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UDSM Proposal February 2016

Health Disparities among Homeless Populations

Living on the streets creates new health problems and exacerbates existing ones. Exposure to the elements, contaminated environments, malnutrition, and lack of access to shower facilities are a few of the factors that contribute to health issues among the homeless. Skin and foot care issues such as onychomycosis, cellulitis, scabies, and tinea pedis occur in the setting of inadequate hygiene and chronic exposure to moisture.[1] Respiratory illness such as tuberculosis and other aerosol-transmitted diseases occur frequently as a result of sharing close quarters with people on the streets or in shelters. One study found that of 221 screened shelter-housed individuals, 50% had at least one respiratory manifestation.[2]  These health issues are compounded by a profound lack of access to care. A national study of homeless people showed that 73% of respondents reported at least one unmet health need, including the inability to obtain needed medical or surgical care (32%), prescription medications (36%), mental health care (21%), eyeglasses (41%), and dental care (41%).[3] For conditions such as diabetes and hypertension that require longitudinal management, lack of access can lead to life-threatening complications such as diabetic ketoacidosis, aneurysm, and stroke. This lack of access to care, in conjunction with hard living conditions, leads to a greatly reduced average life expectancy for homeless individuals. Current estimates place average life expectancy for homeless people at 42-52 years (compared to 78 for the general population).[4] The University District houses a number of services for homeless people, but services such as ROOTS Young Adult Shelter, Neighborcare 45th Street Homeless Youth Clinic, and Teen Feed are targeted to youth and young adults under 25. There is a paucity of resources for adults and older adults. UDSM will be filling a crucial gap by providing basic health services to the adult homeless population.


University District Street Medicine (UDSM) will partner with Christ Episcopal Church to provide point-in-time service for homeless and low-income individuals residing in the University District. Services offered will include the following (pending approval from UW Medicine and Volunteer and Retired Provider insurance (VRP) through WA Dept. on Health) in the following format:

UDSM will utilize Christ Episcopal Church space to provide free drop-in care to individuals identified as in need of acute medical or social services. This model implemented at Christ Episcopal Church will serve as a bridge between non-access to care and access to long-term care at most, and provision of one-time needed care to divert from Emergency Room care at the least. These mini-clinics will provide the homeless community with an opportunity to access a variety of health services at one location. UDSM mini-clinics will host a combination of consistent services and rotating health education resources, with rotating resources being determined by feedback from the community. UDSM will pull volunteers from the following schools for the operation of each clinic: Medicine, Dentistry, Pharmacy, Nursing, Physical Therapy, Rehabilitation Medicine, Social Work, Public Health, and Law. Regularly occurring services include:

●      Foot care

●      Dental screening

●      Vital sign acquisition

●      ACA enrollment and patient navigation

●      Food-to-go or hot meal (dependent on Christ Episcopal facilities)

●      HIV testing

●      Physical therapy services such as workshops on how to properly pack a backpack, helpful preventative stretching, etc.

The proposed services have been specifically chosen to target the most pressing health concerns of the homeless population: dental care, foot care, insurance coverage, and food insecurity. Rotating health education topics will be determined by community needs and patient interest. (i.e., access to free legal advice, flu shot clinics, SSI/SSDI navigation workshop, basic first aid, elder women’s health, etc.) Each discipline involved in UDSM will also be given the opportunity to highlight a topic within their discipline and scope of practice. Additionally, there is the opportunity for community organizations to provide services on a monthly, bi-monthly, semi-annual and annual basis.


The clinic will operate in tandem with current street outreach efforts, with the goal of expanding beyond current outreach efforts. The current outreach dates/times are Monday evenings and Friday evenings, twice per month.

Service Provision


Students groups will consist of a minimum of 3 students and 1 preceptor and a maximum of 5 students and 2 preceptors. Students and preceptors will vary in discipline to provide and interdisciplinary opportunity for those involved.

