‘Housing Is Health Care’ for FNPs Serving the Homeless
While the transition from homelessness to housing may seem like straightforward progress, growing accustomed to the lifestyle change can be complicated.
“If you’ve never been able to do things for yourself, it can be very overwhelming,” said Dr. Amber Richert, FNP, DNP, an adjunct lecturer in the USC Suzanne Dworak-Peck School of Social Work.
Supportive housing teams are one way to ease the transition, teaching recently housed patients how to manage practical skills like budgeting and cooking.
Transitional support is essential to homeless communities, whose challenges to securing permanent housing are compounded by limited access to health care. A nationwide opioid epidemic is among the most dire threats to the health of the homeless – with a 493 percent increase in patients diagnosed with opioid use disorders over the past seven years. For many clinics, serving patients in desperate need of specialty care means bringing social work services to a primary care setting.
The School of Social Work has led a schoolwide initiative to engage students, faculty and community members in conversations about homelessness in Los Angeles and the United States. The infographic below draws parallels between local and national data about homelessness in America.
Dr. Kathleen Becker, assistant professor with the USC Suzanne Dworak-Peck School of Social Work, Department of Nursing, helped open Baltimore’s Health Care for the Homeless (HCH) clinic in 1985. She served as a primary care provider at the clinic for the next 20 years and observed that the health issues of local homeless communities have become more complex over time. To untangle the intricate problem, Becker said that HCH’s approach is “very medically oriented, but very interdisciplinary, very person-centered. You have to meet the patient where they are.”
It’s a strategy that has expanded internally as HCH strives to accommodate the needs of a growing homeless population in the area, Becker said. The clinic allows clients to schedule appointments and welcomes walk-ins as well. On a typical day, providers like Richert have about 10 appointments in the morning, where they offer services including birth control prescriptions and flu shots.
The clinic also makes food and clothing available to clients while they wait for appointments, because providing more than medical services is key to maintaining patient engagement.
“If we don’t address food and clothing first, people will leave,” Richert said. “If the choice is between getting your blood pressure checked and eating lunch that day, you’re going to choose lunch.”
A common misconception that Richert highlighted is the idea that people without homes or jobs have a relaxed schedule.
“Patients have to leave the shelter in the morning; meals are only served at a certain times of the day,” she said. “It’s a rigorous schedule, which a lot of people don’t understand.”
Becker and Richert both emphasized that streamlining medical and social work services in the same facility has helped HCH reach patients more effectively.
“Working at a homeless clinic just reiterated the importance of having a shared mission for the patient and the value of the interdisciplinary team,” Becker said.
The United States Interagency Council on Homelessness recommends a “Housing First” policy because of its proven approach to stabilizing and improving health outcomes among homeless patients. HCH adopted the policy in 2005, and since then has seen an 85 percent housing retention rate among participants, and has more than doubled the number of patients served by the program. The organization put its own spin on the idea by making “Housing is health care” its central tenant.
“People do better when they are in their own space,” Richert said. “Shelter and food will always take priority over medical and mental health conditions.”
An Uncertain Future
In the Baltimore area, substance abuse is among the largest current threats to homeless patients, as the city saw 694 overdose deaths in the past year, up 66 percent from 2015. Despite a critical need for mental health care and specialty providers, Becker said, accessing specialists has long been a structural challenge for clients and the clinics that serve them.
“If you have a complex diabetic with multiple other diseases, accessing a specialist is really challenging, so we tried to access specialists at local Catholic charity hospitals whose mission was to help patients even when they won’t get reimbursed,” Becker said, recalling her experience at HCH.
According to Blue Cross Blue Shield Association, the national rate of opioid abuse diagnoses has grown nearly eight times the rate of medically assisted treatment, leaving patients at the mercy of available specialists for mental health and psychiatric care. The scarcity of specialists is visible in the lengthy waiting periods clients experience when seeking psychiatric care at HCH.
“Even when we had in-house psychiatry it would take 60 days, 90 days, and that was in the best of times,” Becker said. “We don’t have enough mental health services as it is now.” She is concerned that the nation’s turbulent political battle over health care policies will put care further out of reach for homeless communities.
To address these issues, HCH is taking an innovative approach to delivering care beyond facility walls with a mobile clinic. In 2014, Richert became the first primary care provider at the clinic to work with the mobile team, which travels to shelters in Baltimore without medical facilities and to popular locations for unaccompanied youth.
The unique mobile clinic operates through teams of multidisciplinary providers, including nurse practitioners, case managers and outreach workers. Richert and her team work hard to educate patients and promote positive health outcomes, but she also wants draw the medical community’s attention to vulnerabilities of homeless patients by stressing the importance of empathy and proactivity from providers.
“People say it takes a village,” she said. “So we created miniature villages around each patient.”