Making Our Own “New Normal” in a COVID-19 World: Progress Notes on HOMES Clinic’s First Year Back
Written by Nick Peoples
Bridging the Gap
“Have you ever tested positive for HIV?”
“No, and I thank God for that.”
It was a routine question with a routine answer. I met Angel (1) as a first-year medical student during her first visit to HOMES Clinic, which provides free health services to people experiencing homelessness. She was a thin, talkative, middle-aged woman with kind eyes and a body that had visibly endured the brutality of life on the streets. I learned that she had struggled with substance misuse. That she was in the LGBTQ+ community. That she was living under a bridge with her partner. And I learned that she had been a victim of abuse.
From her medical records, I also knew she had a long string of prior ER visits spanning several years. This is par for the course for most of our patients. The emergency room, characterized by brief, targeted encounters for acute problems, is often the only place with a prayer’s chance to be seen by a medical professional (2). Perversely, it is also often the most inappropriate place to seek treatment for the afflictions which beset the homeless (poorly managed chronic conditions and housing insecurity) (3). An analysis of 13 studies on the matter found that homeless patients are “…frequently discharged back to the street, which further perpetuates the cycle of homelessness and negatively affects their health” [1]. Angel’s experience had been no different.
Given this backdrop, it was a victory merely getting her to visit our clinic. Our success with this is best attributed to the unique way we find our patients. Rather than passively waiting for people to show up, we go into the community and find out who needs care. In Angel’s case, her care team left our facility, went out to her location in a community day center called The Beacon (4), walked with her up to the front door of clinic, and then kicked-off her visit immediately. We also brought her lunch. These kinds of practices are not just nice personal touches, but are grounded in an evidenced-based “accompaniment” approach in public health. Accompaniment has been shown to improve important outcomes such as linking people into the social safety net services they need and achieving higher patient adherence to treatment plans that are sometimes complex [3].
As we dug deep into her medical records, we discovered that Angel had multiple positive HIV tests from her ER visits going back as far as 10 years ago. The results of these critical lab values, however, were never communicated to her (5). After falling through crack after crack in our “health” system, it was our clinic that finally caught and divulged the life-altering news.
It was a difficult conversation. Angel was, as one can imagine, devastated. At the same time, she was more empowered than ever before to understand and take control of her health. Modern medicine has done wonders for the treatment of HIV, turning an affliction that was near universally fatal 30 years ago into a manageable chronic condition (6). Likewise, Houston has excellent organizations specializing in HIV care, some of whom we partner with directly (7). Her visit with us lasted over two hours. In the end, we ensured she was informed, supported, and linked into the long-term care she needed.
By the standards of the modern, corporate-driven health care machine, Angel’s visit would be considered “inefficient.” But for people with complex medical and social circumstances, this is often precisely what it takes to provide meaningful care. And in a world where our patients are too often told “no,” the ethos of HOMES Clinic is to become a House of Yes.
HOMES Clinic, which operates under the auspices of Healthcare for the Homeless-Houston (HHH), was founded in 1999 with the mission of “bridging the gap” between people experiencing homelessness and accessible care. Angel’s visit casts that vision into sharp relief. It is difficult to believe, however, that only a couple of months prior to providing her care, HOMES Clinic was a completely non-operational entity.
(1) Pseudonym. Other select details modified at author’s discretion to preserve patient confidentiality.
(2) According to the National Center for Health Statistics, there was an average of 203 ED visits per 100 homeless persons versus 42 ED visits per 100 non-homeless [2].
(3) This is not to disparage the fine work of ER providers, who provide an important safety net for our community. It is a health systems issue. The ER is the most accessible place to receive care when uninsured and homeless. It is also overloaded with high patient volumes, designed to address acute concerns, and does not have full discretion over who receives hospital admission (where services like case management and social work are more readily available) and who is discharged back to homelessness.
(4) The Beacon
(5) Our leading suspicion is that the test was run as part of a routine panel and her providers missed it because they were preoccupied with addressing the other acute concerns she originally presented for. At subsequent visits, all in the ER, her providers either assumed she already knew or didn’t read her charts closely enough as they were targeting her most acute concerns at the time.
(6) Julio Frenk, former Dean of Harvard School of Public Health, has gone as far as to say: “There are more similarities in the way we deal with AIDS and diabetes than between AIDS and an acute infection.” [4]
The Shutdown
On March 14, 2020, for the first time in our 20-year history, we closed our doors as the world was swept by a then mysterious and highly-transmissible virus. This initial closure turned into an indefinite shutdown as governments and institutions everywhere scrambled to determine what was safe and what was “essential.” For the people whom we serve, it was a double blow. The rate of new homelessness skyrocketed as economies and job markets went into freefall. Simultaneously, local safety net organizations exsanguinated under unpredictable restrictions as demand for their services reached astronomic levels. It was (and remains) a crisis.
