Caring for special populations
BY CINDY BORGMEYER
Ask John O'Handley, M.D., how he came to spend most of his waking hours providing health services to homeless people in and around Columbus, Ohio, and he'll modestly ascribe it simply to being in the right place at the right time.
 FP Sharon Lee, M.D., dons a hard hat while giving a tour of
her Kansas City, Kan., clinic. The renovations, which include new patient exam
rooms, counseling offices, a legal aid clinic and an auditorium for health
education activities, should be completed this summer. |
"I sort of fell into it back in 1995," O'Handley says. "I was director of the family practice residency program at Mount Carmel, and they were looking for a volunteer medical director for the outreach program, which goes out to the indigent populations around Columbus. Our residents were involved in the program, and I agreed to see patients and to be the volunteer director."
What began as a part-time obligation has, for O'Handley, evolved into a calling. He's now the full-time medical director of the Mount Carmel Health Systems Community Outreach Program, having stepped down from directing the residency program to devote more time to his outreach activities.
For FP Sharon Lee, M.D., of Kansas City, Kan., the decision to care for indigent patients was made long before she earned her medical degree.
"I went to medical school to acquire skills I could use to help people who were falling through the cracks," she says. "That was my goal from the get-go."
Fifteen years ago, Lee opened a practice in a squat cinder-block building set in one of the city's industrial areas. Originally a gas station, the building had at one time housed the offices of a notorious local purveyor of adult entertainment.
"I started with my mom and dad on the phones," says Lee. Today, her practice, Southwest Boulevard Family Health Care, still has that sense of family, she says.
O'Handley's and Lee's stories put a face on the many caregivers (perhaps many in the AAFP) serving the indigent in America.
Scope of the problem
Depending on who's doing the counting, estimates of the number of uninsured U.S. residents run as high as 44 million. The National Survey of Homeless Assistance Providers and Clients in the late 1990s estimated that in the course of a year, between 2.3 million and 3.5 million individuals in the United States were homeless at some point.
Figures from the 2000 U.S. Census show about 16.5 percent of the residents of Wyandotte County, in which Lee's clinic is located, live at or below the federal poverty level. Although her clinic serves whoever walks, crawls or wheels through the door, the majority of her patients come from the surrounding Rosedale District.
"I was amazed to find that Rosedale was considered an underserved area, as close as it is to KU," Lee noted, referring to the University of Kansas Medical Center, a few blocks from where she works. That's one of the reasons Lee says she chose the area to set up her practice.
In the Columbus area, says O'Handley, "We're probably talking fewer than 4,000 homeless people, maybe closer to 2,000 at any one time. It's hard to document the numbers because a lot of them live out in the woods and it's hard to count them." Area shelters can house only about 1,000 folks, he adds.
Making the rounds
|
Learn how to adapt your practice Homeless people are disproportionately affected by certain health conditions, says the National Health Care for the Homeless Council. Communicable diseases, including HIV infection and tuberculosis, ravage this population. Injuries due to trauma and exposure to foul weather are common. Mental illness and substance abuse disorders are rampant. In short, these patients need regular medical care. They need a personal medical home. The national council offers physicians
resources on adapting their practices to manage the special needs of homeless
patients. Visit http://www.nhchc.org/network.htm #adapting_your_practice to
learn more. |
Mount Carmel's outreach program operates a state-of-the-art mobile coach that travels to area shelters for the homeless and other community sites. The coach sports two fully equipped patient exam rooms and visits some 30 sites throughout Columbus and central Ohio.
In any given week, O'Handley sees between 75 and 100 patients, many of them at Columbus' Friends of the Homeless shelter. But the coach makes other stops, as well.
“We go to some of the Hispanic areas around Columbus,” O’Handley says. “Most of the Latino and Hispanic populations here are uninsured -- they're the working poor. We also go to the YMCA, where many people don't have insurance and are just sort of scraping by."
Medical problems O'Handley frequently sees include diabetes, hypertension, chronic obstructive pulmonary disease, asthma, bronchitis, skin conditions, sore joints and injuries. "We do minor surgery in the coach," he notes. "We take out foreign bodies, take off growths, or incise and drain abscesses."
For Lee, a typical day may have her explaining -- with pictures and color-coded stickers -- a complicated pill regimen to an illiterate patient with HIV infection. Or handing out drug samples to hypertensive patients who can't pay for their medications. Or counseling a teen patient about safe sexual practices.
Every Wednesday evening, Lee's daytime clinic is transformed into the JayDoc Free Clinic -- where medical students from the University of Kansas (think Jayhawks) have a chance to practice what Lee preaches. Although the focus is on helping uninsured teens, no one is turned away, and the clinic is always jam-packed, says Lee.
Here, a single primary care visit can spell the beginning of an ongoing medical relationship, she says. JayDoc staff refer many patients to other clinics around the area for continuing care. The most difficult cases -- patients with HIV infection or those with poorly controlled chronic conditions -- are referred right back to Lee's full-time clinic for follow-up.
Keeping an open mind
|
Be part of nationwide effort This year's Cover the Uninsured Week, May 10 -
16, is intended to draw attention to the plight of the millions of Americans
who lack health coverage. At the same time, the initiative offers physicians a
chance to participate hands-on. To learn how you can be part of this nationwide
effort, visit http://covertheuninsuredweek.org/
and click on "What You Can Do." |
Caring for patients who spend most of their time searching for food and shelter rather than tending to their health care needs is challenging, to say the least. The bottom line, says O'Handley: Keep your eyes, ears -- and your mind -- open. It's a point he drives home when precepting medical students.
"I try to give them an overview of homelessness," O'Handley explains. "A lot of it is choices: We're not blaming people, but we do have choices we make, and not everyone makes the right ones. These choices can lead to homelessness and some bad things.”
For example, he says, "We also see a lot of ex-convicts. Many times they're sent to the shelters after they're released from prison, and they end up on the streets. There is support for them, there are social workers trying to get them jobs and housing -- there's an ongoing process that they can get into if they want to take advantage of it. But again, you can't force them into it."
The nature of the mobile outreach program doesn't permit true continuity of care, O'Handley notes, although he's certainly seen some of the same patients more than once. To help patients obtain that continuity, he says it's important to know what resources are available in the community.
"Some of the area doctors take charity cases," O'Handley says. "We try to divvy them up, not overburden anyone. Also, with the opening of a new neighborhood health center on the city's east side, we can refer patients there who don't have insurance or any means of paying.
"We also try to get them into Health Care for the Homeless, a program with neighborhood health centers around the Columbus area. Basically, we try to get them a medical home."
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
FP Report is published by the
AAFP News Department.
Copyright © 2004 by
American Academy of Family Physicians.