Page 12 - 2023-September-October-Journal

STREET MEDICINE –

MEETING PEOPLE WHERE THEY ARE

By Tim Mercer, MD, MPH, FACP and Matt Hunt, FNP, CARN-AP

r. C almost never made it appointments wasn’t really an option the system that was too fragmented
to his appointments. He for him. On a good day, he would and complex to offer the comprehensive
Mhad horrible heart failure, admit that he didn’t really want to help he needed.
uncontrolled blood pressure, and use drugs anymore. But he felt stuck, Street medicine, and other mobile
struggled with substance use. And because the withdrawal symptoms care models for people experiencing
he lived under the bridge. Clinic were so miserable, and in the end, homelessness have helped to fill that
staff often grew frustrated, labeling sometimes using was better than void. Some say street medicine
him non-compliant. Intermittently thinking about the years of trauma can trace its roots back to Mother
he would end up in the ER, usually and hardship he had endured in his Theresa in Calcutta or even
because he was having chest pain or life. He had tried to get into housing before. In the United States, Dr. Jim
had grown so short of breath that many times, but at the end of the O’Connell and others founded
he felt like he was suffocating. Mr. day, could never find a place that he Boston Health Care for the
C had even overdosed a couple of could even come close to being able Homeless in 1985 and started
times. Paramedics and ER staff also to afford. providing street medicine services in
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grew frustrated having to do the To be frank, our health care their overnight van in 1986. In 1992,
same chest pain rule-out work-up, system is not really designed to help Dr. Jim Withers started one of the
diuresing him for his heart failure, someone like Mr. C. If you think first formal street medicine programs
refilling his chronic meds, and about it, our health care system in Pittsburgh, and went on to
instructing him, again, to follow-up suffers from two fatal flaws when it galvanize a broader movement
with his PCP. It was a vicious cycle. comes to caring for people through the Street Medicine
People experiencing unsheltered experiencing homelessness. First, it Institute as well as establishing the
homelessness suffer a ten times is fragmented and siloed. Mr. C. had first Street Medicine Fellowship
higher mortality rate than the general a multitude of needs, including his training program in the US. The
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population, with an average lifespan chronic health conditions, his Health Care for the Homeless
of 53 years. They die early of addiction and mental health, and all (HCH) movement started as a
cardiovascular disease, chronic liver the social needs he was lacking due series of demonstration projects
disease, or cancer. In the COVID to being homeless. But it seemed that funded by the Robert Wood Johnson
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era, they are increasingly dying of different clinics or agencies were only Foundation (RWJF) and the Pew
fatal drug overdoses, mostly due to addressing one thing and sending Charitable Trust in 1985, prioritizing
the adulteration of the drug supply him somewhere else to get his other both integrated care and outreach to
with deadly fentanyl. Mr. C. had needs met. It was overwhelming patients on the street. There are now
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recently turned 50. The specter of and he felt caught in the middle, over 200 HCH programs across the
this fatal statistic was looming large. burdened, and stressed. Second, the country that receive designated
But when you talked to him and health care system is fundamentally federal funding and subscribe to a
listened to his perspective, he didn’t passive and reactive. The ER waited tailored model of care designed to
seem so “non-compliant,” and his for him when he was acutely ill, but meet the unique needs of people
situation didn’t seem so surprising. he couldn’t seem to access care that experiencing homelessness. Many
His whole life was under that bridge, was proactive and comprehensive. HCH programs also have street
all his worldly possessions, including There were too many barriers– medicine teams to proactively and
important identity documents, and he had nowhere to leave his stuff intentionally meet people where
his dog. Leaving all his belongings or take his dog, he lacked transportation, they are, engaging patients on the
and his most important companion didn’t have a phone, felt discriminated street delivering both acute and
to get on a bus to make it to medical against and judged, and didn’t trust longitudinal care.

12 2023 September • October TCMS