There will be additional teams conducting street outreach simultaneously with clinic hours. These street teams will provide real-time, on the ground basic services such as relationship building efforts, provision of outreach supplies, vital sign acquisition and resource referral and navigation, with the understanding that the outreach location at Christ Episcopal is available for acute/urgent care needs that arise on street outreach. The “brick and mortar” location will serve as a “home base” for street outreach and provide an opportunity for access to acute care and ideally, access to longer-term, primary care via referral networks such as Neighborcare, Country Doctor and UW Medicine. This “home base” will also provide an opportunity for students to engage clients that are historically resistant to care. Many patients are unwilling to engage in the traditional Western medical system due to lack of trust and limited relationships, therefore this location will potentially provide a positive experience because of the relationships that have been consciously built within the community since May 2015.

Patients that are interested in more specific/acute care will be informed of additional services available at Christ Episcopal/UDSM and the opportunity to be accompanied to the site of service will be made available. Limited acute services will be provided and if the patient needs additional/primary/specialty care, that patient will be referred to available resources.

Space Requirements

UDSM proposes that at least three classrooms be utilized for service provision, along with an open space where patients can wait, access non-acute resources and information with service providers and obtain basic needs via outreach supplies. Access to running water in the vicinity and restroom facilities are also requested.

Value to the Community

Students from University District Street Medicine conducted a community needs assessment in August 2014 with 59 homeless residents of the University District. 36% reported that their primary health need was access to primary care. Additionally, 83% reported that they currently access the emergency room as after-hours primary care. When asked about health care needs that would make their life better, respondents suggested “more drop-in center hours,” “an open-door clinic,” and “insurance,” with 30% citing increased access to care as something that would improve their physical and mental health. Current barriers to care included lack of insurance or underinsurance (34%), no access to care (26%), and personal resistance to obtaining care (15%). Our outreach model will address these problems by increasing access to health and social services in the University District as well as providing opportunities for insurance enrollment and patient health education.  

Homeless individuals are three times more likely to access emergency care within a year period, with almost half of those individuals utilizing the Emergency Department (ED) for their only source of healthcare. 9 Furthermore, the authors suggest that ED access is higher for this population because EDs are accessible during non-traditional hours and availability without an appointment. By providing a multi-disciplinary alternative to the ED by providing consistent, community-based services, UDSM has the potential to route patients into primary care instead of continual use of emergency resources. The landscape of healthcare procurement has changed drastically since the introduction of the Affordable Care Act in 2010 and research is still emerging that demonstrates how this legislation is impacting the health of the homeless community. In order to track potential cost savings that result from UDSM’s efforts, we plan to deploy public health students in data collection and analysis roles both at UDSM clinics and in the University of Washington Medical Center Emergency Department.

Social factors such as isolation, discrimination, and power differentials are figure prominently in the lives of homeless people and carry over into their interactions with the health care system. Social exclusion and social isolation factor prominently in the health and health care procurement of homeless individuals.10 The UDSM clinic would provide an opportunity for homeless individuals to be part of a community, given the neighborhood location, frequency and schedule of events and access to multiple disciplines. This community-based location would provide a welcoming environment to patients that may not have otherwise accessed traditional medical services. Additionally, the health fair model has been shown to be effective in addressing the needs of homeless patients. Since these patients tend to be more isolated, accessing health information can be difficult and patients have been shown to respond well to brief one-on-one interactions as opposed to group learning activities.11 Power differentials exist between doctor and patient, even when the patient is well-educated and well-resourced. These power differentials, in conjunction with an average primary care visit length of 18 minutes and perceived discrimination based on their housing status, creates a repellant health care atmosphere for homeless people seeking health care.12,13 The UDSM mini-clinic will be staffed with students that are educated about issues surrounding homelessness and have more time to dedicate to each interaction, insuring that patients have a positive, impactful visit to the clinic.

