Street Medicine: Removing Barriers and Providing Care
Most doctor-patient relationships begin with a physician entering an exam room, shaking hands with a new patient, and sitting at a computer to take notes. But for Dr. Coley King, Director of Homeless Health at the Venice Family Clinic, this experience is quite different.
On the day of our interview, he had just met a new patient while making his street medicine rounds in Malibu, CA. "There was a man, we didn't really know if it was a person or not, he was underneath a pile of covers. We got out, kept a good distance, kind of said 'Hey, hello, how are you doing? I'm Dr. King from Venice Family Clinic.' And sure enough, a man emerged and we introduced ourselves and started the engagement process."
Homelessness by the Numbers
According to the U.S. Department of Housing and Urban Development, nationwide homelessness increased in 2020 for the fourth year in a row. Close to 600,000 people experienced homelessness on a single night in January 2020, with 40% of them in unsheltered locations including the street, cars, and abandoned buildings. In addition, Black and Indigenous people in the U.S. are disproportionately represented in the homeless population.
Unsheltered homelessness continues to rise and largely contributes to the increasing numbers of those experiencing homelessness. Nowhere in the U.S. is this issue more prevalent than in California, which is home to half of the country's unsheltered population. To put this in perspective, California has nine times as many unsheltered individuals as second-highest Texas (113,660 vs 13,212).
While states like Maine, Massachusetts, and New York have low percentages of unsheltered homelessness compared to overall homelessness (6.7%, 7.2%, and 5% respectively), in California 70.4% of the homeless population is unsheltered. The lack of a reliable dwelling and the challenges this adds to everyday life mean the healthcare system must adapt to best serve the pressing healthcare needs of this vulnerable population.
Unique Needs of the Unsheltered Population
Individuals who are experiencing homelessness, particularly those who are unsheltered, face unique and challenging barriers to obtaining medical care. Many lack reliable transportation for medical appointments. Higher rates of medical and mental illness and substance use compared to the general population, combined with decreased access to care. leads to hospitalization rates that are four times higher than the general population. This results in disability and increases unemployment. Ultimately, the impact of these issues shortens the life of unsheltered homeless people by about 30 years compared to those with housing.
The inability of the unsheltered population to access traditional medical care also adds financial strain to the healthcare system. Without reliable primary and preventive care, emergency rooms become a major access point for medical treatment. Furthermore, lack of care in the early stages of illness leads to advanced disease presentations.
What is Street Medicine?
The practice of street medicine, where those experiencing homelessness are met by medical professionals in their own environment, began in the early 1990s. Its establishment started with Dr. Jim Withers, who treated patients in Pittsburgh, PA and is credited with pioneering the field.
Street medicine aims not only to meet individuals wherever they may be living at a given time, it also provides a holistic approach to patient care by addressing pressing social needs while treating medical conditions. The idea is not to provide an ongoing medical home for an unsheltered patient, but rather to address acute needs and assist with overcoming barriers to establishing more stable care.
Street Medicine in Action
Dr. Coley King has been a family medicine physician at the Venice Family Clinic for 14 years. He knew that working with underserved populations was the type of role that best suited him because "those are the people I was drawn to."
Dr. King stated that he "didn't know much about homeless healthcare" when he first started at the clinic. At that time, there were other clinicians holding a street medicine clinic one half day per week along with a case manager from the Ocean Park Community Center.
In the years since, the Venice Family Clinic Street Medicine Program has grown exponentially in size and scope. Dr. King now spends four days a week seeing patients outdoors. There are multiple satellite sites and outreach teams in areas like Venice Beach, Malibu, and Santa Monica. The model of care varies from working with patients on the street to having a standing clinic at a specific outdoor location to meeting the needs of those who live in their cars.
Addressing the mental health needs of those experiencing homelessness is a particularly important concern. Dr. King estimates that about 70% of the patients he sees have a mental health diagnosis. Common diagnoses include bipolar disorder, schizophrenia, and major depressive disorder. Through a partnership with the UCLA psychiatry department, patients are also treated for their mental health needs.
Importantly, the program recently acquired a mobile clinic van that expands their capacity to provide on-the-spot care to patients. It is equipped to offer minor office procedures, including blood draws and Pap smears, thus expanding necessary preventive and treatment measures to populations that may otherwise not be able to access them.