It took a full year, and the superhuman efforts of numerous volunteers and administrators across the Texas Medical Center, to create and approve a Covid-19 plan that enabled our re-opening on February 28, 2021. Angel’s visit was an early sign that we could still fulfill our mission at the highest level. But the early days were also fraught with challenges. Our pool of volunteers and managers had to be rebuilt. Clinic had to convert to telehealth overnight. Outreach activities (8) were indefinitely suspended. New and progressively complicated covid protocols had to be fit into our workflow, while still enabling patients to complete their visits in a timely manner. On more than one occasion, the wait time to see a doctor led some frustrated patrons to walk out of our clinic.
We are now one year out from our 2021 re-opening. In retrospect, what seemed like a curse has been an unexpected opportunity. Coming back in a Covid-19 world has forced us to challenge our own status quo, and, in the process, take ownership of our own new normal. We can proudly say that “new normal” has been the pursuit of improved patient outcomes and a reinvigorated vision of a world without homelessness. Reflecting on the progress inspired by Covid-19, we are now challenged to reimagine the pandemic era as a keystone for change. Angel’s journey rests on the margin of the HIV pandemic, which animated widespread success in etching human rights into global health policy, and Covid-19, where the legacy of our response is still being written. Which direction will we ultimately go? At HOMES Clinic, at least, we have decided to embrace this newest pestilence as a chance to see old problems with fresh eyes and to set the bar higher for ourselves than ever before.
(8) Through collaborations with other institutions, such as Patient Care Intervention Center, multidisciplinary outreach teams went directly to homeless encampments and assisted people in making healthcare and social work appointments. We have preserved elements of this important practice through going into the Beacon community day center and proactively identifying medical needs there.
Rebuilding a House of Yes: This Year in Retrospect
Care Kits
One thing was obvious - our patients needed hygiene supplies, menstrual products, and condoms. Mary Fang, drawing inspiration from novel covid services at The Beacon, conceived of providing care kits. And within a week of inaugurating the 2021 Board of Directors, our newly-minted finance officer, William Lavercombe, had procured a grant to fund thousands of them. We now give care kits to all our patients at the end of their visit – and it makes a difference. Consider the gentleman with odontogenic abscess (a mouth infection) that stemmed from poor dental hygiene. On his way out, we were now enabled to provide him with a personalized care package with a generous helping of dental supplies. The antibiotics we prescribed would resolve the ongoing infection, and the care kit would give him the tools to prevent a recurrence.
Social Services
Another problem emerged. While we routinely espoused the primacy of the social determinants of health (10), there was no defined social service arm of our organization to speak of. Likewise, while physicians are undeniably taught to appreciate social constraints, medical school curricula are curiously silent on how to actually address them in a management plan (11). In response to these challenges, Mary Fang, Susan De la Torre, Dana Clark, M.D., and I developed the “social liaison” role: a phased program where medical students leave the clinic environment and act as adjuvant social workers at The Beacon.
In phase 1, volunteers conducted a longitudinal needs assessment. We needed to understand our patient’s most pressing needs and their personal experience with local resources. For instance, we found out that one person who we had treated in clinic and referred to a reputable local safety net organization had never gone. When our social liaisons asked them why, they replied: “I went, but that building looks awful. None of us want to go in. We don’t want to imagine what must go on inside.” As another example, many places will officially “open at 8 am,” but, unofficially, one must be in line at say, 6 am, to realistic have a chance of being seen. These kinds of concerns are important to know and anticipate. They are also important to document in written form, lest this “insider information” remain strictly word-of-mouth and unavailable to those who could benefit from it.
Social work is little outside the wheelhouse of what the typical medical student is trained to do, so we also needed to understand how the volunteers were doing. Mary and I conducted a small study to this effect. We found that while social liaisons found the experience both meaningful and educational, they needed 1) more standardized training to assume this role, and 2) a simple, organized way to quickly find and share the most important resources with others. This feedback underscored the development of a standardized video orientation and a Social Resource Guide (Figure 1). While other resource guides exist, the one created through the social liaison program uniquely meets our patient’s needs in several ways because it 1) is informed by first-hand user experience, 2) is updated to reflect changes in services/hours during the pandemic, 3) is independently verified for accuracy by a professional case manager, and 4) is exceedingly simple to use (designed to provide streamlined information that fits on a business card, rather than acting as an exhaustive and difficult-to-navigate “info dump”). The front of each card contains the information provided in a typical resource guide, and the back explains how to actually qualify for and access the service in question. We presented the guide design at the 2022 Health Equity Summit and the 2022 Gold Humanism Conference to positive reception.
