Abstract
The concept of street medicine is not new, but data with regards to their effectiveness in improving population health and economic benefit is scant. ‘’Street medicine” is the practice of providing medical care to patients outside traditional medical facilities, who are experiencing homelessness, or those who don’t have access to medical care due to insurance or other socio-economic reasons. It is now more meaningful on a background of widening socio-economic disparity. I took part in a street clinic program in our county, Vigo County, and I want to highlight benefits, challenges and possible solutions to reduce disparity in access to health care. Here we introduce a novel concept of street medicine where we go to the patient, in settings where they come for other reasons like food, shelter, clothes etc. I volunteered with the local hospital and family medicine residency program. We had a team of a resident physician, faculty physician, pharmacist and other healthcare personnel. Street clinic was held monthly, we recorded attendance, diagnoses, educational material distributed, and interventions undertaken. Apart from making simple diagnoses we also distributed hygiene kits, sanitary pads and offered haircuts to further engage patients. Analysis included the impact of the clinic by putting forward a simplistic model of tangible cost saving. Intangible cost saving needs longitudinal follow-up and bigger controlled trials. Results showed significant cost saving by hypothetical analysis. We have incorporated suggestions of community involvement, simple policy changes at residency and employment level, and highlighted the challenges to such clinics for future studies.
Introduction
The concept of street clinics or street medicine is not new. The literature and evidence base regarding impact with regard to improving quality of life and economic impact in a bigger randomized model is absent. After initial submission of this article a review was published in Journal of general internal medicine, (impact factor 6.74/2021) , highlighting that no randomized trials have been done to date1. and further work is needed, especially in the United States. Street medicine in general is the practice of taking health care services to the individuals, for example those who are homelessness and living on the streets, or those who don’t have access to medical care due to insurance or other socio-economic reasons, outside the walls of a traditional medical facility2. As there is paucity of randomized controlled trials, further research is needed to understand how street clinics can be more effective than other care delivery models tailored to populations experiencing homelessness.
Also this review is significant as there is no literature available on studies, where health care delivery is taken to places where potential patients come for other reasons, like Churches, homeless shelters, Soup Kitchens and warming centers. Previous studies mainly include medical mobile units. In these clinics patients come to the clinic whereas our model is where healthcare is going to patients.
Street medicine now acquires more meaning in view of growing socio-economic disparity and growing immigrant population. Our county, Vigo County, is one of the top ten poorest counties in Indiana. The poverty rate in Vigo County is 31.1 %, higher than the national average3. A considerable percentage of the population experiences homelessness and a large number of people have no access to healthcare.
I have been involved with a local street clinic in our county, Vigo County, IN, since Jan 2023. As a high school student my aim was to volunteer, learn and research about street medicine and its impact on public health.
Literature Review
The concept of street medicine to help people experiencing homelessness (PEH) is not new, but no standardized model of street clinic exists. In fact, literature has commentaries and reviews, but to our knowledge no randomized control trials are available4,5.
Also, to our knowledge, no tangible cost saving model has been studied in theory or practice. Here we examine the literature review to understand the extent of the problem and work done so far.
Homelessness in the United States is on the rise. In 2023, approximately 650,000 people experienced homelessness nightly in the United States, the highest number recorded in the country’s history6.
Apart from not having access, homeless people face many barriers to obtaining health care, and their attitudes toward seeking health care services may be shaped in part by previous encounters with health care providers, which can be welcoming or unwelcoming7.
Homeless people’s perceptions of welcomeness and unwelcomeness in Healthcare Encounter has been studied as well by Wen et Al. The authors in this study concluded that conveying welcomeness was an important aspect of health care for homeless people. Whereas this concept is less tangible than other factors that contribute to the accessibility of health care for homeless people, it is no less important. This aspect depends on provider patient interaction and the team delivering care should be cognizant of this fact.
The recent inclusion of street medicine services in the Center for Medicare and Medicaid Services (CMS) billing codes represents a significant step forward. Street medicine, defined by CMS as healthcare provided in non-permanent locations to unsheltered individuals, now qualifies for Medicare reimbursement (Place of Service Code Set).
