How to make house calls for people without houses

Becky kneels down in front of the woman in the wheelchair in Kennedy Plaza and asks if she can look at the dressing on her wound. Becky, as she is known on the streets, is Dr. Rebecca Karb, an emergency medicine doctor. Today, she and Megan Smith, PhD, an assistant Professor in the School of Social Work at Rhode Island College, have come to find N., the middle-aged woman in the wheelchair. They know her well, having treated her when she required an amputation of her right leg above the knee last June.

An infection followed, but N. has refused to go to the hospital. So Becky has been treating her at Kennedy Plaza as best as she can. N. is happy to see them and jokes with Becky about her wrapping skill—laughing that “it keeps falling off.”

House of Hope and Project Weber/RENEW, with support from the Rhode Island Foundation, have been providing consistent and effective street outreach with the unsheltered population for some time, but there has been a gap in the engagement of medical institutions and healthcare providers with this important work. Now, Lifespan is attempting to bring high-quality healthcare out of clinics and hospitals into the community by meeting people where they are—in parks, encampments, under bridges, abandoned buildings, and cars.

Last year, the Rhode Island Foundation funded this first Street Medicine (SM) program. It is a way to deliver much-needed acute care and facilitate trust building between the medical community and unsheltered individuals.

Dr. Karb is taking medicine to the streets. “I started doing intervention work with House of Hope and realized this requires formal institutional support. Let’s make this more of an established thing and develop a structure of operation.”

Homelessness and health influence one another through multiple reinforcing mechanisms. People experiencing homelessness are susceptible to the same issues as people who are not—and then some—and their living conditions tend to make treating the issues much more difficult for even the most routine medical treatment. Something as straightforward as the need for bed rest is complicated, if not impossible, when the patient does not have a bed.

Dr. Karb can rattle off a lengthy list of common health problems that people experiencing homelessness have: lung diseases, including bronchitis, tuberculosis, and pneumonia; wounds and skin infections, malnutrition, mental health problems, substance use problems, dental and periodontal disease, infectious hepatitis.

Megan is well-known on the streets as well. As a social worker, she worked with the homeless community in Providence for 12 years, was the outreach program manager for House of Hope for three years, and remains the outreach program consultant. “I’m still struck by the conversations I have with the communal, resourceful, creative people I meet on the streets. I’m also struck by how deeply our system is still failing them.”

“There are layers of goals for the program,” says Becky, “some practical and some less tangible.” First, SM is providing medical care for a marginalized and under-served population that has difficulty accessing care in the structures that have traditionally been set up. “For example wrapping a wound for someone in a wheelchair at Kennedy Plaza.”

Second, healing the trauma or mistrust that has built up for the healthcare system among this population because of negative experiences they have had—being mistreated, labeled, or judged. “I try to create an experience for them that feels respectful and empowering and might change the way they engage with healthcare moving forward.”

Third, using the experience that physicians have in outreach to inform and transform care, particularly in the emergency department. “When you can meet patients on their terms, you have a better idea of their dimensionality. That has a ripple effect on the way people are treated by techs, nurses, and doctors” in a medical facility. “These are little changes that add up over time.”

When you can meet patients on their terms, you have a better idea of their dimensionality. That has a ripple effect on the way people are treated by techs, nurses, and doctors in a medical facility.

- Dr. Rebecca Karb

Hospital systems in general have been addressing equity and social determinants of health but not always with a tangible concrete commitment. “But the Lifespan folks who have helped put this grant together think this is a good and important program,” stresses Becky. The long-term goal is to ensure they align their money with their values moving forward.

The services being provided through SM are not easily measurable to bill insurance or Medicaid. Most of the unhoused people have Medicaid—because of Project Weber, House of Hope, and other advocates, our Medicaid coverage in Rhode Island is robust. “I don’t see a lot of people who are uninsured,” says Becky. “We will show a reduction in ED visits, but a program like this is never going to pay for itself. It will have a fiscal impact, but it will never be a revenue generating endeavor.”

If you look at street medicine programs across the country, the primary cost is staff. That can be difficult to fund. “We would need Lifespan to say we’re going to pay for physicians and nurses and PAs and NPs. I have a vision, and I can make stuff happen, but I am not a money person, so I’m always wondering where the money will come from.” Both Becky Karb and Megan Smith see options: It doesn’t have to be just hospitals that fund street medicine programs—it can be private foundations and universities and businesses.

“Housing is the biggest obstacle to solving this thing,” observes Becky. “When I’m out there, I focus on what I can control, but I am thinking, ‘what this person really needs is a home.’ The elephant in the room with all of these services is that everything is going to be better and more effective in a house.”

Dr. Karb would like to see the program expanded. Being able to have a sustainable group of consistent providers, not just doing it in their free time; a program coordinator who could do administrative and record-keeping stuff; an ability to determine the biggest needs in the community and respond to them. “For instance, Hepatitis C keeps coming up and treatment is difficult to access—we’re now finding a protocol for that.”

After she finishes wrapping N.’s leg (hopefully a bit tighter this time), she muses, “The collaborative non-hierarchical aspect of this particular program—the medical world and the social services world—makes what we’re doing feel incredibly special.”

UPDATE: Dr. Karb reports that N. entered the hospital in mid-January for follow-up surgery and will be recovering at a skilled nursing facility. Proving that meeting patients on their terms can indeed work.