How can we improve health care for the homeless?

Building trust, ensuring continuity of care and doing no harm are key principles for improving health care for homeless or “homeless” people, experts said at an online briefing hosted by the Alliance for Health Policy Wednesday.

“Trust is a big issue” among the homeless, said David Peery, JD, co-chair of the National Consumer Advisory Council and the National Homeless Health Care Council, who himself spent time to live in the street.

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

One of the reasons for this mistrust may be the criminalization of homelessness or the interference with the “life activities” that homeless people engage in – sleeping, eating, camping, asking for money – through activities such as “sweeping” of camps and prohibiting begging.

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

“We documented cases of a woman having seizures in the street because her medicine had been thrown away by city workers hours earlier, and… of people with disabilities, who 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 the homeless.

Street medicine

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 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 Boston’s radiance; 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 obtained a grant from the Robert Wood Johnson Foundation to set up a health care program for the homeless. A stipulation of the grant was that the homeless should be included as stakeholders in the planning of the program.

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

Of the approximately 40 physicians currently working at BHCHP, most started out as residents or medical students and have stayed there. O’Connell, who himself had planned to work for a year and then move on to an oncology fellowship, also stayed.

Each doctor works alongside a nurse practitioner or medical assistant, and today also with psychiatrists and recovery coaches, all serving the same panel of patients. All providers who encounter patients on the street must be accredited at one of the two main hospitals – another level helping to promote continuity of patient care, as this reduces the need for a referral to another clinician in the hospital. hospital.

Additionally, because consumers asked for care teams who met them where they were, the delivery model involved doctors running a clinic in the hospital during the day – as shelters are typically closed during the day. – then in shelters and streets in the afternoon. and evenings.

For O’Connell and other doctors, meeting patients where they were also meant going on night rides with peers (people with lived experience of homelessness) in a van giving homeless people soup, sandwiches and blankets. Handing out these articles, O’Connell was casually saying to anyone he met, “By the way, if you need anything, I’m a doctor.”

This “backdoor” tended to function both as a way to provide care and to build confidence, he said.

Medical respites

One of the challenges hospitals across the country face on a daily basis is getting homeless patients out after their care is complete.

“We have documented cases in which someone who was sent back to the street has died, several cases… literally, right across the street or right next to the hospital,” Peery said.

He noted that laws and regulations advise against, and in some cases penalize, hospitals for discharging homeless people who “are not sick enough to be kept in acute short-term care, but are far too sick. to take care of themselves on the streets. “Despite all the efforts of case managers and discharge planners to find transitional care sites, homeless people are still being released with nowhere where to go.

One solution has been medical respites, which go beyond a simple 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 first programs functioned primarily as AIDS units during the height of the HIV epidemic, he noted.

Today, medical respites provide a gateway for patients to primary care and behavioral health resources, giving clinicians time to develop a care plan and learn how to better manage patient medications for any chronic illness. .

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

Peery noted that Miami medical professionals were looking to replicate this pattern.

Expanding access to care, reducing harm, housing

Panelists presented the expansion of Medicaid as another way to support and improve care for the homeless.

“The failure to expand Medicaid is not just a moral failure, I would say, but also a public health failure,” said Peery, who lives in Florida, one of 12 states that have no further extended Medicaid eligibility to adults under age 65 whose income is at or below 138% of the federal poverty line.

In addition to consistent continuing care, relationship building and Medicaid eligibility, harm reduction is essential to help provide effective care to people living on the streets, the panelists said.

Through programs aimed at reducing the risk of drug overdose or contracting HIV and hepatitis C, harm reduction may involve providing homeless people with needle exchange services, fentanyl test strips and naloxone (Narcan).

There are also other innovations such as safe consumption sites or safe injection sites that “reduce harmful behavior and keep people alive so that we have another day when we can do the awareness needed to do this.” connect them to care, ”said DiPietro.

One principle that can be lost but which perhaps transcends all other models is the simple idea that “stable housing is important for stable health,” said DiPietro.

Research suggests that the homeless have much higher rates of diabetes, high blood pressure, and other chronic conditions than the general public. In addition, poor health can lead to homelessness, as medical debts can cause a person to lose their housing and access to health care.

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

  • Shannon Firth has worked on health policy as a correspondent for MedPage Today in Washington since 2014. She is also a member of the site’s Enterprise & Investigative Reporting team. To follow

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