How Can We Improve Medical Care for Homeless People?
Building trust, ensuring continuity of care, and doing no harm are key tenets to improving healthcare for homeless or “unhoused” individuals, said experts during an online briefing hosted by the Alliance for Health Policy on Wednesday.
“Trust is a big deal” among homeless individuals, said David Peery, JD, co-chair of the National Consumer Advisory Board and National Health Care for the Homeless Council, who himself spent time living on the streets.
People who have been living on the streets are both emotionally and physically traumatized by the experience, and they often see the very institutions and professionals that others inherently rely on — including police and doctors — as predators, Peery said.
One reason for that distrust may be the criminalization of homelessness, or the interference of “life-sustaining activities” that people who are homeless engage in — sleeping, eating, camping, asking for money — by activities such as “sweeps” of encampments and prohibiting panhandling.
Peery illustrated with examples from Miami how criminalizing homelessness can have a significant impact on health.
“We have documented instances of a woman going into convulsions on the street because her medication had been thrown away by city workers just hours earlier, and … of individuals who are disabled, who have had their own walkers and wheelchairs … thrown away,” he said.
In other parts of the country, decades of outreach and a patient-centered approach have helped build trust with those in the homeless community.
About 75% of people living on the streets of Boston have been vaccinated against COVID-19, said Jim O’Connell, MD, president and founder of Boston Health Care for the Homeless Program (BHCHP) and assistant professor of medicine at Harvard Medical School.
He said there was nothing magical about Boston’s outreach; the vaccines were accepted by people living on the streets simply because they were given by people who had known them for years.
In the early 1980s, the city of Boston got a grant from the Robert Wood Johnson Foundation to build a healthcare program for the homeless. A stipulation of the grant was that the homeless people needed to be included as stakeholders in the planning of the program.
Patients living on the street stressed the importance of continuity of care, telling physicians at the time, “We want you to do this as your profession and not as something you just do as a temporary thing that you move on [from],” O’Connell said.
Of the roughly 40 physicians currently working in the BHCHP, most began as residents or medical students and stayed. O’Connell, who had himself planned to work for a year and then move on to a fellowship in oncology, also stayed.
Each doctor works alongside a nurse practitioner or a physician assistant, and today also with psychiatrists and recovery coaches, all serving the same panel of patients. All providers meeting patients out on the street are required to be credentialed in one of the two major hospitals — yet another layer helping to promote continuity in patient care, as this reduces the need to refer to another clinician in the hospital.
Also, because consumers asked for care teams that met them where they were, the delivery model involved physicians holding clinic in the hospital during daytime hours — as shelters are typically closed during the daytime hours — and then in shelters and streets in the afternoons and evenings.
For O’Connell and other physicians, meeting patients where they were also meant participating in overnight ride-alongs with peers (people with lived experience of homelessness) in a van giving unhoused individuals soup, sandwiches, and blankets. While distributing these items, O’Connell would nonchalantly say to whomever he met, “By the way, if you need anything, I’m a doctor.”
That “back door” tended to work both as a means of delivering care and building trust, according to him.
One of the challenges hospitals around the country encounter daily centers around discharging homeless patients after their care is complete.
“We have documented instances in which an individual who was discharged onto the street has died, several instances … quite literally, just either across the street or right down the block from the hospital,” Peery said.
He noted that laws and regulations advise against, and in some cases penalize, hospitals for discharging unhoused people who are “not sick enough to be maintained within the short-term acute-care setting, but are way too sick to take care of themselves on the streets.” Despite case managers’ and discharge planners’ best efforts to find sites of transitional care, it still happens that homeless individuals are released with nowhere to go.
One solution has been medical respites, which go beyond simply serving as a transitional space and offer a number of benefits, explained Barbara DiPietro, PhD, senior director of policy at the National Health Care for the Homeless Council.
O’Connell had launched the first medical respite in the early 1990s. The earliest programs functioned mostly as AIDS units during the height of the HIV epidemic, he noted.
Today, medical respites offer a bridge for patients to primary care and behavioral health resources, providing time for clinicians to both develop a care plan and to learn to better manage patients’ medications for any chronic diseases.
As a result, these facilities have been linked to better outcomes for patients, shorter hospitalizations, and lower readmission rates, which saves costs throughout the healthcare system, DiPietro said.
Peery noted that healthcare professionals in Miami are looking to replicate this model.
Expanding Access to Care, Reducing Harm, Housing
Panelists touted Medicaid expansion as another way to support and enhance care for unhoused individuals.
“The failure to expand Medicaid is not only a moral failure, I would contend, but also a public health failure,” said Peery who lives in Florida, one of 12 states that has yet to expand Medicaid eligibility to adults under age 65 whose income is at or below 138% of the federal poverty level.
In addition to consistent continuous care and building relationships and Medicaid eligibility, harm reduction is essential to helping provide effective care for those living on the street, panelists said.
Through programs aimed at reducing a person’s risk of drug overdose or getting HIV and hepatitis C, harm reduction can entail providing homeless people with syringe exchange services, fentanyl test strips, and naloxone (Narcan).
There are also other innovations like safe consumption site or safe injection facilities that “reduce the harm behaviors, and keep people alive so that we have another day where we can do the outreach necessary to get them connected to care,” DiPietro said.
One principle that can get lost but perhaps transcends all of the other models is the simple idea that “stable housing is important for stable health,” DiPietro said.
Research suggests that people who are homeless have far higher rates of diabetes, hypertension, and other chronic issues than the general public. Moreover, poor health can cause homelessness, as medical debt can lead an individual to lose a home and access to care.
“So when we say ‘housing is healthcare,’ that’s where we’re coming from,” DiPietro said. “Nothing that we do with healthcare providers works as well if someone goes back to the shelter or under the bridge or to the encampment.”
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