A Mobile, Nurse-Supported Hybrid Care Model Is Breaking Down Barriers the Healthcare System Has Ignored, Saving Lives and Money
In the early years of the pandemic, healthcare was forced to transform in many ways. One of those ways was the rapid expansion in access to telehealth services. While these services improved overall healthcare accessibility, they were designed with a very specific scenario in mind. As a result, many people, including unhoused people, were unable to access them.
But some organizations are working hard to solve this problem, and their methods can be adopted by the wider healthcare system.
The Issue with Telehealth While Homeless
Telehealth is an incredible tool for many situations, but it’s not the right tool for every job. It does have limitations, such as the inability to collect basic vital signs from the patient or to provide common medications directly at the appointment. A patient may attend a telehealth appointment virtually only to be told that they need to come into the office anyway, even though the circumstances that led them to opt for telehealth in the first place likely have not changed.
And, of course, outcomes and access rely heavily on each individual’s access to and competency with technology. These factors can make telehealth a great accessible option for some people with certain conditions, while remaining completely inaccessible to others. So, in addition to telehealth, we need other options available to serve the widest population possible. Luckily, there are people developing solutions to this very problem, and they’re happy to have their work copied!
Specific Considerations for Unhoused Patients
Unhoused patients often face difficulties in accessing healthcare at all, but there are particular challenges around preventative care, management of chronic illnesses, and follow-up services after an initial appointment. These are areas that any health service hoping to help homeless patients must focus on. Due to deficiencies in these areas, unhoused patients often end up with no better option than to seek care in the emergency department, which is less than ideal for everyone.
Healthcare providers should also be aware that their homeless patients are likely to have been harmed by the healthcare system before. From individual healthcare providers who dismiss homeless patients as drug seekers unworthy of proper treatment, to a larger system of hospitals discharging patients back onto the streets, homeless patients are often mistreated by the healthcare industry. It’s essential that providers are aware of that harm and work with their patients to build trust in spite of it in a trauma-informed way.
Living without access to a stable shelter and the usual facilities can also pose unique challenges to maintaining health. Providers should be prepared to modify treatment plans based on what is achievable for the patient and should avoid assuming which amenities are easy to access. Storing medications, maintaining a certain hygiene routine, and even sticking to a follow-up appointment schedule can be difficult for many homeless people, and each individual will, of course, have their own unique set of challenges as well.
Effective Changes for Homeless Health Services
Recent research published in Telehealth and Medicine Today shows how a few simple changes can break down barriers to care and make telehealth services significantly more accessible to people experiencing homelessness.
Remote Area Medical (RAM) is a nonprofit organization that delivers free medical, dental, and vision care to those who need it. And I mean “delivers” literally. Their services are provided through mobile clinics across the country that travel directly to their patients. You don’t need to schedule an appointment in advance; you just show up and take a number.
It essentially works as a hybrid of telehealth and in-person care, with a nurse present to take vital signs and obtain medical histories from each patient, and to facilitate contact with a physician who is connected remotely. This way, patients don’t need the equipment or skill to navigate telehealth services on their own, and they are reassured that a medical professional has seen them in person to ensure an accurate diagnosis.
Clinics are often held at an existing homeless shelter, and RAM provides all necessary medical equipment and an on-site nurse. Basic medications are also kept on hand and provided free of charge to uninsured patients at the same appointment.
Speaking of insurance, RAM provides malpractice insurance for all its medical providers, which is essential to attracting the volunteer medical professionals its model relies on. There have been no malpractice suits against RAM or its providers to date, even though telehealth generally presents unique risk factors for medical errors. RAM credits this clean record to its unique model, which ensures every patient is seen in person by a nurse who can communicate with the doctors and prevent misunderstandings.
In addition to these shelter-based services, RAM also operates a medical van that provides these same services to patients who are unhoused but not staying in a shelter.
Big Changes In Little Time
The report published by RAM documents the results its program has achieved over a 6-month period, during which 650 patient visits were conducted. Of those patients, about 60% did not have an established primary care physician, even when they had insurance coverage. Nearly 20% of visits were to obtain refills of medications for chronic illnesses, underscoring the unmet need for longitudinal care in these communities.
43% of visits resulted in antibiotics being prescribed, which is significantly higher than the expected rate for the general public. This is not unexpected, since several studies have shown that homeless patients have a greater need for antibiotics than housed patients. This is likely a result of greater exposure to infectious diseases, greater exposure to the elements, and a lack of adequate hygiene facilities.
The most frequently prescribed medications overall were blood pressure medications, followed by diabetes medications and antidepressants. Cardiovascular medication and antibiotics rounded out the top five. Over-the-counter medications were also supplied if required.
In terms of costs, the study authors estimate significant savings, reporting, “Emergency department costs that were potentially avoided ranged from $945,000 to $2.83 million. This is a stark contrast to the estimated $14,000 cost to operate the RAM telehealth
program over the study period.”