Treating people wherever they live is becoming increasingly important
July 5, 2023
CHICAGO – Ebony Funches is young, Black and speaks carefully and sensitively. She has a PhD in nursing and is deeply involved in street medicine in Venice, California, just outside Los Angeles. Her patients often have a tri-morbid condition, meaning they’re suffering with substance abuse, mental health challenges and physical problems.
They’re also poor and homeless. In short, they’re at the bottom of the social ladder and they’ve got huge issues to deal with.
To top it off, they tend to avoid coming into brick-and-mortar clinics.
At the HIMSS meeting in April, Dr. Funches described how she and her colleagues at the Venice Family Clinic are helping these patients – whose numbers have been growing in recent years, as the rich get richer and the poor spiral downwards.
“We’re going out and treating people right where they are – under the freeway, in abandoned buildings, even in the mountains,” said Dr. Funches. “They don’t access regular care. They may have been [emotionally] burned, they don’t trust other people, they have the stigma of homelessness, the shame, and they don’t want to be judged. But they deserve healthcare.”
Dr. Funches gave an example of a successful intervention with a street person in need of care.
“She was a young African-American girl suffering from mental illness and substance abuse. She could only tell me her first name, and she had schizophrenia. I spent time with her each week, gaining her trust. I did blood work and started giving her anti-psychotic drugs. In time, I was able to help her get organized.”
Dr. Funches continued, “A few weeks later, she gave me another name, her real name. I then found out that she had health insurance and SSI, which covered the cost of renting a house for her.
“She’s now living in the house and considering going back to school.”
Getting homeless patients stabilized, physically and emotionally, and into housing, are the goals of street medicine.
Dr. Funches asserted that anyone can become homeless and find themselves without financial resources, physically sick and mentally ill. “It usually stems from a catastrophic event,” she said. “Like the loss of a job or a divorce. And we see many people who come to California to pursue a career in acting, where their plans don’t work out, and they start taking substances.”
Without steady income, these people find themselves on the street, fighting for survival.
Technology has been a tremendous help in visiting and treating the street population. In particular, smartphones have been key tools.
“Our phones are outfitted with an app that integrates with the electronic health record at the clinic. We can take pictures of people, which is important for trying to identify clients who can’t tell us who they are. When they have documents, we can take pictures of them, too, for their files. And we can dictate by voice.”
Assisted by smartphones in this way, a team from the Venice Family Medical Clinic can see 10 patients in a half-day.
Typically, the clinic will send out a clinician, such as a doctor or nurse, along with a case manager to handle the social services side of things, and a peer – someone who has experience with living on the street and can reassure clients.
Dr. Funches said that in addition to her cell phone, she travels with a backpack filled with equipment – including a stethoscope, an ophthalmoscope for eye exams, and an otoscope. “We find lots of bugs in their ears,” she noted.
She also carries personal protective equipment – PPE. “You never know what you’re going to be exposed to,” she observed.
During an encounter, she can give topical medications and provide wound care. With the help of prescribing physicians, various medications can be ordered and brought to the site where the clients are living.
Dr. Funches added that she totes around a portable stool. “It’s for when there’s nowhere to sit. And in this job, you need to sit down.”
The Venice Family Clinic has 13 clinicians working in street medicine. They also have three mobile units, with vans equipped like doctors’ offices. In 2022, the Venice team conducted 2,347 street visits and saw 872 unique patients.
The clinic dates back to 1970, with volunteer physicians providing community care at a borrowed dental office after regular hours. It has evolved dramatically since then, and now has 17 locations, plus mobile clinics and its street medicine program.
Dr. Funches said the street medicine activities expanded greatly in 2007, when the banking crisis in the U.S. set off a major recession. It grew again during the recent Covid pandemic.
Street medicine, as an organized approach, dates back to 1992, when Pittsburgh, Penn., physician Jim Withers went out onto the streets to treat the city’s homeless population, assisted by a former street person who acted as a guide. Dr. Withers decided to devote his career to caring for the poorest of the urban poor.
He connected with other clinicians treating the underclass in cities around the world. In 2005, Dr. Withers and his colleagues launched the International Street Medicine Symposium in Pittsburgh, bringing together clinicians from many nations. In 2009, they launched the Street Medicine Institute (SMI), which focuses on developing street medicine as a specialty, training caregivers and supporting programs worldwide.
There are now street medicine programs in over 85 cities across 15 countries on five continents. According to the SMI, the movement continues to grow.
Anthony Villaneuva, CIO at Neighborhood Health, in Nashville, Tenn., also spoke at the HIMSS session. The street medicine program in Nashville is much newer than the one in Venice, California. Villaneuva explained that a brick-and-mortar building in Nashville had to be closed just around the time that COVID-19 struck.
“We had 5,000 patients experiencing homelessness,” he said. “When the pandemic started, we had to put programs together quickly. We ramped up and saw our first patients in 2020.”
These, too, were people suffering from substance abuse and mental health issues, as well as physical ailments – the triple morbidity. In Nashville, many of the street people are former members of the armed forces. For one reason or another, they’ve fallen on hard times.
Villaneuva said technology has been extremely helpful in treating the homeless population, enabling staff and clinicians to do a lot of work in a short period of time, all remotely. Again, smartphones have been a key instrument. “We’re doing coding, billing and charting,” said Villaneuva. “And we’re using speech-to-text, with the note going right into the chart.”
To refine the technology, Villaneuva explained, Neighborhood Health’s I.T. team went out into the field and followed around a clinical team to see how they worked. This showed them how things could be improved, and together, the I.T. staff and the clinicians were able to come up with better ways of charting and billing.
Villaneuva recounted the story of one client, a pregnant woman living in a tent under a bridge in Nashville. The visiting team of street clinicians were able to provide her with regular obstetric care. They also arranged insurance, enabling her and the newborn to obtain housing.
“Things like that inspire us to come into the office each morning,” said Villaneuva.
Every day, medications are being prescribed to homeless clients, delivered by Jeep, and dispensed right where they are living. Teams are providing wound care and taking care of the general health of the urban poor. Importantly, Neighborhood Health inoculated the homeless with the COVID-19 vaccine during the pandemic.
“The government of Tennessee relied on us to vaccinate the homeless on the streets of Nashville,” he said. “In 2022, just under 1,000 patients were vaccinated in one year.”
Neighborhood Health has two street teams. They go out into the field with a Winnebago that’s outfitted like a clinic and a Jeep that can transport people, equipment and meds. Since 2020, the teams have conducted nearly 6,000 visits.
While technology can be a big help in treating the urban indigent, session moderator Dr. Robert Murry, chief medical officer at NextGen Healthcare, emphasized the need for the human touch. “Collaboration, kindness, and humility are all-important,” he said.
For her part, Dr. Funches said that establishing a human connection with the homeless is essential to treating them.
“I come into their tents at 8 in the morning, yelling and telling them who I am,” she said. “They’ll start telling me their stories – they may have been divorced with nowhere to go and started living on the street.
“They’re very open, and they want to get better. They want to be housed and to be accepted members of the community.”