Characteristics of Homeless Temporarily-Housed in Project RoomKey During the COVID-19 Pandemic.

INTRODUCTION: People experiencing unsheltered homelessness (PEUH) have higher disease burden yet limited access to healthcare. COVID-19 introduced even greater risk for PEUH aged 65+ years with an underlying chronic health condition and were temporarily housed in hotels/motels for Project RoomKey (PRK). This study aimed to characterize a PRK cohort who received primary care from a street medicine program. METHODS: This observational case series study included a sample of 35 PRK participants receiving primary care from a street medicine team at a single site from July to September 2020. We used the HOUSED BEDS assessment tool for taking history on PEUH. RESULTS: Participants were 63% male, 40% Hispanic/Latino/a, 40% white, 94% English-speaking, and 73% had chronic health conditions. Assessment revealed: average Homelessness (H) of 4 years; 76% had no prior social service Outreach (O); average Utilization (U) was 4 emergency department visits in prior 6-months; 68% received Salary (S) from government income; Food access or Eat (E) was commonly purchased (29%) or donated (26%); clean water to Drink (D) for 59% of participants; 86% had access to a Bathroom (B); Encampment (E) was varied and 38% reported safety concerns; Daily routine (D) showed 76% could access a telephone, 32% received social support from family; 79% reported past or current Substance use (S). No participants contracted COVID-19 during study period. CONCLUSIONS: This study describes health and demographic characteristics of PRK participants in Southern California. Findings inform policies to continue PRK that includes onsite healthcare such as via street medicine.

Behavioral Health Care Delivery Through Street Medicine Programs in California.

Mental health and substance use disorders are prevalent among people experiencing homelessness. Street Medicine can reach unhoused people who face barriers to accessing healthcare in more traditional medical settings including shelter-based clinics. However, there is little guidance on best practices for mental health and substance use treatment through Street Medicine. The aim of the study was to describe behavioral health care through Street Medicine by analyzing data from the California Street Medicine Landscape survey and follow-up qualitative interviews. Most street medicine programs utilize non-psychiatrists to diagnose and treat mental health and substance use disorders, though the capacity to provide the level of care needed varies. There is a lack of street-based psychiatric clinicians and programs have difficulty making referrals to mental health and addiction services. This report shows that Street Medicine could serve as a strategy to expand access to behavioral health care for the unhoused.

Preceptors' preparedness to teach about substance and opioid use disorder: a qualitative study.

STUDY AIM: Little is known about preceptors' comfort and readiness to teach clinical students about the care of patients with substance and opioid use disorder (SUD/OUD). This study explores preceptors' views about caring for such patients, and their preparedness to teach about SUD/OUD management, to improve graduate competencies. METHODS: Participants were recruited by convenience and snowball sampling. Semi-structured interviews were conducted with physician, physician assistant, and nurse practitioner preceptors who taught medical and physician assistant students. Interviews were conducted via Zoom® videoconferencing. Transcripts were generated and independently analyzed for themes by 4 experienced coders using constant comparison and a grounded theory approach. RESULTS: Fifteen interviews were conducted to theme saturation. We identified 3 major themes and 10 subthemes supported by exemplar quotes. The major themes were: education about SUD/OUD in primary care (subthemes include need for longitudinal curriculum, redefining 'success' in treatment, and precepting challenges), treatment of SUD/OUD in primary care (need for systemic support and care continuity), and medication-assisted therapy (MAT) training as a tool for teaching (preceptors' own training, and need for clinical students to be trained). CONCLUSIONS: Preceptors agreed that treatment of SUD/OUD belongs in primary care and students should learn about SUD/OUD from the start of their medical education. Data analysis enabled the construction of an emerging conceptual framework reflecting a diversity of experiences and opinions of preceptor comfort and preparedness to teach about SUD/OUD, associated with various barriers and motivators. This framework can guide future strategies to address facilitators and obstacles to advance and promote preceptor preparedness to teach students about the care and management of patients with SUD/OUD.

