Delivering 'Street Medicine' With Operation Safety Net

STREET MEDICINE MODEL AND ITS EFFECTIVENESS IN MEDICAL CARE

Street medicine has emerged over the past few decades as a way to offer medical care to the homeless population in their own communities under bridges, long roadways, and integrated buildings, but is the street medicine model effective and what are its implications for other medical fields? You are listening to ReachMD, the Channel for Medical Professionals. Welcome to the Clinician's Roundtable. I am your host, Dr. Michael Greenberg and joining us to discuss street medicine, Dr. Jim Withers, founder of the non-profit street medicine organization, operation safety net and faculty member of the Department of Medicine at Pittsburgh Mercy Health System.

DR. MICHAEL GREENBERG:

Welcome Jim.

DR. JIM WITHERS:

Thank you.

DR. MICHAEL GREENBERG:

Now take a minute and tell us about yourself first, how many years have you been in practice and how you started on this project?

DR. JIM WITHERS:

Well, my carrier is focussed on teaching medicine. I am an internist and I teach here at the Mercy Hospital at Pittsburgh and my focus over the years has really been on how do we reach people who sort of have been left out by the healthcare system. All this goes back to when I was a kid and I made house calls with my dad and his little BW in the countryside and there was something really powerful about the way he connected with his patients and later I realized its also a very good way to engage patients in their care. So, in my teaching career, I was looking for ways to kind of recapture some of that. So, one of the groups of folks that definitely were not receiving consistent or good care where the folks who were sleeping outside, under bridges, and along riverbanks and I thought what a better classroom could there be even under the bridges to learn really how to work with people on their terms.

DR. MICHAEL GREENBERG:

Now when you first went out, I read that you gone out dressed as though you were homeless yourself, is that true?

DR. JIM WITHERS:

Yeah, the first year it was just me and a homeless guide that were going out. My thought was that I didn’t want to come off in any kind of a position where, you know, I had the answers for people that I was intimating them or whatever. I am not sure my thinking was totally clear, but I read a book it said, you know, if you want to meet street people or homeless people, you need to dress in such and such a fashion, so yeah I did, I kind of dressed like a homeless person and went out at night because that’s where the folks are actually sleeping. You know who is actually sleeping outdoors and they actually didn’t tell the hospital for the first year, sort of my own little experiments to see if this was going to make any sense or not.

DR. MICHAEL GREENBERG:

Who are these unsheltered homeless people? We get the idea sometimes when he don’t see them all the time that these are like the dragon society, but there are really people like you and me, aren’t they that are just unfortunate or in unfortunate circumstances.

DR. JIM WITHERS:

I am eager to know the focus on the streets the more similarities I see in them in my own life. I have never been homeless, but what are the same kinds of mistakes and weaknesses and other things you know I can certainly see in myself now, people in the street do have some characteristic factors that seem to be associated with street homelessness, but for the most part it’s really hard to pin down exactly who “they are.” If you get to know each individual, which is another teaching point that I would like to make, then you see how it will fit together and how that particular person ended up on the street, a lot of it is simply kind of a long list of things that they were not, it is more like a process of exclusion.

DR. MICHAEL GREENBERG:

And it isn't the job of doctors really to get the note of patients anywhere in the medical who they are?

DR. JIM WITHERS:

Right. Osler said, it’s more important to know what person the disease has than to know what disease the person has and I think that’s definitely true.

DR. MICHAEL GREENBERG:

Were you scared at first or are you ever scared going out there by yourself that among homeless people you are going to find somebody who is not quite going to respect you as a doctor and maybe mug you?

DR. JIM WITHERS:

Well the first year, especially I am not sure you know how much of that was my perception of danger, I think it was dangerous. That’s why it was invaluable to have a formerly homeless person with me who had already been going out to deliver blankets and food to folks and he served as my guide. There were some kind of scary times in the very beginning.

DR. MICHAEL GREENBERG:

What are some of the challenges that face you when you treat homeless people obviously? You don’t get the same kind of followup, they may not be there the next week, they are not going to be able to walk in the pharmacy and just fill your prescription. How do you work all of these issues?

