any attempt to follow plan of care.
• Contact information. Re-confirm at every visit where patient is staying, address, phone number, cell phone, emergency contact number(s) where message can be left, case manager's name (if seen in clinic), clinic numbers (if seen in shelter).
• Drop-in policy. Encourage appointments but allow walk-ins, to promote better follow-up care and increase access to reproductive health services.
• Educate staff, co-workers to increase their knowledge of contraceptive options and comfort level with homeless patients.
• Nursing protocols Clinics should consider the establishment of protocols that allow nursing staff to administer walk in quick start and emergency contraception prior to a provider visit.

None provided

The recommendations were based on a comprehensive review of published reports and consensus opinion of the group regarding their relevance to the reproductive health care of homeless patients.

• Improved sexual and reproductive health of homeless individuals
• Improved public health

Side effects and risks of contraceptive methods

• Irregular or abnormal bleeding with progesterone contraceptives
• Risk to the fetus if a hormonal method is given inadvertently in early pregnancy
• Nausea with Plan B (emergency contraception)
• Demineralization of bone caused by progesterone contraceptives

• Intra-uterine devices are contraindicated for women with high sexually transmitted disease (STD) risk.
• Estrogen-containing methods are not recommended for women 35 years of age or older who smoke.
• Oral contraceptives are contraindicated in patients with acute viral hepatitis (patients with increased bilirubin, etc.) as well as in advanced chronic liver disease such as cirrhosis.
• NuvaRing currently has the same US Food and Drug Administration (FDA) contraindications as the combined oral contraceptive pill.

The information and opinions expressed in the guideline are those of the Advisory Committee for the Adaptation of Clinical Guidelines on Reproductive Health Care for Homeless Patients, not necessarily the views of the U.S. Department of Health and Human Services, the Health Resources and Services Administration, or the National Health Care for the Homeless Council, Inc.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness
Patient-centeredness

• Allen J, Bharel M, Brammer S, Centrone W, Morrison S, Phillips C, Rogers H, Strehlow AJ. Adapting your practice: treatment and recommendations on reproductive health care for homeless patients. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2008. 27 p. [48 references]

2003 (revised 2008)

Health Care for the Homeless (HCH) Clinician's Network - Medical Specialty Society
National Health Care for the Homeless Council, Inc. - Private Nonprofit Organization

Health Resources and Services Administration

U.S. Department of Health and Human Services

Advisory Committee for the Adaptation of Clinical Guidelines on Reproductive Health Care for Homeless Patients

Committee Members: Judith Allen, DMD, Cincinnati Health Care for the Homeless Program, Cincinnati, OH; Monica Bharel, MD, Boston Health Care for the Homeless Program, Boston, MA; Sharon Brammer, FNP, H.E. Savage Health Care for the Homeless, Mobile, AL; Wayne Centrone, MD, Outside In Medical Clinic, Portland OR; Sharon Morrison, RN, MAT, Boston Health Care for the Homeless Program, Boston, MA; Claudia Phillips, FNP, CNM, MPH, Springfield Health Care for the Homeless, Mercy Medical Center, Springfield, MA; Heidi Rogers, MSN, FNP-C, Albuquerque Health Care for the Homeless, Albuquerque, NM; Aaron Strehlow, PhD, FNP-C, RN, UCLA School of Nursing Health Center, Union Rescue Mission, Los Angeles, CA

The Health Care for the Homeless Clinicians' Network, which oversaw development of this guideline, has a stated policy concerning conflict of interest. First, all transactions will be conducted in a manner to avoid any conflict of interest. Secondly, should situations arise where a member is involved in activities, practices or other acts which conflict with the interests of the Network and its Membership, the member is required to disclose such conflicts of interest, and excuse him or herself from particular decisions where such conflicts of interest exist.

No conflicts of interest were noted during preparation of this guideline.

This is the current release of the guideline.

This guideline updates a previous version: Bonin E, Brammer S, Brehove T, Hale A, Hines L, Kline S, Kopydlowski MA, Misgen M, Obias ME, Olivet J, O'Sullivan A, Post P, Rabiner M, Reller C, Schulz B, Sherman P, Strehlow AJ, Yungman J. Adapting your practice: treatment and recommendations on reproductive health care for homeless patients. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2003. 22 p.

None available

This NGC summary was completed by ECRI on May 24, 2004. The information was verified by the guideline developer on June 24, 2004. This summary was updated by ECRI on October 4, 2006 following the new FDA advisory on Ortho Evra. This summary was updated by ECRI Institute on February 4, 2008 following the new U.S. Food and Drug Administration advisory on Ortho Evra Contraceptive Transdermal Patch. This NGC summary was updated by ECRI Institute on April 3, 2009. The updated information was verified by the guideline developer on April 27, 2009.

All material in this document is in the public domain and may be used and reprinted without special permission. Citation as to source, however, is appreciated. Suggested citation: Allen J, Bharel M, Brammer S, Centrone W, Morrison S, Phillips C, Rogers H, & Strehlow AJ. Adapting Your Practice: Treatment and Recommendations on Reproductive Health Care for Homeless Patients, 27 pages. Nashville: Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc., 2008.