Challenges of caring for homeless patients with inflammatory arthritis: 12-month follow-up observations and identification of certain barriers to care.

Homelessness is a public health crisis and there is a paucity of information about patients with rheumatic disease experiencing homelessness. We sought to develop approaches to improve care for this unique patient population. We previously reported observations on 17 homeless patients with inflammatory arthritis (15 rheumatoid arthritis (RA), 2 psoriatic arthritis (PsA)). We obtained follow-up information from our original 17 patients and compared this to data summarized and published about them from 12 months previously. We also created and administered a 100-question needs assessment survey. Follow-up 12-month clinical information was available from 13/17 homeless and 13/17 non-homeless controls. Homeless patients remained less well with more disease than non-homeless patients-poorer access to clinic appointments (80% vs 91%, p < 0.05), more emergency services use (20 vs 5 ED visits), less DMARDs use (43% vs 100%, p < 0.01), and more steroid use (29% vs 0%, p < 0.01). Homeless patients also had higher inflammatory markers than non-homeless patients (ESR 32 vs 26 mm/h and CRP 17 vs 5 mg/L), although these findings were not statistically significantly different. Seventy-eight percent of homeless patients were stable, 14% improved, and 7% worse; 21% had stable controlled and 57% stable active disease vs 62% and 0% of non-homeless (p < 0.01). Among the homeless, 6 (4 RA, 2 PsA) completed the survey, 2 declined, and 9 could not be reached. All 6 had found housing although all still had housing insecurity; 4 (67%) were homeless in the past. Three out of six (50%) obtained housing from social assistance during hospitalization following disease exacerbation while homeless. The average monthly income was $873. 5/6 (83.3%), were unable to work due to health, and were in considerable pain that adversely impacted their physical and mental health and ability to perform ADLs. Their perceived "greatest need" included dental care, physical therapy, knee surgery, employment, socialization secondary to isolation, and stable housing. Our understanding of the unique challenges of patients with rheumatic disease experiencing homelessness is improved, but not complete. Strengthened collaboration between street medicine providers and rheumatologists is necessary to improve care for homeless patients, especially given poorer outcomes compared with non-homeless counterparts. Key Points • We report 12-month follow-up information from our original 17 homeless patients with inflammatory arthritis (related in this journal in 2021) and their responses to an extensive needs assessment survey designed to identify barriers to care. • Homeless patients with inflammatory arthritis continued to have worse disease outcomes, use more corticosteroids and less DMARDs, and be seen less often in rheumatology clinics and more frequently in emergency departments than their non-homeless counterparts. • Survey data indicated that social assistance during hospitalization was a key area where healthcare providers could intervene to provide housing security for homeless patients and improve outcomes. Patients perceived "greatest needs" went beyond housing and rheumatological care and critically included access to social/specialty services. • Street medicine is the direct delivery of healthcare to people experiencing homelessness wherever they reside. Our observations, obtained in collaboration with street medicine colleagues, suggest important and salutary opportunities for this partnership to improve care for these particular patients.

Addressing the Opioid Crisis: Medication-Assisted Therapy Waiver Training for Students.

PURPOSE: Physician assistant (PA) graduates should be prepared to care for patients with substance use disorders. Medication-assisted therapy (MAT) allows PA graduates to provide that care by becoming licensed to prescribe buprenorphine. However, it is unclear how feasible and effective it is to implement online MAT waiver training during PA school. This study examined student knowledge and attitudes after training to assess its impact and perceived value. METHODS: We conducted a 15-question survey after one class of students completed training during clinical rotations. Students self-reported pre/post change in awareness, knowledge, interest, comfort and confidence, perceived usefulness to practice, and assessed quality using 5-point Likert scale (higher scores = more positive) and narrative responses. Data analysis was performed using the Wilcoxon signed rank test and descriptive statistics. Free text comments were analyzed for themes using constant comparison. RESULTS: Fifty-five (100%) students completed training within 6 weeks. The survey response rate was 49/55 (89%). Pre-to-post score changes were significant (p < .05) from +0.39 to +1.35 with the greatest changes seen in knowledge (+1.35), comfort (+1.14), awareness (+1.06), and confidence (+1.08); the lowest change was in interest (score change +0.39). Students reported being satisfied with content organization and quality (mean 3.82) and recommended training to colleagues (3.98); 82% reported they would have preferred 3 months to complete training; 46% would have preferred training prior to the start of clinical rotations. Major themes indicated a desire for better preparation and flexibility of platform, with ambivalence about relevance to practice. CONCLUSION: Online MAT waiver training is feasible and effective. However, students may not be convinced of its relevance to future practice. Faculty should offer adequate preparation and optimize integration into existing curricula.

