Street medicine: Primary care outside the box

People experiencing chronic street homelessness suffer a disproportionately high burden of morbidity and mortality, often attributable to preventable and treatable chronic diseases within the scope of primary care management. Those chronic medical conditions are frequently complicated by co-morbid mental health disorders, substance abuse and addiction problems, and social disenfranchisement. Moreover, health care utilization costs for this subpopulation are many times the national average, typically due to overutilization of emergency rooms and excess inpatient hospital days, with care rendered often going uncompensated due to lack of health insurance. As a result, it would be easy for mainstream health care systems to conclude that caring for people experiencing chronic street homelessness is an undesirable burden to be minimized, diverted, or avoided altogether. This presentation will argue a counterpoint, namely that hospitals and health care systems have much to learn from these vulnerable and cost-intensive homeless patients, because they efficiently expose the kind of weaknesses in care delivery systems that have the potential to put all of us at risk for poor outcomes and high costs. The essential characteristics and composition of a flexible, integrated, and interdisciplinary primary care model grounded in the core philosophies and basic strategies of successful Street Medicine programs will be reviewed. The presentation will also explore how this reality-based primary care delivery model has the potential to creatively overcome many of the barriers that chronically unsheltered homeless populations face to engagement in meaningful, cost-effective health care.