DR. JIM WITHERS:

Well, the starting point is just actually having access to them so that you can engage them and I mean, that sounds really simplistic, but it is a profound issue because a lot of these folks just aren’t even getting to the point where someone’s talking to them and its kind of a Mexican standoff if we well, I mean they are distant chanted and not willing to engage services and for the most part, the health and social systems have kind of come the same conclusion about street people, is it, you know when they are ready though, I guess they will come to us. So there’s this impasse and then you see people out there who have illnesses that are mostly normal, with you well, but they have really gone to a very bad stage. So once you are out and you get to know people and you kind of understand what their health issues are and their mental issues, etc., then you start trying to go into the health system with them, which is what I call in-reach work as opposed to outreach because you do have a really strong sense of who that person is and what they can do and you see how difficult it is for that particular person to navigate their way into the health system and that’s where we become their ambassadors to work with them to tax us those things.

DR. MICHAEL GREENBERG:

Hold on for 1 second.

If you are just tuning in, you are listening to the Clinicians Roundtable on ReachMD, the Channel for Medical Professionals. I am your host, Dr. Michael Greenberg and joining me to discuss Street Medicine providing care to the homeless is Dr. Jim Withers who is the founder of the non-profit street medicine organization operation safety net and faculty member of the Department of Medicine at Pittsburgh Mercy Health System. That being said, Jim is the guy who goes out on the street and is actively treating homeless people, which I think is really astoundingly brave and needed. Let’s get back to some of the challenges.

DR. MICHAEL GREENBERG:

How do you get medication for your patients?

DR. JIM WITHERS:

I used to do mountaineering and some wilderness medicines. So I was comfortable with putting together a backpack with medicines in it. The street kind of taught me what it needed, which end of doing if you just sort of do this on your own was you would realize that there is a person under a bridge who has been seen in the emergency room and its raining and their prescription is melting and they can’t afford it and they weren’t going to tell anyone and they are still ill. So, certain things you begin to just have to take and you put in them as a block bags and am seeing, you have a backpack with medicines. These things you don’t want to bring course or any controlled substances or anything that if a person overdosed or didn’t take them well because yet to think about their ability to understand.

DR. MICHAEL GREENBERG:

Where do you get the medications from?

DR. JIM WITHERS:

Well in the beginning, I just pretty much either bought them myself or like bandage supplies, I actually would steal from the hospital. Later on I fessed up and talked to the administrator and she was actually delighted with what we were doing because the Mercy Hospital actually started with nuns that walked the streets about 150 years ago that realized sort of recreating the wheel here.

DR. MICHAEL GREENBERG:

And don’t you kind of save money for the hospital, anyway doesn’t the emergency room utilization go down by these people when you go out there and treat them?

DR. JIM WITHERS:

In fact, yeah, we see a lot of people whose only care would have been in an emergency room and you know the emergency room is throughout the city of Pittsburgh that all benefit from us seeing the folks and sort of triaging, but also there is a lot of times when a street person came to an emergency room and for whatever reason that encounter wasn’t complete or very good and the person ends up back on the street and there are issues that were very dangerous that had not been fully taken care of. So, we have a kind of a quality assurance function there as well.

DR. MICHAEL GREENBERG:

Okay, now you are using the pleural, us and we, is it more than you out on the street now?

DR. JIM WITHERS:

Oh yeah! It involved there was a nurse who started asking to come out and perceiving teared up medical people with their own formally homeless partners and specialized in different parts of the city, my secretary began receiving phone calls at the Department of Medicine from street people and she got a kick out of that. So, we finally got a grant and then she quit her job and became the secretary for the homeless. In 1993, we were able to start our organization officially and we got an administrator and from that point on, we just built and so we have case management for the focus that we see at night, I think there is really an obligation that they can come during the daytime and then work on their health insurance getting into medical care, but increasingly into housing and all the other services. So volunteer wise, we probably have maybe 30 people, doctors, nurses, paramedics that go out.

DR. MICHAEL GREENBERG:

Is this just in Pittsburgh?

DR. JIM WITHERS:

That’s correct.