Most recently, the clinic has been awarded a United Way grant that will allow them to expand their teaching capabilities to include more future physicians with an interest in street medicine. This focus on training the next generation of clinicians is a critical aspect of street medicine programs. It is essential for carrying on and expanding street medicine services where they are most needed.
Teaching While Treating
Dr. Chelsea Dean is the perfect example of how the influence of teaching within street medicine programs creates the next generation of leaders to carry on the work. As an internal medical resident at Santa Barbara Cottage Hospital, Dr. Dean began volunteering with the local street medicine program, Doctors Without Walls, in 2015. Despite her busy residency schedule, she made it a priority to get outside and see patients at least once or twice a month.
Fast-forward to 2021, and Dr. Dean is now the Co-Medical Director of Doctors Without Walls. After graduating from residency, she remained in the Santa Barbara area and was eager to take on a leadership role in the organization that had become so meaningful to her during her training.
Doctors Without Walls is designed to be a "student led organization," according to Dr. Dean. Students from University of California, Santa Barbara (UCSB) participate in patient care and acquire valuable skills along the way. This helps to effectively "build up student humanitarian leaders" who may someday follow in Dr. Dean's footsteps.
When a Pandemic Hits
When a global health crisis like the COVID-19 pandemic strikes, the most vulnerable populations are always at the highest risk. In this case, the combination of an easily transmissible disease and a population with significant baseline morbidities living in crowded conditions was a potential recipe for disaster.
California responded to this crisis by developing Project Roomkey in March 2020 with financial assistance from the Federal Emergency Management Agency (FEMA). This program aims to provide safe living options for individuals experiencing homelessness who have or were exposed to COVID-19, as well as those who are considered medically high risk if they were to become infected.
With travel at a minimum early in the pandemic, empty hotel rooms provided the perfect setting to shelter those who qualified. While these housing options are meant to be temporary, the program also focuses on working with those who want permanent housing to achieve this goal.
As the pandemic slowly winds down in the U.S. and life begins to normalize, the future of Project Roomkey is uncertain. Although the program was scheduled to shut down in March 2021, Los Angeles has pledged to continue it until at least the end of September.
One of the biggest barriers faced by the project since its inception is a surprising one: instead of too many people and too few rooms, many areas had more rooms available than people interested in filling them. Nonetheless, advocates and elected officials continue to push for funding so that those who are interested can have a safe living option.
The Future of Street Medicine
As the pandemic demonstrated, street medicine programs are more prone to "curve balls" in their future planning than other fields of medicine. Dr. King continues to see the lack of housing options as the biggest barrier to ongoing medical care for his patients in Los Angeles. The extension of Project Roomkey offers some hope that more intensive placement services will be available for at least a few more months, but longer term solutions are less certain.
In Santa Barbara, increased scrutiny of outdoor encampments and their potential risks as fire season opens has led to much public debate. Two encampments in Pershing Park and Dwight Murphy Field were recently swept by police despite the Centers for Disease Control and Prevention (CDC) directive that these camps should not be disturbed during the pandemic. Clearing encampments both endangers the community by potentially spreading COVID-19 and creates additional barriers to services for the homeless population by separating them from the location where their services are typically obtained.
Dr. Dean notes that a group of 20 tiny pallet homes built near UCSB within the past year have been met with enthusiasm by the homeless community. They are so popular, in fact, that there is a waitlist for them as demand outweighs supply. However, much like Project Roomkey, the future of this program is up in the air, as it was originally designed for a temporary 6-month timeframe to provide emergency shelter during the COVID-19 pandemic.
Since uncertainty about the future is woven into the fabric of street medicine, Dr. King and Dr. Dean both remain undistracted from their daily work by these concerns. The founding principle of street medicine is the concept of meeting patients in their own environment, and whether that is an encampment, pallet home, car, or on the street, healthcare workers, students, social workers, and other support staff dedicated to street medicine will continue to carry out their mission wherever they are needed.
About the Author
About Angels in Medicine
Angels in Medicine is a volunteer site dedicated to the humanitarians, heroes, angels, and bodhisattvas of medicine. The site features physicians, nurses, physician assistants and other healthcare workers and volunteers who reach people without the resources or opportunities for quality care, such as teens, the poor, the incarcerated, the elderly, or those living in poor or war-torn regions. Read their stories at www.medangel.org.
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