In promoting the value of the Health Care for the Homeless model of care, it is important to share the challenges and successes of programs that embody the virtues and practices of holistic care. One of the most unique challenges to caring for populations experiencing homelessness is the complexity of barriers to access to care. From transportation, conflicting prioritization, trust and much more, it is a challenge to meet the patients where they are in their readiness for care.
One exemplary program that succeeds in overcoming these barriers both literally and figuratively is Homeless Outreach Medical Services (HOMES), a program of Parkland Health & Hospital System. For more than 30 years, HOMES has physically brought their mobile clinical services to patients in Dallas County experiencing homelessness wherever they are: family shelters, encampments under bridges, permanent supportive housing, drug treatment and mental health agencies, criminal justice diversion or recent release programs, and serves all ranges of people from men and women, families, teens and victims of domestic violence.
“We serve homeless individuals of all ages,” said Susan Spalding, MD, Medical Director of the HOMES program, “although the vast majority are adults between the ages of 25 and 59 years old. We find that all groups of people experiencing homelessness feel comfortable accessing the mobile clinics.”
HOMES utilizes four mobile medical clinics and one mobile dental clinic at 28 mobile clinic locations in Dallas County. The program also operates two fixed site locations, Monday through Friday.
The services the HOMES program brings to these groups include class D pharmacies and point-of-care lab testing available on-site. A 22-seat shuttle with wheelchair accessibility is available five times per day to bring patients to Parkland’s main campus, which supports the clinics with a full range of laboratory, radiology, pharmacy and subspecialty services.
In addition to medical services, HOMES offers services in podiatry, social work, dentistry, dietary, glasses fitting, psychological, licensed professional counseling, and substance abuse counseling. Residential drug treatment for those who need it is also provided through an affiliate, Turtle Creek Manor.
Bridging Barriers to Care Holistically
The estimated homeless population in the Dallas County area is about 15,000, Dr. Spalding said, and Parkland’s mobile clinics serve about 9,000 of them.
It is difficult to compare the utilization of the mobile clinics by specific groups of people as opposed to a fixed site location, Dr. Spalding said, but she has some observations from her experience.
“We try to go where homeless populations are congregating, typically at an agency where they are organizing people to come out and see us,” she said. “The mentally ill might have more difficulty accessing clinics; Active drug users are a group that are more difficult to reach as well.”
This is why HOMES brings its services to drug treatment and mental health agencies – bringing care directly to the groups whose health care needs may otherwise go unmet.
“These sites are not exclusively homeless,” Dr. Spalding said, “but it is a large base of their demographic.”
By developing a standing relationship with these agencies and with these communities, HOMES is also able to establish a bridge across another barrier – trust.
“Some of the clinics have been in the same location and at the same time for almost 30 years, so both the homeless population and agencies know where we are going to be,” Dr. Spalding said. “The bright blue mobile clinics are recognizable among members of the communities who are familiar with them. We’ve seen that if a potential patient is resistant, they’ll warm up when someone they know says, ‘These people are ok.’”
HOMES has also expanded its capacity based on the needs of the population it serves. Two years ago, Parkland opened its first transgender clinic primarily for the homeless population. Less than a year later, they helped one of the community clinics open a second Parkland location.
For patients seeking care, HOMES encourages them to call ahead if they can so they can be directed to the closest location depending on the patient’s need.
Though HOMES does promote its services through brochures and even in an app that circulates when and where their services will be located, Dr. Spalding said they have found that interacting with people and with other agencies helps better direct patients to the care they need.
“When we go to street encampments, we go with other agencies so they can funnel people in our direction,” she said. “We often go with housing agencies, such as Metro Dallas Homeless Alliance, City Square, and Prism Health North Dallas, which organize outreach to encampments with housing providers who prioritize registration and assess their needs. As they find issues that are health care related, they funnel them to us.”
Ensuring the Standards of Care
Patients who utilize the services provided at mobile HOMES clinics may not be there for your regular standing doctor’s visits, Dr. Spalding said.
“People come to the clinics mainly for acute or chronic issues, like musculoskeletal pain or a virus infection,” she said. “Not many patients want a check-up unless someone else is requiring it [like a housing or employment requirement]. Nevertheless, we measure blood pressure, screen for suicide and depression, offer cancer screenings, apply fluoride varnish and give immunizations.
“We think preventive services have lots of value, but I suspect the patients appreciate the respect and empathy they receive more,” she explained.
Dr. Spalding said that although data is harder to get for HCH clinics in general, they measure their care using national, community health care and hospital benchmarks. Dr. Spalding emphasizes that their mobile clinics can do anything that would typically fall within the jurisdiction of a primary care physician at a fixed location. The mobile clinics even use the same EHR as the Hospital System and work in real time using cellular connectivity.
“We strive to provide the same quality of care that any excellent primary care provider would,” she said. “We benchmark ourselves using the same goals and measures used by Federally Qualified Health Centers and the Parkland community clinics.”
There is no difference in the care provided, with the potential exception of the number of ancillary care providers on hand, she said. Those providers would be prioritized by services offered and the need in different locations.
For example, drug treatment and criminal justice centers may already provide their own ancillary services in their respective areas, but HOMES clinics always have a behavioral health consultant on site or on call for instances of dual diagnosis.
Individual mobile sites are encouraged to expand and contract based on the need.
“When things are slower, we try to spend more time with each patient to address more issues,” Dr. Spalding said. “Although we strive to meet the same goals, we realize that our patients have lots of barriers to what we think of as optimal health care and management of chronic diseases. Our patients have very little to say about what food they eat, what kind of exercise they can do, and they struggle to follow medication regimens and keep subspecialty appointments,” she said.
“People—both homeless and housed—are often surprised to find a regular clinic inside our mobile vehicles. It’s just a tiny clinic and an excellent way to overcome transportation barriers,” she said. “Some patients have asked to see me in my office, and I let them know they are in my office.”
Building trust and providing services is a good step to enabling people experience homelessness toward prioritizing their own health, but the road doesn’t end there. HOMES works with patients transitioning into housing to keep access to health care available to them.
Most of the patients seen by the HOMES program are uninsured – up to 70 percent, Dr. Spalding said. So all of the services provided by the program are free.
“While a patient is homeless, we are their medical home,” Dr. Spalding said. “Once the patient has been stabilized in housing, we continue to provide care until they can be seen by one of their community providers on a sliding scale so that they can contribute financially to their health care.”
Dr. Spalding said that sometimes there can be a fairly long wait before patients can be seen in their new medical homes, during which time they can continue to be seen at HOMES clinics. Others may be retained as patients a little bit longer because of other conditions or circumstances. Regardless of the barriers, HOMES continues to make health care for the homeless their top priority because of the value they see their services provide.