Providing quality medical care to people who are chronically homeless requires skills not often taught in med school. Their medical needs are often complex, with multiple co-morbidities exacerbated by the instability and hardship of life on the street. And it takes empathy and patience for a doctor to build trust with a person who is part of a vulnerable, marginalized population. But with persistence and good follow-up, health care providers can succeed in helping homeless people take better care of their health. Los Angeles Schweitzer Fellow Roee Astor knows these things firsthand.
Astor’s Fellowship project aims to improve follow-up care for homeless patients of the Whole Person Clinic at LAC+USC Medical Center Urgent Care using a one-on-one case management format, and by increasing the involvement of USC med students in coordinating homeless patient care with the hospital and other local service providers.
Astor, a third-year student at USC Keck School of Medicine, has been working with homeless people in Los Angeles in different capacities since 2010. First, as a USC undergrad he shadowed in the HIV Youth Clinic at the Department of Adolescent Medicine at Children’s Hospital, where he met many of the homeless youth of the Hollywood area. After that, he spent time interviewing homeless youth in Hollywood and Santa Monica for two separate research projects for USC School of Social Work, one of which was published in the Journal of Adolescent Health. Since starting med school, Astor has been required as part of USC’s Introduction to Clinical Medicine (ICM) course to conduct a weekly one-hour patient history and physical exam for randomly assigned patients at LAC+USC.
People who are homeless comprise a significant portion of the hospital’s patient population, and many of Astor’s patients were homeless. Astor grew concerned that after his hour with a patient was complete, because, although he felt he was improving his own history taking and physical exam skills, he wanted a clearer mechanism for him to do follow-up with the person as a medical student. These treatment gaps led Astor to develop his Fellowship project, and later to work with Curriculum leaders who have embraced and encouraged Astor’s suggestions along with second year medical student Linda Rangel
Now, Astor and Dr. Rebecca Trotzky-Sirr, his mentor and founder of the Whole Person Clinic, spend time calling the homeless patients with comorbidities that frequent LAC+USC’s Emergency Department (ED) to develop doctor-patient relationships and encourage them to return for primary care checks at the clinic.
“For instance, we are able to more closely monitor blood glucose in diabetic patients and have additional opportunities to work with drug abusers to take the next step toward reduced drug use or quitting,” says Astor. “This way, our patients often manage their diseases better and many have fewer serious health events.”
As an example, Astor cites the case of a young homeless patient who is diabetic, addicted to heroin, and has Hepatitis C. The patient is also a frequent visitor (more commonly known as a “frequent flyer”) to the ED, who is well-known to hospital staff. “Many of them almost laughed when Dr. Trotzky-Sirr told them she was calling this patient’s phone regularly to get her to come to our clinic for regular blood glucose checkups,” Astor recounts. “They were doubtful the effort would amount to a real change in our patient’s health or behavior.”
Ultimately, they persuaded the patient to receive regular primary care. Eventually, they helped her achieve a normal blood glucose reading and stabilized her usually dangerously labile diabetes. The patient’s progress reaffirmed Astor’s commitment to the program.
“It made a difference for her that day, that week, that month,” he says. “And just as the recovering addict must take one day at a time, I realized we need to face the struggle with our patients to help them manage their health and work in increments toward that goal. Before we demand that others exhibit profound self-discipline by quitting and improving lifestyle toward healthier living, we must exhibit this ethic ourselves and model it for the patients via our dedication to their better health.”
Astor points out that patients who can better manage their diseases make fewer visits to the ED―a more costly form of treatment than primary and preventive care―which means the follow-up program is cost-effective.
“Similar programs to ours elsewhere have shown improved outcomes for ‘frequent flyers,’ as well as large cost-reductions for hospitals,” says Astor. “We hope to do the same for our patients and our hospital so that more resources will be put into the program to expand and improve our homeless follow-up efforts.”
Astor and Dr. Trotzky-Sirr are also developing a protocol for students doing random weekly patient exams at LAC+USC through the ICM course to facilitate their ability to document and pass on the information they gather to the primary care team. Additionally, they’re working to implement changes to Keck’s curriculum aimed at training students to take a more active role in identifying social factors―like homelessness―that affect a patient’s health.
“We want to integrate our efforts into the medical school curriculum to train future physicians to be involved with the society in which they practice, to encourage active thinking, and to view their patient’s health issues as a culmination of historical, socioeconomic, environmental, mental, genetic, and individual lifestyle factors.”
Astor says he was surprised and inspired by the many existing efforts to improve conditions for L.A.’s homeless population that he discovered as he embarked on Fellowship project. “Dr. Trotzky-Sirr has made great strides by starting the Whole Person Clinic where our project is based,” says Astor. “My other mentors Dr. Jo Marie Reilly and Dr. Greg Harlan have been particularly encouraging and have helped coordinate our project’s integration with the medical school curriculum.” Astor also points to the work of Mel Tillekeratne, founder of Monday Night Mission, which feeds homeless people on Skid Row who were turned away from homeless shelters.
Then there are the members of his Fellowship cohort who are working on similar projects. “Marl Ayson and Heesoo Kim are two other Schweitzer Fellows, for instance, who have been working on a parallel project with homelessness follow-up on Skid Row with Dr. Paul Gregerson,” Astor notes. “Having the ability to compare experiences and work with each other on similar projects from different angles has been invaluable.”