Street medicine institute was established in 2009. In fact, street medicine institute (SMI) published guidelines as recently as 2018. It is a not-for-profit organization but has a significant membership fee. It has guidelines on different aspects of street medicine including, Asthma, COPD, Hypertension, Frostbite, Immersion Foot, Opioid Overdose, Rheumatoid Arthritis, Scabies, and Stasis Ulcers.
PEH have higher mortality rates due to infectious diseases, cardiovascular disease, accidental injury, suicide, homicide, and substance abuse disorder (SUD)8.
In different street clinic models different aspects of medicine have been studied. For instance, in one program in California, they studied follow-up care plans after hospital discharge for unsheltered homeless patients. This is challenging, and no-show rates at follow-up clinic appointments are high. PEH has higher rates of hospital readmissions and Emergency Department (ED) visits. Thus, there is a pressing need for innovative approaches to hospital follow-up and continuity of primary care for PEH9.
In another paper, an integrated framework for understanding the basis of cardiovascular disease disparities in homeless people and suggestions were given tailored to the needs of this population, with emphasis on coronary artery disease prevention, diagnosis, and treatment was evaluated10.
A study by Rebecca et al, focused on the need of homeless geriatric adults and highlighted the need for identifying this cohort as they may have more comorbidities11.
Internationally some data exists from street clinics from India and Brazil, where mobile clinics play significant roles in healthcare for PEH. In Delhi, India, street medicine teams conducted consults with more than 16,000 individuals, diagnosing conditions such as upper respiratory infections, gastritis, tinea, and helminthiasis12.
Street medicine with regard to diabetes education and hypertension has also been studied from a pharmacy perspective, showing improvement in diabetes, but again their role is ill defined13.
The value of street psychiatry as a novel and innovative approach to address the mental health needs of unsheltered individuals has been studied. Key factors that contributed to the successful implementation of the program included consistent outreach, robust collaboration with the local community and other stakeholders, relying on an integrated care model to build the core team, using crisis-response resources as needed, and networking with other street medicine programs14.
With patients experiencing homelessness, laboratory monitoring is even more critical. However, getting to a laboratory can be an enormous challenge. For these reasons, the Street Medicine program can include point-of-care testing (POCT) as essential to its delivery model. POCT can play an integral part in providing quality care to homeless patients. Collaboration between health providers and the clinical laboratory can ensure that a robust POCT program is put into place for this purpose. Currently, as our Street Medicine program is actively using glucose meters and is refining processes and procedures to introduce the other tests in the future, our Street Medicine program seeks to expand its patient population and plans to continue to monitor the needs and utilization of POCT in the field. A study once demonstrated the need for obtaining its own CLIA Certificate of Waiver15.
In essence different aspects of street medicine have been studied in literature which suggest that street medicine could help but there are no randomized controlled trials or qualitative assessment of these reviews.
Our study emphasizes the “Go to patient” model. Even though very simplistic, it provides a start to looking at tangible effects of street medicine and emphasizes a need for a standardized model.
Aim
This is a retrospective observational data study. The aim of my study is to bring attention in a simplistic manner to how “Go to the patient” street clinics can work, in providing access to medical care and basic education about prevention and hygiene in underserved populations. It also underlines easy access to health care for easily treatable conditions and therefore prevents unnecessary emergency room visits or ambulatory care visits, and to identify any chronic conditions.
Methodology
I joined a team in our town that held monthly street clinics in collaboration with Churches, homeless shelters, Soup Kitchens and warming centers. The space to see patients was given by the above-mentioned organizations. The team was primarily composed of members of a local hospital and affiliated Family Medicine residency program. The hospital serves 6 counties in Indiana, with Vigo County being the largest, and is deeply involved in community health improvement efforts. The street clinic was led by the behavioral health specialist and pharmacist, from the Family Medicine residency program, along with personnel from the hospital like nurses, respiratory therapists and social workers. A faculty physician and resident physicians oversaw the clinic on a voluntary basis each month. This was incorporated in their community outreach and public health curriculum.
