Persons experiencing homelessness (PEH) can be some of the most complex patients on hospitalists’ services. Chronic conditions such as hypertension, hypercholesterolemia, and diabetes are inadequately controlled in this population.^1,2 Similarly, high rates of cancer, heart disease, chronic obstructive pulmonary disease, and geriatric syndromes, such as functional impairment, frailty, and depression, have been described.^3,4,5,6 Lastly, homelessness is associated with high rates of acute-care utilization and hospital readmission and is an independent risk factor for mortality.^7,8,9,10 As homelessness in the U.S. continues to increase, the effects on our patients and hospitals are likely to persist. It’s important that hospitalists be equipped to provide care to this population.¹¹

The health care problems plaguing PEH are unlikely to surprise hospitalists, but clinicians may feel inadequately prepared to address these issues. Nuances in insurance coverage, access to medications, and the ability to follow up for regular outpatient appointments can complicate discharge planning and create barriers to the management of acute and chronic health problems. Additionally, patients may understandably exhibit resistance to hospitals and their staff because of stigmatizing or traumatizing interactions with the health care system.^12,13 All of these factors can pose challenges to hospitalists that an inpatient street medicine consult service can potentially solve.

Street medicine is a specialty focused on bridging health care gaps experienced by persons experiencing unsheltered homelessness (PEUH), sometimes known as “rough sleepers.” Initially pioneered by Dr. Jim Withers and others more than 30 years ago, this approach involves providers going directly to unsheltered patients wherever they live, offering health and social services through a highly patient-centered and patient-directed care model.¹⁴

One health care system using this approach is Allegheny Health Network (AHN) in Pittsburgh. Within the Center for Inclusion Health, a team of interdisciplinary street medicine providers engages with patients in both the outpatient and inpatient domains. On the outpatient side, they go on “street rounds” to visit patients in encampments, under bridges, and inside drop-in centers. On the inpatient side, members of the street medicine team, including community health workers (often individuals with lived experience), social workers, nurses, and physicians, provide expert consultation, since many PEHs are not identified as needing care until they are hospitalized for an acute illness.

Because mortality rates for rough sleepers are typically higher than those living in homeless shelters, and because PEH may transition between sheltered and unsheltered settings, street medicine teams are uniquely structured to follow their patients across the spectrum of homelessness and health care.^15,16

“Street rounds” represent an important collaboration between medical professionals and non-medical street outreach teams, where outreach workers lead engagements and build trusting relationships with patients, and medical professionals integrate health care access when needed. Clinicians treat acute and chronic diseases, offer rapid access to mental health and substance use disorder treatment, and recommend navigation to higher levels of care whenever indicated. Although the team’s ability to deliver health care on the streets may avoid unnecessary acute care utilization, its primary goal is to facilitate meaningful and durable access to services through reality-based, trauma-informed, and harm-reduction-focused pathways. The same clinicians who visit patients on the street can also follow them in more traditional clinic settings, or on the inpatient consult service. This model builds trust, reduces care fragmentation, and provides an opportunity for comprehensive, wrap-around care.

When PEH are admitted to an AHN hospital, inpatient teams can place a “consult to street medicine.” The street medicine team then visits the patient, offers clinical recommendations, coordinates benefits, screens for social determinants of health, connects to community-based resources, and assists with safe discharge planning. If the patient is amenable, the team negotiates a plan to follow the patient in the outpatient setting or fosters a connection to other primary care or homeless health care resources. The consult team then discusses the patient’s care and post-discharge plans with the primary team and hospital staff. For example, they may suggest medication changes that prioritize the patient’s preferences and unique social situation (e.g., limiting the use of diuretics given lack of access to restrooms) or provide patient education (e.g., how to store perishable medications, such as insulin).

