Doctor’s Orders
Barbe West was a woman with a plan. A plan with a van. To be precise, her plan involved two vans.
West serves as Executive Director of the Free Clinic in Vancouver, Washington, a city on the banks of the Columbia River just outside Portland, Oregon. Early last year, the clinic’s leadership decided to take action to ensure that homeless people in Clark County could access the primary and urgent care they needed.
The Free Clinic has a long, proud history of delivering care to those who need but can’t afford it. Its 500 volunteers treat approximately 8,000 uninsured Clark County residents per year, free of charge. Still, one group has continued to slip through the cracks.
“We’ve been very concerned that the homeless in Vancouver and its surrounding communities are not seeking care until it’s too late,” says West. “Most end up in an emergency room, and the ED is the wrong place to start receiving treatment.”
For various reasons, the majority of the area’s homeless had not been finding their way to the Free Clinic or similar services to nip looming health emergencies in the bud. So the Free Clinic decided to take a new approach. Instead of waiting for homeless patients to show up on their doorstep, they opted to take the show on the road, bringing the clinic to the places where homeless people spend the most time.
Last fall, a crack team of Free Clinic volunteers began making monthly visits to Share House, a community gathering space five miles from the clinic where Vancouver’s homeless go for meals, showers, and beds. Here they began offering urgently needed medical and dental services from two vans.
The monthly convoys include physicians, nurses, dentists, and dental hygienists. A pharmacist goes along for the ride as well, dispensing essential medicines like antibiotics from a locked cabinet in one of the vans.
Both vans the Free Clinic uses were designed to provide mobile dental services. “We didn’t have a medical van,” says West. “When we broke the news to the care team, they said, ‘No problem. We can adapt. We’ll just lay the chairs down flat and, voila! They’ll become exam tables.”
Indeed, necessity’s the mother of invention, and organizations like the Free Clinic trying to tackle the problem of delivering health care to homeless people need ingenuity in spades.
HEALTH AND HOMELESSNESS
Homelessness exacerbates almost every condition that would make a patient high-risk anyway. People experiencing homelessness spend a lot of time outdoors, many of them struggling with mental-health and substance-use disorders that put them in constant danger. This naturally leads to high rates of illness, injury, and death.
For homeless people, access to preventive, primary, and urgent care services they can actually use is limited. Conditions that for most patients present temporary setbacks, such as minor wounds or common colds, often progress and become life-threatening among the homeless.
Data describing morbidity and mortality patterns among the homeless are incomplete. However, what data exists consistently shows that simply being homeless dramatically reduces life expectancy, often by half. A recent study in Vancouver, BC, for example, found that the city’s homeless tend to die between the ages of 40 and 49 years old. The life expectancy of the average person in British Columbia is 82.
For financial, practical, and social reasons, homeless people rarely visit community-based clinics for primary and urgent care.
“Many are uncomfortable in care settings where the rest of us feel at ease,” says Daniel Malone, Executive Director of Seattle-based DESC (formerly the Downtown Emergency Service Center). “Simple things like meeting a set appointment time or sitting in a waiting room—these can be quite challenging for our clients, even if the clinic is specifically geared to accommodate them.”
“We can't expect people to heal and recover properly
if they don't have a safe place to go after discharge.”
—Daniel Malone, Executive Director, DESC
Instead, people who are homeless hold out until they’re deathly ill, finding their way to emergency rooms when they can no longer go without help. Consequently, they tend to use emergency services and become hospitalized at much higher rates than the general population.
To make matters worse, the treatments homeless patients receive in acute-care settings often have only a short-term benefit. “When a hospital discharges a patient back to the streets, the care the patient received often gets unwound,” says Malone. “We can't expect people to heal and recover properly if they don't have a safe place to go after discharge.”
BRINGING URGENT CARE TO THE HOMELESS
While people experiencing homelessness may not seek treatment in community-based clinics, they do want care when they need it. “The most effective approach is to bring clinical services into environments where homeless people are already comfortable,” says Malone.
That’s where solutions like the Free Clinic’s two-van plan come in.
The Free Clinic is starting out by visiting the Share House one evening per month, hoping to see about 20 patients each time. If they encounter higher demand than that, they may increase the frequency of visits or try to expand the capacity of the mobile care team.
“Some patients will need follow-up care and won’t be able to wait a month,” says West. “We’ll be working with Share House to arrange transportation to our clinic in those cases.”
The other challenge West anticipates is ensuring continuity of care for patients who lack a permanent address, phone number, or other reliable means of contact. Two of the Free Clinic’s program managers will work closely with colleagues at the Share House to try to maintain the connection between the care team and its homeless patients.
In an entirely different urban landscape, DESC pursues similar strategies to bring health care to homeless people and prevent unnecessary trips to the hospital. All of its shelters, housing facilities, and daytime drop-in centers employ clinical staff charged with identifying and addressing health issues as they arise. DESC also has a mobile crisis team that first responders can call on when someone on the street appears to be having a mental-health crisis.
HOUSING AS HEALTH CARE
Poor health is both a symptom and a cause of homelessness. People frequently become homeless as a result of serious health issues, and those issues only worsen once they lose a permanent place to live. In a practical sense, stable housing and stable health are inextricably linked.
DESC’s organizational philosophy emphasizes housing as an indispensable component of prevention, treatment, and recovery. Its nationally recognized Housing First program has successfully modeled how much more effective it is to provide homeless people with permanent housing first—and then give them the services they need to support their recovery.
In fact, many housing-first advocates have persuasively argued that providing permanent homes to homeless adults with addictions, untreated mental illnesses, and other chronic health issues can actually save human-services dollars in the long run. Allocating resources to supportive housing from public health funds, though perhaps not a viable political objective in most states, makes good financial sense.
In a 2009 study of the DESC Housing First program, researchers at the University of Washington found that providing housing to 95 chronically homeless people with alcohol addiction saved Seattle taxpayers more than $4 million in crisis-service costs in a single year—roughly half of what services for the same group had cost taxpayers the previous year.
Malone argues that one of the most important steps physicians can take to improve the health status of the homeless population is to support the development of stable housing options. “Doctors are highly respected, influential members of their communities. By advocating for policies that create more housing for people experiencing homelessness, they can have a tremendous impact on the problem.”
Doctors can make their voices heard by reaching out to politicians and trade groups representing their interests. Over the past year, for example, the Washington State Hospital Association (WSHA) has been soliciting comments from its membership on the idea of extending Medicaid coverage to supportive housing. The Centers for Medicare & Medicaid Services (CMS), meanwhile, recently approved supportive-housing services as part of its Medicaid Transformation Demonstration project in Washington State.
No matter how many vans and volunteer doctors we deploy, our ability to improve the health of homeless people ultimately rests on the success of game-changing efforts like these.