Diabetes treatment is diabetes treatment, but delivering treatment to a diabetes patient in a hospital setting is entirely different from delivering treatment to a homeless diabetes patient on the street, who also has a mental health condition and substance use disorder. While the former is a standard scenario doctors are prepared for, the latter requires a specialized expertise that very few doctors are trained in.
The Venice Family Clinic’s (VFC) new street medicine curriculum seeks to change that. By drawing on the knowledge of Dr. Coley M. King, VFC’s director of homeless health care services, and of other leading street medicine practitioners, the unique curriculum strives to build a new generation of skilled, adaptable and compassionate homeless healthcare providers.
These practitioners will be able to deliver tests, diagnoses and some treatments directly on the streets to unhoused patients experiencing a broad range of health challenges—like diabetes for example—or trauma injuries, dental problems, infections, mental illnesses, sexually transmitted diseases and many other maladies.
Homelessness is a deadly condition. According to data from the Department of Medical Examiner-Coroner, the average age of death for people who are experiencing homelessness in Los Angeles County is 48 for women and 51 for men. Unfortunately, the vast majority of unhoused individuals have very limited access to health care outside of the 911 system.
“The important key benefit (of practicing street medicine) is that you actually see the patient and the key detriment if you don’t do that is you will never see the patient, the patient will never see you and they will not receive proper primary care. They’ll end up in an emergency room and then they’ll repeat that pattern of emergency room visits,” said King.
According to King, there are numerous reasons why homeless individuals are often unable to receive treatment in a traditional clinical setting, with lack of insurance or money only being the tip of the iceberg.
Many unhoused individuals have neither the transportation or the ability to keep their possessions unattended for the time necessary to visit a doctor. Additionally, many unhoused individuals suffer from mental health and substance use issues that make them disorganized and unable to stay on top of doctors visits or treatment plans. Lastly, people experiencing homelessness may feel unwelcome in a clinical setting due to their hygiene condition, the stigma around homelessness or their distrust of authority figures.
Venice Family Clinic’s street medicine curriculum, which was created with financial support from the United Way of Greater Los Angeles, takes all of these factors into consideration. It contains extensive training on how to best approach unhoused individuals and get them to a place where they are comfortable accepting treatment.
“We try to teach these techniques of approaching people in a very non-threatening way, including physical language, body posturing to try to be very calm and non-threatening to give people a chance to get to know us, understanding this may take months. This may take up to a year or two years to really fully engage and gain trust in our patients,” said King.
While some patients are willing to accept treatment immediately, many unhoused individuals require repeated engagement over a period of time. King said this starts small, with a smile and if possible a brief conversation, recognizing that unhoused individuals have been through serious trauma and are primed to be suspicious of others.
“We consider ourselves trauma informed and we were built that way long before the term being trauma informed was coined. We were built around seeing patients and understanding their needs and their situation,” said King. “So simply just being nice to people and understanding the horrible luck they’ve been through and trying to be calm and nice with that helps welcome them in.”
Many unhoused patients receive treatment directly on the street over the course of their engagement with the Venice Family Clinic. Some patients will build up a rapport with VFC’s street medicine providers and then be willing and able to come into one of VFC’s healthcare facilities for follow-up care.
An additional challenge that comes with street medicine, and something the curriculum focuses on, is that many homeless individuals are tri-morbid — meaning they are simultaneously experiencing a mental health issue, a physical health issue and a substance use issue, all of which typically negatively reinforce each other.
For example an unhoused individual may use meth to cope with the trauma of living on the street, which can cause a series of health complications including high blood pressure, insomnia, skin scores and brain damage. It may also exacerbate pre-existing mental health conditions such as anxiety or psychosis or cause an individual to develop new mental illnesses, which coupled with physical pain leads the individual to intensify their drug use.
A trained street medicine provider could realize that a patient is tri-morbid and respond appropriately. For example, they may deliver a shot of anti-psychotic medicine directly on the street, which allows the patient to become more calm and organized, receive treatment for their physical health challenges, and consequently rely less on drug use for pain management.
In the long-run the goal of street medicine providers is to get their patients to a state where they are able to accept housing resources and work with homeless service providers. In many instances, providing sorely needed health care on the streets is the first step towards getting homeless individuals into a condition where they can maintain housing and, if possible, reenter the workforce.
“I feel like I’ve seen so much success with following this model of engaging them in the street with medicine, with mental health care, with case management and getting to know them and getting them thought ready and contemplating making change in their life and moving into housing,” said King.
There are already several cohorts of resident doctors from universities including UCLA, USC and Charles Drew, who are receiving training in the street medicine curriculum. It is the hope of King and of the Venice Family Clinic that these young doctors will become the next generation of homeless health care providers and continue to develop and advance the practice of street medicine over the course of their careers.