House Calls Without Walls: Street Medicine Delivers Primary Care to Unsheltered Persons Experiencing Homelessness

THE INNOVATION

Access to primary care services remains difficult for people experiencing homelessness as a result of innumerable barriers, both structural and economic.^1,2 Street homeless men and women have life spans nearly 30 years shorter than their housed counterparts,³ and less than 10% have a primary care clinician.⁴ The 49,500 homeless individuals in Los Angeles County comprise 10% of the homeless in the United States.⁵ The majority are unsheltered. Street medicine is an emerging model of care for some of the most vulnerable subsets of people experiencing homelessness, those who do not readily utilize shelters or adjunctive services co-located within shelters.⁶

WHO AND WHERE

Keck School of Medicine (KSOM) of University of Southern California (USC) Street Medicine comprises a clinical provider (advanced practice clinician or physician), nurse, and a community health worker (CHW). These 3 roles form the core of a street medicine team. Our CHW is the team lead in locating patients on the street and navigating the complex system of community-based services, accessing resources and benefits. Ideally the CHW is someone with lived experience in homelessness and provides an essential bridge in building trust.

HOW

KSOM of USC Street Medicine provides full-service primary care on location under the bridge, on the sidewalk, or anywhere the patient resides with the belief that the patient will receive care where they prefer or are able. It’s our duty to provide the same level of care on the street as in the clinic. We conduct walking rounds with backpacks and the motto of “Go to the people.” At the initial encounter, or subsequent encounters as trust is built, the team conducts a comprehensive medical and psychosocial history while obtaining detailed information about patients’ whereabouts to locate them in the future. We focus on building trust by listening to patients share their stories, addressing felt needs, and avoiding clinician-driven agenda setting.

Maximal efforts are made to deliver high-quality clinical care on the streets if the patient desires. Many people experiencing homelessness have had multiple negative experiences in traditional clinic settings, resulting in reticence to seek care in such settings. Underlying these experiences is the stigma and social isolation associated with homelessness.^7,8 The range of clinical services provided by our team includes chronic disease management, wound care, routine vaccinations, and even antiretroviral therapy and monitoring for people living with HIV. Clinicians remain mindful about preventive health maintenance such as cancer screenings once primary acute issues have been addressed and the patient has bought into these interventions as being beneficial.

LEARNING

Although the composition of the street medicine team may vary, consistency among team members who interface with patients is essential to establish familiarity and trust. Clinical practice guidelines, while acknowledged, must sometimes be modified in order to practice reality-based medicine.⁹ Routine laboratory testing is often taken for granted in the traditional clinic setting, but when necessary, can be done with point-of-care testing or phlebotomy on location. Inability to obtain lab results should not preclude clinicians from initiating care if a reasonable level of safety can be assured. As with all medical interventions, shared decision making and individualized conversations regarding risks and benefits are essential.