Any patient who came to the clinic was part of data collection. Diagnoses on patients were obtained from the records kept by physicians. The tools used by physicians included blood pressure instruments, blood sugar testing, urine dipstick and physical exam using stethoscope. Resident physicians performed health checkups, pharmacy was responsible for distributing simple antibiotics, hygiene and safety kits, and helped to arrange prescription medicines. Immunizations were also given at the clinic. This monthly clinic was started with the aim to boost the population’s health, improve medical literacy and possibly reduce health care costs.
As a high school student, I was responsible for taking blood pressure, checking blood sugar and helping in educating people about hygiene. I also learned about the functioning of the clinic and its impact on the health of the local population
Here I present data for 6 months of the street clinic.
Data Results
Ethnicity | 30 Caucasians, 5 African American |
Gender | 20 Males, 15 females |
Age | 31 adults, 5 children |
Diagnosis | Intervention Done | No of patients |
Dental Infection | Antibiotic prescription given | 4 |
Rash | Antihistamine prescription given | 5 |
Foot Infection | Antibiotic prescription given | 2 |
High Blood pressure | Medication, compliance addressed and reassurance | 6 |
High Blood Sugar | Medication started and education given | 7 |
Abdominal pain | Clinically ruled out any major etiology, pain medication dispensed | 3 |
Pregnancy | Diagnosis made and further follow up arranged | 2 |
Urinary tract infection | Antibiotic prescription given | 2 |
Active drug withdrawal | Same day appointment in clinic to address it urgently | 1 |
High Blood pressure in pregnancy | Same day appointment in clinic to address it urgently | 1 |
Skin abrasion | Wound clean, dressing done | 2 |
Ethnicity | 42 Caucasians, 7 African American |
Gender | 30 males, 19 females |
Age | 44 adults, 5 children |
Type of education | Intervention | No of patients |
Immunization | Vaccine given | 5 |
Hair cuts | Haircut and hygiene education | 4 |
Sanitary pad | Distributed with Education about hygiene | 5 |
No medical insurance | Education patients about affordable health care act | 25 |
Hygiene | Safety and hygiene kit distribution | 10 |
Discussion
Street clinics play an important role in promoting and maintaining the health of people who have limited access to health care. It allows for easier access to healthcare services and early interventions.
Street clinics have been hypothesized in analytical models, to help with cost saving, representing a cost-effective delivery model that improves health outcomes in underserved populations16,17.
Street clinic helps in triaging patients according to severity of their illness, addressing minor acute health problems in the clinic and also in diagnosing chronic diseases, preventing progression of the disease and more serious complications, and thus avoiding emergency room visits, helps to reduce health care cost burden. Cost also has been studied by taking into account several individual conditions including, heart failure, diabetes, sexually transmitted diseases, to name a few18.
To help understand the importance of our street clinic, we can have a simplistic assumption that by assessment and treatment of 35 patients, we prevented approximately 29 emergency room visits over six months or ambulatory or convenient care visits. Average ER visit out of pocket cost in Indiana is approximately $ 161819. This amounts to approximately $ 47,000 that was potentially saved by triaging and providing care to patients in our street clinic. The average out of pocket cost of ambulatory care visits is $ 175. This amounts to $ 6,125. A simplistic range over 6 months is $ 6,125 to $ 47, 000 which can still amount to tremendous cost saving on a national basis
These hypothetical numbers don’t include patients who would have needed further hospital admission, progression of chronic undiagnosed condition if the underlying condition progressed. To further understand the financial impact, it should be noted that the average cost of a hospital per day stay in Indiana is about $ 300020. Also, we cannot put a number to the impact of education and preventive care in potentially reducing disease burden. The Morkov model is a good idea for future studies, especially if there is follow-up of these patients. The ability of the Markov model to represent repetitive events and the time dependence of both probabilities and utilities allows for more accurate representation of clinical settings that involve these issues21.
From discussion and interview of the providers, their perspective is that we are going to patients in settings where they are coming for other reasons like food, clothing, shelter and it helps to take the clinic to them. The other way to improve attendance is to offer haircuts, hygiene kits, sterile needles, sanitary pads etc. These patients will either ignore their medical condition or wait till it is late. In the absence of medical literacy there is clear bias towards wait times, cost and ignoring health as other factors predominate including access to food, shelter and clothing.
