How can we improve the medical treatment of the homeless?

Building trust, ensuring continuity of care and not doing harm are key principles in improving the health care of homeless or “homeless” individuals, experts said during an online briefing held by the Alliance for Health Policy on Wednesday.

“Trust is a big thing” among homeless individuals, said David Peery, JD, co-chair of the National Consumer Advisory Board and National Health Care for the Homeless Council, who themselves spent time living on the streets.

People who have lived on the streets are both emotionally and physically traumatized by the experience, and they often see precisely the institutions and professionals that others naturally depend on – including police and doctors – as predators, Peery said.

One reason for this mistrust may be the criminalization of homelessness or the interference of “life-sustaining activities” that homeless people engage in – sleeping, eating, camping, asking for money – in activities such as “sweeping” of camps and prohibition of panhandling.

Peery illustrated with examples from Miami how criminalizing homelessness can have a significant impact on health.

“We have documented the case of a woman who had seizures on the street because her medicine had been thrown out by city workers a few hours earlier, and … by people with disabilities who have been given their own walkers and wheelchairs. “thrown away,” he said.

In other parts of the country, decades of outreach work and a patient-centered approach have helped build trust in those in the homeless community.

Street medicine

About 75% of the people living on the streets of Boston have been vaccinated against COVID-19, said Jim O’Connell, MD, president and founder of the Boston Health Care for the Homeless Program (BHCHP) and assistant professor of medicine at Harvard Medical School.

He said there was nothing magical about the spread of Boston; the vaccines were accepted by people who lived on the streets, simply because they were given by people who had known them for years.

In the early 1980s, the city of Boston received a grant from the Robert Wood Johnson Foundation to build a health program for the homeless. One provision in the grant was that the homeless should be involved as stakeholders in the planning of the program.

Patients living on the streets stressed the importance of continuity of treatment, telling doctors at the time: “We want you to do this as your profession and not as something you just do as a temporary thing as you move on. with [from]said O’Connell.

Of the approximately 40 physicians currently working in the BHCHP, most began as residents or medical students and remained. O’Connell, who himself had planned to work for a year and then go on to a scholarship in oncology, also stayed.

Each doctor works with a general practitioner or a medical assistant, and today also with psychiatrists and recovery coaches, all of whom serve the same panel of patients. All providers who meet patients on the street must have identification at one of the two major hospitals – another layer that helps promote continuity in patient care, as this reduces the need to refer to another clinician at the hospital.

Because consumers asked for care teams that met them where they were, the delivery model involved doctors holding clinics in the hospital during the day – as shelters are typically closed during the day – and then in shelters and streets in the afternoons and evenings.

For O’Connell and other physicians, meeting patients where they were also supposed to participate in overnight rides with peers (people with lived experience of homelessness) in a van that gave uninhabited people soup, sandwiches, and blankets. While distributing these items, O’Connell casually said to the person he met, “By the way, if you need anything, I’m a doctor.”

The “back door” tended to act both as a means of providing care and building trust, according to him.

Medical respite

One of the challenges that hospitals around the country face on a daily basis is centering on discharging homeless patients after their care is completed.

“We have documented cases where a person who was discharged on the street has died, several cases … literally, either across the street or just down the street from the hospital,” Peery said.

He noted that laws and regulations discourage, and in some cases punish, hospitals for discharging uninhabited people who “are not sick enough to be maintained in the short-term emergency care but are too ill to take care of themselves”. even on the streets. ” Despite the best efforts of caseworkers and discharge planners to find places for transitional care, it still happens that homeless people are released without going anywhere.

One solution has been medical respite, which goes beyond just serving as a transitional space and offers 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 respite offers 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 chronic diseases.

As a result, these facilities have been associated with better patient outcomes, shorter hospital stays and lower readmission rates, saving costs across the healthcare system, DiPietro said.

Peery noted that health professionals in Miami are seeking to copy this model.

Expanding access to care, reducing damage, housing

Panelists hailed the Medicaid expansion as another way to support and improve the care of people who are not at home.

“The failure to extend Medicaid is not only a moral failure, I would argue, but also a public health failure,” said Peery, who lives in Florida, one of 12 states that have not yet extended Medicaid eligibility to adults under 65. years whose income is at or below 138% of the federal poverty level.

In addition to consistent ongoing care and relationship building and Medicaid eligibility, harm reduction is critical to helping provide effective care to those living on the streets, panelists said.

Through programs aimed at reducing a person’s risk of drug overdose or getting HIV and hepatitis C, harm reduction may mean that homeless people are offered syringe exchange services, fentanyl test strips and naloxone (Narcan).

There are also other innovations like a safe place to consume or safe injection facilities that “reduce the injury behavior and keep people alive so we have another day where we can do what is necessary to get them connected to care,” DiPietro said.

One principle that may be lost, but perhaps surpassing all 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 incidences of diabetes, hypertension and other chronic problems than the general public. In addition, poor health can cause homelessness, as medical debt can cause a person to lose a home and access care.

“So when we say ‘housing is healthcare’, that’s where we come from,” DiPietro said. “Nothing like we do with health care providers works so well if someone goes back to the shelter or under the bridge or to the camp.”

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    Shannon Firth has been reporting on health policy as MedPage Today’s Washington correspondent since 2014. She is also a member of the site’s Enterprise & Investigative Reporting team. Follow

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