Brett Feldman, MSPAS, PA-C Director of Street Medicine for Keck School of Medicine of USC checks on patient after recent hospital admission for heart failure.
“One foot in the grave,” he said. “Is that how you feel?” I asked. “No, it’s how I live.”
Unsheltered for 38 years, he had lived primarily behind a dumpster floating in and out of the medical, social and judicial system. In the month before the new Keck School of Medicine of the University of Southern California (KSOM) Street Medicine had seen him, he had six visits to the emergency department and one hospital admission, all of which were related to his poorly controlled, life-long seizure disorder.
Ten times more likely to die
His bleak statement about living with one foot in the grave could not have been more accurate. A landmark study published in September 2018 revealed a stark reality. The unsheltered population in Boston, MA had been ten times more likely to die during the ten years of the study than the general population. And in a comparison that had never been done, the research team compared the sheltered and unsheltered populations experiencing homelessness. They found that the unsheltered population had a 3-times higher mortality rate, demonstrating the fundamental, protective nature of simply having shelter, even if it isn’t permanent.
What’s more, the unsheltered homeless are dying of seemingly “normal” things, most prominently heart disease and cancer. They also died of chronic liver disease and overdoses (including opioid overdoses that are now widely considered an epidemic in the U.S., and recently covered here at our blog). The first two causes of death are disease processes your family doctor is probably trying to prevent in you, with timely screening and treatment. The outdoor community of street sleepers and doorway dwellers could have the same chances too, except they lack one thing: access to acceptable primary care.
Accessible and acceptable primary care
According to the World Health Organization [pdf], access and acceptability are two main features of quality assurance.
Accessibility involves much more than an office time-slot or transportation, but needs to be tailored to the circumstances of the patient. People experiencing homelessness spend a great deal of time and effort meeting basic survival needs like finding food, shelter and maintaining safety rather than obtaining healthcare. These “competing priorities” make them more likely to go without needed care. As in many cities, camp sweeps by police to move people along or for sanitation result in belongings being thrown in the garbage, especially when inhabitants aren’t “home”. How likely would you be to leave your home for a doctor’s appointment if there was a chance it would all be gone when you return?
Acceptability is another barrier to the traditional healthcare system. Distrust of physicians is thought to be common among people experiencing homelessness. It may be rooted in prior negative experiences or feeling disliked due to the perception that their homelessness is unwelcome, and it can result in a decreased desire to seek care in the future. Evidence for this is that homeless patients are almost twice as likely to leave against medical advice (AMA), which itself is associated with an increased 30-day mortality and higher readmission rates.
It comes as no surprise that people experiencing homelessness have more emergency department visits and hospitalizations than the housed population in general. (This was discussed in another recent post on this site.) Rationally, this makes sense. If the general population had difficulty accessing an acceptable primary care provider and relied on the ED as the initial point of entry into the healthcare system (as many people experiencing homelessness do) then ED visits across the county would skyrocket.
Corinne T. Feldman, MMS, PA-C provides wound care to a patient living outside.
Street medicine as a viable solution
Street medicine is a healthcare delivery model that aims to turn these statistics on their head. It is based on the idea that everyone matters, including the people who are not typically found in the waiting room of the local doctor’s office. Armed with backpacks full of medical supplies and brains full of medical knowledge, these healthcare teams take the doctor’s office to the sidewalk, underpasses and bridges to deliver transitional primary care until the patient can be incorporated into the mainstream healthcare system.
Acknowledging that this transition may take months, years, or may never happen, street medicine practitioners aim to maintain a comparable level of quality to that seen in a traditional clinic setting. The fundamental approach to street medicine is to engage people experiencing homelessness in their own environment and on their own terms, with the goal of maximally reducing or eliminating barriers to care. Medical history-taking, check. Physical exam, check. Drawing labs, check. Dispensing or delivering medications, check. Building a relationship rooted in recognizing each other’s humanity, for all its beauty and disaster… check.
There is early evidence that this model can provide great value in terms of health outcomes per dollar spent. Street medicine can improve the health of unsheltered patients and decrease the use of emergent and acute healthcare services. Early street medicine programs, such as Lehigh Valley Health Network (LVHN) Street Medicine, created alternative primary care access points that are both accessible and acceptable to the population. While results are preliminary, LVHN Street Medicine demonstrated decreased ED visits of over 80% and 30-day readmissions decreases by almost 70%. In a population that is notoriously difficult to provide treatment for chronic conditions, LVHN Street Medicine patients with hypertension had better blood pressure control than the traditional clinic population. While this certainly bodes well for hypertension control, it also speaks to street medicine’s ability to gain trust to the point where patients are willing to follow up longitudinally.
Street medicine was created with the intent to relieve suffering and has grown into a legitimate alternative healthcare delivery model for a population that requires it. The rapid growth, led by the Street Medicine Institute (www.streetmedicine.org) has reached over 100 programs worldwide, over half of which are in the U.S. These programs range from underfunded to unfunded, resulting in time spent delivering care, with little attention to research.
The rapid growth of the street medicine movement is a result of its success as a social justice movement and an effective healthcare delivery system. However, to achieve the vision of all unsheltered homeless having access to basic medical care, more research is needed to gain mainstream acceptance and achieve the vision of redefining what our waiting rooms look like. At USC, we are embarking on an effort to strengthen research in this area.
If you are interested in learning more about street medicine, please reach out or comment below. Also, make sure to visit www.streetmedicine.org.
Corinne Feldman
Latest posts by Corinne Feldman (see all)