The social liaison program has hosted over 150 volunteers to date and has moved into phase 2. Now, armed with the resource guide and better onboarding and training, we are in a trial run where our social liaisons take a more direct role in actively counseling people on how to meet their psychosocial needs. Establishing performance metrics to evaluate Phase 2 will now be the focus of our continued efforts here.
Figure 1. Excerpt from Social Liaison standardized training on the Social Resource Guide
(10) In fact, it’s in our name: HOMES is an acronym that stands for “Houston Outreach Medicine Education and Social services.”
(11) I’m reminded of this particular statement by Farmer, et al. 2006 in Structural Violence and Clinical Medicine [5]: “Unfortunately…awareness [of the social determinants of health] is seldom translated into formal analytic frameworks that link social analysis to everyday clinical practice…Physicians can rightly note that such interventions are ‘not our job.’ Yet since social interventions might arguably have a greater impact on disease control than conventional clinical interventions, we would do well not to confuse our own quests for personal efficacy with the needs of the poor.”
Consistent Quality Standards
Upon re-opening, our entire workflow looked completely different. It was also frequently evolving in response to covid. Managers, out of practice for a year, had to rely on personal, pre-covid experience, which varied widely. It soon materialized that key tasks were being routinely missed, producing inconsistent quality in care delivery.
In response, we developed the Manager Checklist (Figure 2). In “The Checklist Manifesto,” Harvard physician Atul Gawande argues that checklists are the most effective tool to get complex tasks right [6]. Architects, commercial pilots, and surgeons all depend on well-designed checklists to ensure no essential steps are missed. Additionally, research from student-run free clinics directly supports the use of checklists specifically for improving clinic workflow [7]. In a similar fashion, the HOMES Manager Checklist now ensures no critical tasks – covid policies, patient care protocols, medical documentation, or new federal mandates – are missed. It protects patients and volunteers while providing a standardized, easy-to-use recipe for running clinic, and is modifiable in real time so it can adapt with clinic needs.
Figure 2 – Excerpt from the Manager Checklist. Steps highlighted in yellow are “cannot miss” as they ensure patient and volunteer safety.
Ophthalmology Specialty Clinic
Eye care is another critical need for our patients. Studies across the country show this persuasively [8-11], and by our own needs assessment in The Beacon, 69% reported that they had vision concerns and 42% felt that they needed new glasses. Ophthalmology services, as one might expect, however, are hard to come by for the Houston homeless population. The result is common but easily treatable eye diseases, such as cataracts and diabetic retinopathy, go chronically unmanaged until damage is permanent. To bridge this gap, our Directors of Projects – James Fan and Evan Shegog – won $3,500 in grant funding to finance the creation of a HOMES Ophthalmology Clinic (12). With the support of HHH and an ophthalmologist on their staff, we are on track to begin meeting patients at locations familiar to them and providing direct access to free, high-quality eye care
Research and Advocacy
The continuous flux of covid times has only shored up our belief that research is essential to identifying patient needs and target areas of improvement. Using the HHH database, our then Associate Director of Research, Thomas Gebert, led a study entitled: Associations of incomplete SARS-CoV-2 vaccination among patients with unstable housing in Houston [12]. They found that 30% of those with unstable housing missed their second vaccination dose – a proportion far above the national average. Notably, they also found that those with a Harris County Gold Card (an exceptional safety net program providing financial assistance for health care expenses to low-income individuals) and permanent supportive housing through HHH were significantly more likely to follow-through on their second dose. These findings, published in the Journal of Health Care for the Poor and Underserved (13), immediately put a spotlight on some of the most influential factors affecting successful covid vaccination among our patients. Correspondingly, they have enabled us to better tailor our efforts going forward.
Our day-to-day work at HOMES also offers a unique vantage point to understand the needs of our local community and the platform to voice that perspective. A few of us ran an op-ed arguing that student-run free clinics, such as HOMES, are uniquely positioned to help bridge local service gaps [13]. In a similar vein, Dr. David Buck (14) and I wrote a manuscript entitled: “Healing the homeless, fixing a broken aid industry, and challenging the status quo,” published in the Journal of Social Distress and Homelessness [14]. We argue that the proliferation of non-profit organizations has fragmented care, when service integration (a “one stop shop”) produces the best outcomes (I will point again to Thomas’ study, which found that housing access was an important enabling factor for covid vaccination completion).
(12) $3000 Medical Community Grant, $500 AMA Section Involvement Grant
(13) This work was also presented at the National Homeless Council to positive reception
(14) David Buck, MD, MPH is the Dean of Community Health at University of Houston College of Medicine. In 1999, he was one of the chief co-founders of HOMES Clinic.
