Laura Swoboda, DNP, APNP, FNP-C, FNP-BC, CWOCN-AP 

Disclaimer: This blog's author is not affiliated with the Street Medicine Institute and wrote about this subject because of the increasing number of homeless. In the United States, from 2020-2022, chronic homelessness rose to 16%.¹ Due to factors including the lack of affordable housing and the retrenchment of social programs, the prevalence of those experiencing homelessness in the United States and those residing in homeless encampments and tent cities has increased.^2,3People experiencing homelessness have their own markedly increased health care disease burdens, in addition to issues with complex health care access.

The Factors Surrounding Outcomes

Even when delivering office-based medical care, we know that 80% of outcomes aren’t due to the care we, as clinicians, provide.^4,5 Instead, these outcomes are related to our patients' environment and social conditions. These factors are collectively known as social determinants of health (SDOH). Disparities in SDOH contribute to up to a 30-year reduction in life expectancy for people experiencing homelessness. This lowered longevity is due to issues including the following³:

• Overdose
• Nutritional deficiencies
• Alcohol and tobacco abuse
• Mental health disorders
• Poor self-management of chronic and infectious disease

Street Medicine: How to Increase Access to Care

Some providers, especially medical and nursing students, have developed Street Medicine programs to increase access to health care and attempt to limit the downstream health impact of homelessness. Street Medicine refers to the provision of health care to unsheltered homeless individuals directly where they live. This program includes walking teams and ad hoc mobile clinics that directly access and provide care in areas with rough sleeping conditions, such as tent encampments and overpasses. This type of medicine has some inherent medical, legal, and safety risks. Clinicians looking to increase access to services like wound care through Street Medicine can help design safe, compliant programs by consulting organizations like the Street Medicine Institute. The vision is that everyone sleeping on the street will have access to health care.

Tools for Care: Wound Care Basics

Inherent supply and follow-up issues present in Street Medicine can challenge a provider’s creativity. When delivering Street Medicine, providers don’t have access to the same tools and interventions as they would in a clinic or in office-based care. When educating or forming plans of care, providers cannot assume that patients have access to basic human necessities, such as clean clothing, running water, or regular nutrition. Wounds are a common disease burdening people who are experiencing homelessness. Common wound etiologies include trauma, injection drug use, infestations, and chronic disease.^6-9 To meet these immediate needs while delivering Street Medicine, clinicians must view standards of care that would otherwise be followed in an office setting with flexibility. Clinicians must carefully evaluate their default risk versus benefit analysis in this new setting. For example, wound cleansers that providers may otherwise avoid due to potential cytotoxicity, such as bleach solutions or chlorhexidine soaps, may be recommended, as the benefit of infection prevention and risk of poor follow-up now outweigh the potential for delayed wound healing due to cytotoxicity. Bleach is an easily accessed ingredient, and teaching the correct recipe, storage, and use of wound cleansers made with bleach is one option for Street Medicine programs. In encampments, laminated recipe handouts with wound care recommendations on the back can be shared with others. Ongoing patient access to affordable supplies is also an important consideration. While “hanging wet-to-dry dressings out to dry” is an accepted historical maxim in the wound care community¹⁰, gauze, abdominal pads, and even female sanitary napkins or infant diapers are readily accessible, clean products patients everywhere are familiar with. Directly providing care packages with clean supplies can help bridge care until the patient can obtain more. Clinicians should also share the basics of wound hygiene, including regular cleansing and moist wound healing using clean dressings. When more severe concerns are identified, social programs, such as referral to free clinics and hospital charity care programs, can be used to increase the level of care. Knowledge of available community resources and nearby access is critical when further treatment is required.

Conclusion

Street Medicine is an emerging specialty with its own clinical practice guidelines and specialty organizations. Wounds are a common disease burdening those experiencing homelessness. To best care for those with wounds, street medicine providers should receive training on wound hygiene best practices in the context of limited resources.

References

1. HUD Releases 2022 Annual Homeless Assessment Report: U.S. Department of Housing and Urban Development; 2022. HUD Public Affairs. https://www.hud.gov/press/press_releases_media_advisories/HUD_No_22_253…. December 19, 2022. March 6, 2023.
2. National Law Center on Homelessness and Poverty. 2014. Welcome Home: The Rise of Tent Cities in the United States. Washington, DC: National Law Center on Homelessness and Poverty.
3. Enich M, Tiderington E, Ure A. Street Medicine: A scoping review of program elements. International Journal on Homelessness. 2022;3(1):1-49. doi:10.5206/ijoh.2022.2.15134
4. Medicaid’s Role in Addressing Social Determinants of Health. Robert Wood Johnson Foundation. Published February 1, 2019. Accessed on November 17, 2021. https://www.rwjf.org/en/library/research/2019/02/medicaid-s-role-in-add…
5. Social Determinants of Health. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Accessed February 20, 2023. https://health.gov/healthypeople/objectives-and-data/social-determinant…
6. Suryabanshi A, Timilsina B, Khadka N. Wound myiasis resulting from a neglected insect bite wound. Clin Case Rep. 2023;11(1):e6874. doi:10.1002/ccr3.6874
7. Wound Care Difficult for Homeless Patients and Providers. Healing Hands. 2004;8(3):1-4
8. Maxmen, A. The Devastating Biological Consequences of Homelessness. Nature. 2019;569: 467-468. doi: https://doi.org/10.1038/d41586-019-01573-0
9. Zhao, L. Wound Care for the Homeless: A Long and Painful Path. Social Justice News Nexus. 2018. https://sjnnchicago.medill.northwestern.edu/blog/2018/11/29/wound-care-…
10. Ovington LG. Hanging wet-to-dry dressings out to dry. Home Healthc Nurse. 2001;19(8):477-484. doi:10.1097/00004045-200108000-00007

About the Author Dr. Laura Swoboda is a Professor of Translational Science, Nurse Practitioner, and Wound Healing Coordinator at Froedtert & the Medical College of Wisconsin, where they advocate for nurse practitioners and nurse participation in research. They completed their Doctor of Nursing Practice degree at University of Wisconsin Milwaukee (UWM). Dr. Swoboda is a faculty member of the Clinical & Translational Science Institute of Southeast Wisconsin where they serve as principal investigator for quality improvement, evidence based practice, and research projects including the planning, implementation, management, and dissemination of projects in chronic wound care. They further participate in the research process in serving as a peer reviewer for scientific journals. Dr. Swoboda is on the National Pressure Injury Advisory Panel’s Prophylactic Dressing Standards Initiative Task Force, a member of the editorial board for the Wound Care Learning Network and Wound Management and Prevention, and on the board of directors for the WOCNCB and the AAWC. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.