If patients are unable to establish stable housing before discharge or are still too unwell to be discharged to their prior place of living, patients can be referred to medical respite care. Medical respite is a post-acute care model providing a temporary surrogate home environment for patients requiring a period of continued recuperation or outpatient treatment who would otherwise be discharged home (if a safe and stable home environment existed). For example, a patient admitted with infective endocarditis and a history of injection drug use may be deemed an unsuitable candidate for home infusions of intravenous antibiotics. However, medical respite could allow them to receive these services in a lower-cost setting that enhances their likelihood of treatment completion and improved social stability with a focus on trauma-informed care and harm-reduction principles.

Street medicine programs have already been shown to benefit health care systems. Although typically rooted in the outpatient setting, at least one program has demonstrated reductions in acute care utilization by engaging patients in the hospital setting. The street medicine program at Lehigh Valley Health Network in Allentown, Pa., noted substantial decreases in emergency department visits and admissions among their patients, ultimately leading to $3.7 million in hospital savings in 2017.¹⁷ More data is needed to determine the potential benefits of the dual outpatient-inpatient street medicine model for both patients and the health care systems with which they interact. At a minimum, collaborating with street medicine providers can give hospitalists an additional tool in their toolkit when caring for PEH. Like other consultants with specific expertise, these teams can use their experience to provide patients with individualized resources and facilitate safer discharge planning. By partnering with street medicine providers in both the inpatient and outpatient settings, hospitalists can continue working toward equitable care for patients experiencing homelessness and housing instability. 

Dr. Desmarais

Dr. Fitton

Dr. Perri

Dr. Miller

Dr. Desmarais, @betsy_desmarais, is a board-certified internal medicine physician working as a hospitalist at the University of Colorado School of Medicine in Aurora, Colo. Dr. Fitton is a hospitalist at the Allegheny General Hospital in Pittsburgh. Dr. Perri is the medical director of the Center for Inclusion Health at Allegheny Health Network (AHN) in Pittsburgh, and on the faculty of the AHN internal medicine residency program. He also directs the Street Medicine Institute in Ingomar, Pa. Dr. Miller is the lead physician for the Center for Inclusion Health Street Medicine Team at AHN, serves as clinical faculty for the internal medicine residency program at AHN, and also provides outpatient pediatric primary care.

References

1. Child J, et al. Unexpected factors predict control of hypertension in a hospital-based homeless clinic. Mt Sinai J Med. 1998;65(4):304-7.
2. Lee TC, et al. Risk factors for cardiovascular disease in homeless adults. Circulation. 2005;111(20):2629-35.
3. Baggett TP, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189-95. 
4. Brown RT, et al. Geriatric syndromes in older homeless adults. J Gen Intern Med. 2012;27(1):16-22.
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10. Lee TC, et al. Risk factors for cardiovascular disease in homeless adults. Circulation. 2005;111(20):2629-35.
11. HUD releases 2022 Annual Homeless Assessment Report. U.S. Department of Housing and Urban Development (HUD) website. https://www.hud.gov/press/press_releases_media_advisories/HUD_No_22_253. Published December 19, 2022. Accessed January 30, 2023.
12. Purkey E, MacKenzie M. Experience of healthcare among the homeless and vulnerably housed a qualitative study: opportunities for equity-oriented health care. Int J Equity Health. 2019;18(1):101
13. Wen CK, et al. Homeless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters. J Gen Intern Med. 2007;22(7):1011-7.
14. The Street Medicine Institute Story. Street Medicine Institute website. https://www.streetmedicine.org/our-story. Accessed June 30, 2023.
15. The U.S. Department of Housing and Urban Development, Office of Community Planning and Development. The 2022 Annual Homelessness Assessment Report (AHAR) to Congress. U.S. Department of Housing and Urban Development website. https://www.huduser.gov/portal/sites/default/files/pdf/2022-AHAR-Part-1.pdf. Published December 2022. Accessed June 30, 2023.
16. Roncarati JS, et al. Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009. JAMA Intern Med. 2018;178(9):1242–8.
17. How ‘street medicine’ saved one hospital $3.7M in ED costs. Advisory Board website. https://www.advisory.com/daily-briefing/2017/12/01/street-medicine. Posted on December 01, 2017. Updated on March 18, 2023. Accessed June 30, 2023.