BOSTON — To make health care more accessible and higher quality, insurers and providers are experimenting with a number of new approaches — from storing patient information in the cloud to opening clinics inside of grocery stores.
Close cousins to many of these tactics, however, were implemented even earlier in the homeless health care system. Homeless patients’ unique characteristics — they frequently have multiple chronic conditions, they move around often — overlap with some of the pressures driving medicine’s evolving care model today. And the cost and time constraints of the homeless revealed the weakness of the health care system before others saw it.
Here, four of those innovations that have not only shaped homeless medicine, but are now also finding echoes in mainstream health care.
1. Electronic health records
More and more hospitals are adopting electronic health records as the Affordable Care Act has pushed their use to reduce errors and streamline care. This trend has grown steadily since the early 2000s, but doctors for the homeless had integrated the technology into their practice a decade earlier.
One of the earliest electronic health record (EHR) systems was designed for the Boston Health Care for the Homeless Program in 1994 by engineers at Massachusetts General Hospital’s Laboratory of Computer Science. Before such systems were widely available, this one allowed multiple providers caring for the homeless — in one case, as many as 50 unique providers — to access a single patient’s record.
The system met a practical need: Homeless patients are constantly in transit, and see their doctors at multiple locations: at a clinic, in the hospital, on the street.
“When we got our first EMR, I truly thought this was one of the best things that had ever happened to us,” said Dr. Jim O’Connell, president of the Boston Health Care for the Homeless Program.
Clunky desktop computers were stationed at 20 shelters across the city. Doctors and nurses would use dial-up modems — there was no wireless Internet — to keep track of a patient on the move.
Nowadays many other health care for the homeless programs across the country rely on a modernized version of such digital bookkeeping. EHRs are especially helpful for homeless medicine, one early analysis pointed out, given that doctors are often operating in the field where paper files would be burdensome. Digital records also allow the organizations to better track how their patients fare, which is helpful in reporting back to granting agencies.
2. Mixed providers in one setting
To make health care more holistic, a growing number of clinics are trying to integrate primary care with other fields. Some of the ideas being tested include adding dentists and psychiatrists to primary care clinics to insure that patients get a full workup when they come for their annual physical.
This kind of integrated care is something doctors caring for the homeless have long been practicing. For instance, at the Boston Health Care for the Homeless Program, physicians, psychiatrists, case managers, and substance-abuse coaches work in teams so that complex, interrelated health conditions are addressed across the various dimensions.
Each Thursday morning, the “street clinic” at Mass. General in Boston kicks off with a team meeting, in which physicians, psychiatrists, nurses, and case managers crowd into a single room to swap notes on their patients.
“We were not innovative — rather we seemed to be getting nowhere and just began to find better ways,” said O’Connell.
This is the only street clinic at an academic medical center, but collaborative care is part of homeless medicine programs across the country — the various providers, if not integrated, are at least collocated, said Matt Warfield, a health policy analyst at the National Health Care for the Homeless Council.
Having a one-stop shop means that homeless patients can take care of multiple issues in a single visit — a helpful arrangement both for saving on transit money and saving time. When homeless Boston resident Susie Holden visited the street clinic in June — to see her physician for edema as well as her psychiatrist to talk about stress — she had to miss a morning of selling newspapers outside Whole Foods. “I’m very tired and I’m not really taking care of myself,” she said. But she hoped to be back at her regular spot later that afternoon.
And in both homeless medicine and mainstream medicine alike, when providers communicate across specializations, they tend to give better care. “You have to take care of the whole person,” said Dr. Howard Koh, a professor at Harvard T.H. Chan School of Public Health and former assistant secretary for health at the US Department of Health and Human Services.
3. Transitional care
Hospital stays are shorter than they’ve ever been, thanks to minimally invasive procedures and insurers tightening up reimbursement rates. The average length of a hospital stay fell from nearly eight days in 1965 to less than five days in 2010, according to the Centers for Disease Control and Prevention. But that means that more recovery is taking place at nursing facilities or at home. Various services have sprouted up to fill this gap, including a growing number of hospitals employing “transition coaches” to help patients through the discharge process, and funding under the Affordable Care Act specifically targeted at so-called transitional care.
Transitional care is something the homeless health care system has had to grapple with for decades, since shelters often aren’t able to support patients who need their bandages changed or medication dosed out. There are now 78 medical respite programs across the country.
The first, Barbara McInnis House, opened in September of 1985 as a cluster of cordoned-off beds at a Boston shelter. It is now a 104-bed facility, the largest in the country, where patients stay for an average of two weeks seeking anything from opiate detox to wound dressing to end-of-life care.
For many homeless patients, respite care is “a way to hit the reset button, slow things done, get things under control,” said Dr. David Munson, medical director of the facility.
Paul Williams, a homeless Boston resident, stayed at the center after his most recent hospitalization in May because of his recurring seizures. Williams said the staff at the respite center is helping him to stay sober, take his medicines every day, and look for housing. “They have been helping me get back on track. I honestly think I can handle [living alone] as long as I am responsible and care for myself,” he said.
4. Bringing care to you
From mobile mammography vans to supermarkets offering vaccines, doctors are finding that they can better reach patients if they bring the doctor’s office to where people are. Patient visits to down-the-block clinics at stores like Walgreens and CVS have risen from 1.5 million in 2006 to 10.5 million in 2014.
Care for the homeless must be even more nimble, because many patients are unable or unwilling to go to any clinic. Homeless doctors have for decades pioneered the approach of packing medical supplies into a van or even a backpack to reach patients in narrow alleys or under bridges.
And it’s not just for urgent care — street doctors help the homeless manage chronic conditions like diabetes since they lack a refrigerator in which to store insulin.
“For patients with diabetes trying to use their insulin, it isn’t easy to do this under a bridge,” said Dr. Monica Bharel, the commissioner of the Massachusetts Department of Public Health.
Street doctors and nurses in Boston will do blood tests on the street, concoct medicine regimes patients can manage outdoors, and “squeeze the drug companies for those insulin pens,” said O’Connell.
Another vehicle for medical care — quite literally — are mobile clinics and medical vans that scores of health care for the homeless programs across the country use to deliver care on the street.
In Boston, the Pine Street Inn shelter mixes medical care into the other needs of homeless residents. Every night of the year, an “outreach van” staffed with counselors, nurses, and doctors provides food, clothes, and blankets to people on the streets — and if a patient pipes up with a concern like, “my arm hurts,” they can begin a check-up.
“The only way a system of health care would work is if the doctors and nurses left the traditional clinics and went directly to where homeless people were,” O’Connell said, reflecting on the founding principles of the Boston Health Care for the Homeless Program. “If we waited for them to come to us, the game was up.”