Value to Students

UDSM’s first priority is to focus on providing quality care to the homeless people of the University District. Nevertheless, we anticipate that we will also provide valuable learning experiences to our volunteers. One study found that medical students held more negative attitudes towards homeless people at the end of their training than at the beginning of it.14 Fortunately, it has also been shown that these negative attitudes can be changed through participation in service-learning clinical rotations with individuals experiencing homelessness.15,16 As health care providers we are called to provide equitable high-quality care to our patients regardless of their living circumstances. Participation in UDSM will arm volunteers with knowledge about the medical and sociocultural issues confronting homeless people and equip them with skills that will serve them well through the rest of their careers.

In addition, for many students UDSM will be their first exposure to providing interprofessional care. Participation in interprofessional care can enhance professional confidence, promote understanding between professions, facilitate communication, and encourage reflective practice.17 The UDSM mini-clinic will promote community and University involvement in the University District and further UDSM’s focus on interdisciplinary work by providing UW’s health sciences schools and other UW graduate schools with the opportunity to work together through the provision of monthly health screenings and care referrals and implementation of special

Future Goals

UDSM ultimately proposes to partner with UW Roosevelt as a clinical partner and avenue to primary care in the future.


1.           Wrenn, K. Foot Problems in Homeless Persons. Ann Intern Med. 1990; 113(8): 567-568.

2.           Badiaga S, Richet H, Azas P, et al. Contribution of a shelter-based survey for screening respiratory diseases in the homeless. Eur J Public Health. 2009; 19(2): 157-160.

3.           Baggett T, O’Connell J, Singer D, Rigotti N. The Unmet Care Needs of Homeless Adults: A National Study. Am J Public Health. 2010; 100(7): 1326-1333.

4.           National Coalition for the Homeless. Health Care and Homelessness. July 2009. http://www.nationalhomeless.org/factsheets/health.html

5.           Baicker K, Taubman SL, Alle, HL, et al. The Oregon Experiment – Effects of Medicaid on Clinical Outcomes. N Engl J Med. 2013; 368(18): 1713 – 1722.

6.           Seifert RW. Home Sick: How Medical Debt Undermines Housing Security. St. Louis Univ Law J. 2007; 51: 325-352.

7.           Folsom DP, Hawthorne W, Lindamer L, et al. Prevalence and Risk Factors for Homelessness and Utilization of Mental Health Services Among 10,340 Patients with Serious Mental Illness in a Large Public Mental Health System. Am J Psychiatry. 2005; 162: 370-376.

8.           Mackenzie D, Chamberlain C. Homeless Careers: Pathways In and Out of Homelessness. Melbourne, Australia; 2003.

9.           Kushel, MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons. JAMA 285.2 (2001): 200-206.

10.        Moore G, Gerdtz M, Manias E. Homelessness, health status and emergency department use: An integrated review of the literature. AENJ. 2007; 10(4): 178-185.

11.        Robertson MJ, Greenblatt M. Homelessness. In: Robertson MJ, Greenblatt M, Homelessness. Springer US, 1992.

12.        Bruen, BK, Ku L, Lu X, et al. No evidence that primary care physicians offer less care to Medicaid, community health center, or uninsured patients. Health Affairs. 2013; 32(9): 1624-1630.

13.        Wen CK, Hudak PL, Hwang SW. Homeless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters. Journal of General Internal Medicine. 2007; 22(7): 1011-1017.

14.        Masson N, Lester H. The attitude of medical students towards homeless people: does medical school make a difference? Med Educ. 2003; 32: 869-872.

15.        Buchanan D, Rohr L, Kehoe L, Glick S, Jain S. Changing Attitudes Toward Homeless People: A Curriculum Evaluation. J Gen Intern Med. 2004; 19A: 566-568.

16.        Lowenson KM, Hunt RJ. Transforming Attitudes of Nursing Student: Evaluating a Service-Learning Experience. J Nurs Educ. 2011; 50(6): 345-349.

17.        Barr H, Freeth D, Hammick M, et al. Evaluations of interprofessional education. London: United Kingdom Review of Health and Social Care. 2000.