29.8% of Indiana residents had incomes below 200% of the Federal Poverty Level (FPL) in 2022, which was larger than the U.S. share of 28.3%22. According to the health insurance status distribution of total population in 2021, over five percent of the total population of Indiana is uninsured23. Vigo county is one of the poorest counties in Indiana. 10.3% of the population in Vigo County has no health insurance, which is lower than the national median of 11%. Educating patients about the Affordable care act and helping them get insurance will help in reducing their threshold for obtaining medical care in future when needed, as cost and lack of insurance appears to be a barrier in access to healthcare. Of all the patients seen at our street clinic, only 4 patients were enrolled in Medicaid. All patients were educated by social workers on the health insurance options and patients were given assistance in enrolling into insurance programs.
Education regarding nutritional counseling24, dental hygiene25, and preventive care with regards to distribution of sterile needles and condoms etc. will have long term tangible effects on the health of the population.
The street clinic model can be emulated in poor counties throughout the state of Indiana and other areas in the country. High school students can be involved in approaching local physicians or local residency programs to emulate this model in different counties.
There are also certain challenges involved in this process, for example not all counties will have residency programs where residents can be involved in community outreach. In such a case one can approach local physicians and mid-level providers to get their support for street clinic functioning. Pharmacy support helps in improving the overall program26. and thus participation of locally run pharmacies is crucial to the success of such clinics.
Patient access to the clinic due to lack of awareness and lack of transportation are other challenges which may be overcome by involving local charitable organizations and by proper advertisement of the clinic. A study was conducted on 126 patients of a dental clinic in Bucharest, from January 2015 until October 2016 to evaluate the role of digital methods of promoting medical services. The results of the study demonstrated an increased need for digital methods of promoting medical care services and revealed an important role of social networking sites in healthcare promotion. Social media communication platforms can promote certain behaviors thus influencing decision-making and they can provide a means for medical institutions to communicate with the patients, to advertise and promote strategies27.
For these clinics to be replicated and successful on a larger scale several things are needed, including policy change and community involvement. Starting with places where there is a residency program, core curriculum should include mandatory service and possibly a rotation in these clinics. Similarly employed physicians, where there is no residency program, should have some responsibility in their employment contracts to serve in such clinics. Medical students can also fill in this gap and their involvement may help them in understanding public health concepts and community needs. High school students need volunteer hours, a connection with school administration should be made to involve them in education, digital advertisement. Further community involvement includes help to advertise and transport
The street clinic model that is run in our county is operated by volunteers and this can be another challenge to get health care providers to participate. Raising awareness about the community’s needs and gaps in health care may help circumvent this issue by getting more participation from the medical community. The shortage of primary care physicians in the United States is expected to grow to 17,800-48,000 physicians by 2034. A study by Thompson et al showed that medical students who volunteered with the interprofessional community clinics were more likely to match into primary care residencies. Students who volunteered more frequently were more likely to match into family practice28.
More critically looking at data, we know there is no standardized model available. Whether medical mobile units are better vs ‘go to the patient ‘model that is going to places where one is more likely to find PEH. Additionally, to our knowledge there is no defined way to approach patients with regards to acute vs chronic health issues. There are no defined standards to what may constitute a team to deliver street medicine services, for example apart from physician provider, other healthcare personnel including pharmacist, counselors, behavioral health provider, nurse etc. should be included or not. Another important aspect needing a good model post hospital discharge patient needing follow-up.
There are definite challenges to the street clinic model. It needs volunteers which if not incentivized or paid may not work from a provider viewpoint, as medical providers are the backbone of this model. From a patient perspective these included concerns about privacy during consultations, the unavailability of essential medications, limited services offered, lack of doctors, and inadequate management of clinical records leading to diagnostic inaccuracies29.
Conclusion
Street medicine is crucial in promoting the health of a community, by providing healthcare directly to the unsheltered homeless where they live, thus circumventing certain barriers to healthcare access like lack of transportation, poverty, and it helps to reduce health inequity. Our clinic was different as it adds a newer dimension of going to patients where they come for other reasons. Further studies are needed to evaluate social and economic impact in randomized controlled settings.
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