Delivering Meaningful, Not Marginalized, Care to the Homeless

Too often, homeless people receive medical treatment only after an emergency. Hospitals and medical schools are trying to change that.
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More than 550,000 people in the United States are estimated to be homeless on any given night, according to the U.S. Department of Housing and Urban Development . And those who are homeless also are likely to have medical needs that go unmet or receive treatment only after a medical emergency occurs.

Today, medical schools and teaching hospitals are working to provide vulnerable patients with more and  higher-quality medical care. Homeless people often have conditions that are aggravated by sporadic care and the rigors of their living situations, from chronic diseases such as diabetes to acute ailments, mental illness, or substance addiction. 

The once-common attitude, “treat ’em and street ’em,” about health care for the homeless is giving way to greater awareness about providing homeless people with meaningful medical services. “This is a really complex population that requires much more intense observation and care than we have probably thought about in the past,” said James O’Connell, MD, president of Boston Health Care for the Homeless Program (BHCHP), an organization that provides comprehensive care to about 12,000 homeless adults and children. 

Homeless patients often lack access to care and continuity of care between providers and facilities. As their conditions worsen, they can become high users of costly emergency or inpatient services. Some have Medicaid or other insurance. Others receive treatment without being insured, an impact felt by many academic medical centers, which provide about 35% of U.S. charity care. 

“People will do total knee replacements [on BHCHP patients] because they know this homeless person will have follow-up.” 

James O’Connell, MD 
Boston Health Care for the Homeless Program

Although there are “homeless medicine” projects around the United States, BHCHP is one of the most long-established and well-developed programs, partnering with institutions including Boston Medical Center (BMC), Massachusetts General Hospital (MGH), Brigham and Women’s Hospital, Tufts Medical Center, and Beth Israel Deaconess Medical Center. Last year, BHCHP provided learning opportunities in its homeless medicine clinics to 73 students from five medical schools and trainees from 12 residency programs. 

“The challenge for medical schools and teaching hospitals is to understand what the needs are in their own particular communities,” said O’Connell, who will be discussing BHCHP for the Voices of Medicine and Society Series at Learn Serve Lead 2017, the AAMC’s annual meeting, in Boston this November. “With the support of hospitals and a wide community network, you can deliver good care with great outcomes to people struggling with chronic homelessness.” 

Health care for all

BHCHP began in the mid-1980s when the Robert Wood Johnson Foundation gave grants to 19 cities to develop homeless health programs. Today, it brings medical care to homeless people in about 60 locations—on the streets as well as in shelters, motels, soup kitchens, and even a horse racetrack (for stable workers). 

The program has hospital-based outpatient clinics for homeless patients at both BMC and MGH, open five days a week. Clinic doctors and nurses are indistinguishable from others in the facilities. Laboratory and imaging services are available at both institutions in addition to specialists. The interconnection of the clinics is “seamless, right into the usual flow and operations of medical care here. It’s not an appendage or a parallel thing,” said Thea James, MD, vice president of mission and associate chief medical officer at BMC.

There’s also a 104-bed medical respite unit for homeless patients who are recovering from a hospitalization, recuperating from a serious illness, or undergoing treatment such as chemotherapy. The unit is housed in BHCHP’s facility on the BMC campus. It gives area hospitals “a safe place for patients who no longer need expensive acute care facilities” but need to recuperate and have medical monitoring, said Joan Quinlan, MPA, vice president for community health at MGH. More than 300 homeless MGH patients received care in the respite unit in 2015.

Homeless people are four times more likely to die prematurely than those who are housed.

Source: Boston Health Care for the Homeless Program

Staff for the homeless health program, which is a federally qualified health center, includes more than 20 physicians, plus advanced practice providers, dentists, behavioral health specialists, and social workers. Many staff doctors rotated through the program when they were medical students or residents.

Stephanie Lie, now a third-year student at Boston University School of Medicine, participated in the school’s Homeless Health Immersion Experience with BHCHP during her first two years. “It was a great way to get into the clinic and remember why I’m spending all this time in the library,” she said.

Medical care on the streets

About 1.5 million Americans experience homelessness in the course of a year. And BHCHP studies have found that homeless people are four times more likely to die prematurely than those who have housing.

While shelter residents often go to clinics located where they are staying, the chronically homeless living on the streets are harder to reach with medical services. “You need to go to them, and then you can manage much of their preventive and primary care,” O’Connell said.

The BHCHP street team does just that, with a full-time psychiatrist, internist, nurse practitioner, social worker, and recovery coaches. The team is based at MGH and sees patients where they live, day and night. Team members share care of 600 to 800 street patients.

Monday, August 14, 2017

Learn Serve Lead 2017: The AAMC Annual Meeting

Learn Serve Lead 2017: The AAMC Annual Meeting, Nov. 3–7 in Boston, will feature content on the role of academic medicine in reducing health disparities.

Stories from the Shadows: Reflections From a Street Doctor 
Saturday, Nov. 4, 1:30–2:45 p.m. 
James O’Connell, MD, will discuss homeless medicine and his book Stories from the Shadows, about the history of homeless medicine in Boston. Hear about the treatment, triumphs, and tragedies of Dr. O’Connell’s most memorable patients.

Finding Solutions for Meeting the Needs of Medically Underserved Communities
Saturday, Nov. 4, 3:15–4:30 p.m.
Learn how academic medical centers are reducing health disparities and addressing access problems through team-based strategies and opportunities to enhance training for physicians and students through community engagement in both rural and urban communities.

Anchor Institutions: Investing in Our Communities to Promote Local Health
Monday, Nov. 6, 1:15–2:30 p.m.
Explore how community institutions are contributing to local economic stability in nontraditional ways. Speakers will share the lessons they have learned and their strategies for maximum impact.

One morning each week, BHCHP runs a walk-in clinic at MGH solely for unsheltered homeless people. MGH “felt a certain obligation to that population” because many unsheltered homeless “lived and hung out right around the hospital,” said Quinlan. Known as the Street Clinic, it was launched in 2002 to manage the complex medical, psychiatric, and substance abuse disorders these patients experience. According to O’Connell, it is the only clinic within an academic medical center that is dedicated to the “street homeless.”

An electronic medical record (EMR) keeps track of care for all BHCHP patients, an innovation for homeless medicine that the organization created in 1996 with MGH assistance. The EMR supports integrated care, which helps the program win trust from specialists and others in the health care community. “Lots of things then become possible,” said O’Connell. “People will do total knee replacements [on BHCHP patients] because they know this homeless person will have follow-up.”

Program research indicates that providing continuing, integrated medical care for the homeless is effective. One study of 64 BHCHP patients treated for hepatitis C showed a 97% cure rate. In addition, the BHCHP team treated 259 patients with HIV from April 2016 through March 2017. Of those, 92% received HIV medications and 89% achieved undetectable viral loads. 

“Even though we can’t solve their homelessness,” O’Connell said about the positive outcomes, “we can ease suffering and treat potentially deadly diseases.”

Read the second article in this series to find out how medical schools across the country are engaging students in caring for the homeless.

During the AAMC Annual Meeting, BHCHP has agreed to open its doors to 30 attendees on Friday, Nov. 3. To schedule a visit, please email Catherine Minahan at cminahan@bhchp.org with your preferred tour time: 2, 2:30 or 3 p.m. We also are asking members of the academic medicine community to consider making a donation to BHCHP in advance or at the meeting.