Harm Reduction Principles in a Street Medicine Program: A Qualitative Study.

There is ample evidence that homelessness is associated with high rates of morbidity and mortality. Street Medicine seeks to eliminate these disparities by providing healthcare on the streets to people who are unsheltered. While extant research describes health disparities for the unsheltered and programmatic approaches to addressing housing instability, there are few published studies describing how healthcare providers build and maintain relationships with patients on the street. This insight is central to specifying how street medicine differs from traditional forms of care and defining aspects of street medicine that contribute to successful patient engagement. Through a collaboration between Operation Safety Net (OSN), a street medicine provider in Pittsburgh, Pennsylvania, and [name redacted], an exploratory qualitative study was designed and implemented using harm reduction principles as a guiding framework. Qualitative interviews were conducted with eleven OSN street medicine providers and a thematic analysis using a deductive approach was used to analyze the data. Findings identified the ways that relational harm reduction was central to all aspects of patient care provided through this program. Major themes included: (1) individualism, or meeting patients where they are figuratively and literally; (2) humanism, which refers to valuing and holding true regard for patients; and (3) nonjudgmental care, in which providers do not hold negative attitudes toward patients and their decisions. These themes are consistent with relational principles of harm reduction. Challenges that were discussed also aligned with these principles and included frustration with systems providing care that did not meet patients' individualized needs, and pain and trauma experienced by providers upon losing patients for whom they genuinely cared. Understanding these relational principles of harm reduction may help providers operationalize ways to effectively engage and maintain homeless patients in care and subsequently bridge the gap to traditional models of care. This study may provide valuable insights to expand the street medicine field in research and applied clinical and community settings.

Delivering health care on the streets: challenges and opportunities for quality management.

Street Medicine focuses on the health needs of unsheltered homeless through mobile teams that provide care in the locations where individuals are found. Innovative strategies are needed to manage the quality of care provided within the atypical clinical settings encountered. In our study, contextual elements and practices for managing quality of care were explored through qualitative analysis of program components presented at the 2007 and 2008 International Street Medicine Symposia. Our analysis identified several common contextual elements, including unconventional living situations and lack of financial resources of patients, inconsistency in contact with transient patient populations, and informal clinical settings. Several practices were developed to address these elements and improve the quality of care delivered. Best practices included the use of mobile clinic vans, electronic medical records, collaboration with community clinics and hospitals, and provision of comprehensive social support. An example of quality auditing was also found in the reviewed programs. Additional work is needed to further quality management in Street Medicine and support achievement of replicable practices and measurable outcomes. We propose that 2 short-term outcome measures be used that acknowledge the contextual challenges faced in Street Medicine. These are patient engagement and patients' subjective assessment of their well-being.