DR. MICHAEL GREENBERG:

How about other cities?

DR. JIM WITHERS:

I have been there working with cities mostly in the United States, but also in Northern Europe and India and Central South America to pull together those who do this and then I started calling it street medicines some years ago. So, this became obvious to me that there is actually a field of medicine where people do take medical care right out into the streets and under bridges and try to work with people and they had no group to speak with each other or about. So, in 2005, we hosted the first International Street Medicine Symposium with some funding from GlaxoSmithKline. It brought together these folks, these pioneers really from all over the world. We had an annual meeting and many cities have asked us to help them initiate programs to deal with their street people. So, in this fall, we started a new organization called the Street Medicine Institute, which will continue that work and improve it to help communities throughout the United States particularly that want to work with their street homeless populations to provide street medicine.

DR. MICHAEL GREENBERG:

So, how could our listeners if they want to do something and participate, get in touch with you or your organization? Is there a website?

DR. JIM WITHERS:

They could either contact home base here, which is www.operationsafetynet.net or they could go to the street medicine website, which is www.streetmedicine.org.

DR. MICHAEL GREENBERG:

But you do not recommend that we just start it on our own?

DR. JIM WITHERS:

No, please call me, (laughs). Please call me or if there is different region of the country I can connect you with experts in the field.

DR. MICHAEL GREENBERG:

Well, I mean, if the polity is really helping now in hospitals because with the kind of way it is, we are going to see more people who are homeless these days and not on the street. Is this something that government is working with also?

DR. JIM WITHERS:

I think they are just beginning to wake up to the fact that this is really a non-acceptable situation. You have got all these people, growing numbers of people sleeping outside who their morbidity and mortality is really high. Their problems aren’t getting addressed adequately. You need something like a street medicine program and I would like to eventually see street medicine as something that is normal if there are street people out there as the fire department or the paramedics. We have made a big dent in the number of homeless here by combining the old doctor house call visits and that trust with housing. So we have actually gotten 228 people from the streets into scattered housing in the last 3 years with about an 80% retention rate.

DR. MICHAEL GREENBERG:

Let me ask you another question about mal practice coverage. How do malpractice carriers view this as their, they view it as a greater risk or lesser risk? How you covered?

DR. JIM WITHERS:

Well, you know I did have some concerns about that and eventually had to make that phone call to my malpractice carrier and the guy asked me, said, “Are you doing anything outside of the scope of your training” and I said “no” and they said, “Are you keeping records of what you do” and I said “yeah.” In fact we have a really good computerized system, but he said well, you know that pretty much covers it for you. Now different states have different approaches to this, but we could also help anyone who is interested in doing this address those issues because our administrators become somewhat of an expert on that.

DR. MICHAEL GREENBERG:

But you are 501C3, are you not?

DR. JIM WITHERS:

That’s right.

DR. MICHAEL GREENBERG:

So, if listeners wanted to contribute, if they couldn’t contribute time can they contribute to the organization?

DR. JIM WITHERS:

Certainly, certainly and we are only supported actually by the money that we can get from donations and grants. It is a little difficult since we don’t charge the patients directly.

DR. MICHAEL GREENBERG:

Thank you and this is I think a great opportunity for students who are listening for our physician and health professionals who are listening to get involved either by supporting the organization or actually going and doing it.

DR. JIM WITHERS:

Thank you. This is a great opportunity to get the medical world that’s been in a little bit of uphill battle to sort of get the idea across to the medical field and people really ask me, “why did you did this? If I am thoughtful what I say is “I went out on the streets to try to help physicians because I really think that we have incredible difficulty seeing through other people lives.”

DR. MICHAEL GREENBERG:

I would like to thank my guest from Pittsburgh, Mercy Health System, Dr. Jim Withers. We have been speaking about street medicine providing care to the homeless.

I am Dr. Michael Greenberg and you have been listening to the Clinician’s Roundtable on ReachMD, the Channel for Medical Professionals. Be sure to visit our website at www.reachmd.com, which has been newly decorated, which features on demand podcast of our entire library including this show and we thank you for listening.