Going Forward
When I first spoke with Dr. Buck, he told me: “We should be failing better (15). We should be trying to improve healthcare every day by using every visit to learn from our mistakes.” He also said: “It is a failure for people to stay homeless. People in our field say all the time ‘I love getting to see the same patients over and over again’ No. That’s failure.” As I transition, along with Thomas Gebert, into the leadership of HOMES Clinic, these admonishments are taken to heart. We are at the cusp of inaugurating a talented and energetic new Board of Directors, and I believe we must embrace the covid era as an opportunity to re-imagine our institution from the ground up. This includes:
Creating Our Institutional Identity
Drafting and ratifying an official vision statement and mission statement for HOMES Clinic
Building our public brand and redesigning our website – from scratch – to communicate the high quality of our mission and impact to the public
Invigorated attention to:
Updating and consolidating our bylaws
Documenting standard operating procedures
Financial stewardship and transparency
Creating needed administrative policies (e.g. volunteer safety policy)
Codifying improved governance practices into our policies and procedures manual
Achieving Excellence in Clinic Operations
Ensuring consistent, high-quality volunteer performance by implementing:
Standardized trainings for all volunteer roles
Position-specific checklists
Securing a streamlined supply chain for care kits into clinic
Integrating validated preventative health screenings into every visit
Building an innovative social work program for linking patients to long-term safety net services
Continued annual health fairs and vaccine drives
Increasing number of patients seen and achieving a deeper roster of physician preceptors
Leveraging Data to Improve Patient Care
Establishing pipelines for longitudinal evaluation of patient outcomes
Do patients successfully get linked into the services (e.g. housing, case management, employment) we refer them to?
What are their clinic re-presentation rates / hospital re-admission rates after receiving treatment? Are we consistently exceeding the standard of care?
How many of our patients remain homeless at the end of the year?
Establishing performance metrics for the HOMES Ophthalmology Clinic, Social Liaison Program, and our regular clinic
Producing published, peer-reviewed research to move forward the care of Houston’s unhoused population, and staying current with the expanding evidence base to improve our own practices
Proactive Community Engagement
Re-launching the Street Medicine program, bringing care directly to our catchment population in places they know
Expanding our digital presence and highlighting our work throughout social media
Donation drives to source socks, shoes, blankets, bug spray, sunscreen, cell phones, and cooler bags for insulin storage in the summer months
Taking HOMES “outside the clinic” via a public lecture series and skills workshops for our volunteers
Building partnerships with local institutions (e.g. University of Houston College of Medicine, University of Houston School of Social Work, and the Albert Schweitzer Fellows program) to create diversified patient services
Leveraging our unique platform to pursue “on the hill” advocacy with state and national legislators to affect large-scale change
This is an ambitious agenda, to be sure (16). But do our patients deserve anything less?
People like Angel continually redefine the word “resilience.” Her story is a living testament that medicine is social justice work. Therefore, our caregiving must rise to that occasion. We must dare to think big – while taking care not to fall into the trap of unreflective activism. We must also have a healthy dispassion, recognizing that the wheels of change turn slowly, without succumbing to the paralysis of cynicism. Somewhere in between those two fault lines lies the House of Yes. The road there is uncertain, but asking if basic services, accompaniment, and a vision of a world without homelessness can be reimagined as the status quo is the right place to start. At HOMES Clinic, “bridging the gap” in the era of Covid-19 can play a larger role in combating homelessness than we may have previously dared to imagine. And to fully honor the lives and stories of people like Angel, that is the “new normal” we must continually strive to find.
(15) By his own admission, phrase borrowed from Samuel Beckett’s Worstword Ho [15].
(16) To the reader who may remark, “too idealistic”: I am not purporting we will necessarily ever achieve a world without homelessness, but I do argue this must be our vision. Consider the Millennium Development Goals – one of the most ambitious projects of idealism ever enshrined in human history. Though objectively, most countries fell short of achieving the formal targets, evidence abounds that merely having these goals, unattainable as they were, measurably accelerated progress [16-17]. According to McArthur 2014, “Results suggest that much of the greatest structural progress has been achieved by countries not likely to achieve the formal MDG targets, even if their progress might be linked to the pursuit of those targets.” So, thinking big is not without its merits. I will ask once more: do our patients deserve anything less?
Acknowledgements
Dr. Dana Clark, Mary Fang, Thomas Gebert, William Lavercombe, James Fan, Evan Shegog, Susan De la Torre, and Dr. David Buck for their clear and substantive contributions to the mission of HOMES Clinic. Special acknowledgement again to the first two individuals and Dianne Wade and Vianna Quach for sharp and constructive feedback on this narrative. The Deans and administrators from all our partner organizations, who went above and beyond to help HOMES re-open and serve our community once again. Most of all our patients, like Angel, who give us the greatest gift of them all by allowing us to care for them.
Disclaimer
The views and opinions expressed herein are the author’s alone and do not necessarily express the official policy or position of Baylor College of Medicine or other affiliates of HOMES Clinic.
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