Inclusion of the homeless in health equity curricula: a needs assessment study.

Exposure to homeless patients is a potential strategy to teach about social determinants of health and health inequities. Little is known about student attitudes and preferences for learning about the homeless in curricula addressing vulnerable populations. A needs assessment to determine student readiness may inform strategies for teaching. A mixed-methods study of one matriculating physician assistant student class, with a cross-sectional survey and 3 focus groups (FG). The validated 19-item Health Professionals' Attitudes Toward Homelessness inventory (HPATHI) and new 7-item Learning Attitudes scale were administered to explore perceptions and preferences about relevance of caring for the homeless to future practice. FGs were conducted to theme saturation. Verbatim transcripts were independently read and coded by 3 researchers using constant comparison. Survey response rate was 100% (N = 60). Overall HPATHI mean score was 3.97 ± 0.04 of 5, indicating positive attitudes toward the homeless. The highest mean score (4.26 ± 0.04) was for the social advocacy subscale; the lowest (3.02 ± 0.06) for personal advocacy. The Learning Attitude scale (Cronbach's alpha 0.89) mean score was 4.47 ± 0.07 out of 5, showing a positive attitude toward curricular exposure. Older students and those with prior experience with the homeless had higher HPATHI scores (p < 0.05). Four major themes emerged: vulnerable patients cannot advocate for themselves; learning about homelessness is relevant to future practice; preference for multiple teaching strategies and adequate preparation for street rotations; and anticipated anxiety about safety. Students recognize the value of learning from homeless patients as part of gaining skills in caring for vulnerable populations. Experiential learning opportunities focusing on this group are seen as an acceptable and valuable way to gain skills applicable to all vulnerable patients. Students express fear and anxiety around non-traditional settings such as the street. Their anxieties should be adequately addressed when designing clinical rotations.

Early Exposure to Underserved Patients and Its Impact on Initial Employment Decisions Regarding Physician Assistants.

PURPOSE: This study explored the impact of early, repetitive, and required participation in a homeless shelter-based, student-run free clinic (SRC) on career choice in primary care, underserved medicine, and future volunteerism in physician assistants (PAs). The investigators hypothesized that students required to participate in the SRC would be more likely to select a career in primary care, be providers to underserved populations, and to volunteer. METHODS: A 30-question online survey, which included open- and closed-ended questions, was administered to alumni of the DeSales University PA program from January 2015 to April 2015. Alumni who had and had not been exposed to the SRC were included in the sample. RESULTS: Completed surveys were obtained from 43 graduates who attended the university before the opening of the SRC and from 114 graduates who were required to participate in the SRC, for an overall response rate of 31.2%. Graduates who were exposed to the SRC were significantly more likely to have an initial and current career in primary care. Furthermore, alumni who had worked in the SRC were more likely to report that they believed their DeSales University experience influenced their decision to enter primary care as compared to those who did not have exposure to the SRC. CONCLUSION: This study provides initial evidence that early, repetitive, and required exposure to a student-run free clinic impacts graduates' decisions on career choice and volunteerism. The structure of this particular clinic and its location in a homeless shelter may have provided an opportunity for students to explore how social determinants affect health in an underserved population.