How telehealth is connecting the unhoused to care in SC

Housing instability encompasses various challenges related to housing, including difficulties paying rent, overcrowding and being periodically or permanently unhoused. Itis a critical social determinant of health, impacting physical and mental health and the ability to seek and receive healthcare services.

Patient populations who are unhoused face significant hurdles to care access, a higher risk of disease and death, and poorer health outcomes because of this social determinant of health. As a result, health systems must develop creative ways to connect with these groups.

For Medical University of South Carolina (MUSC Health), the approach took the form of a hybrid in-person and virtual care program that reduces barriers to care for the unhoused in Charleston, South Carolina.

"We intend to increase health equity for the unhoused population by providing primary care and preventive care in a space of trust," said Cristin Adams, DO, family medicine physician and associate professor at MUSC Health. "So [we're] going to where people are staying, breaking down transportation barriers and really providing the same care that anyone would be given if they were housed."

Launched in 2018, the CARES for the Unhoused program has grown to about 500 visits with 250 patients a year. In an interview with Virtual Healthcare, Adams described the program, how it has evolved since its inception and crucial insights gleaned from a recent evaluation.

WHAT IS THE CARES FOR THE UNHOUSED PROGRAM?

The CARES for the Unhoused program has three components: in-person visits at a community-based organization (CBO), video visits at a CBO and street medicine outreach with CBO staff.

Initially, the program only included an hour of telehealth availability at partner CBOs where unhoused individuals seek social services, Adams said.

There are a lot of barriers to medical adherence for everyone, but especially for the unhoused population. A lot of times folks are labeled as non-compliant...So, being able to meet people where they are, take care of them in their space, on their terms, and in partnership with people that are helping them to achieve their social needs as well is mutually beneficial and that it makes it more flexible for the medical provider, but also much more attainable for the patient.

But today, with financial support from the HHS and Health Resources and Services Administration (HRSA), the program has evolved to include a resident physician seeing patients in person at a CBO and telehealth services that connect the physician and their patients to attending physicians. The program's clinical team also provides street medicine services, caring for patients outside the CBO and supporting community outreach workers in the field via telehealth. 

"So, for example, the medical team could be out with community outreach workers, physically seeing patients where they're staying under bridges in parks, that sort of thing," Adams said. "Or the community outreach worker might be going out. They might find someone with a medical need, and then they would coordinate a telehealth visit with us."

The clinical team includes pharmacy and nursing students and medical residents from family medicine or internal medicine. If patients require specialty care, the clinical team works with community partners to ensure they have health insurance and then helps them set up a specialist appointment, Adams noted.

WHAT DID STAKEHOLDER INTERVIEWS REVEAL?

To ensure the program is expanding care access for the unhoused, MUSC clinicians and researchers conducted stakeholder interviews guided by the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework and recently published their findings in Frontiers in Public Health.

The MUSC research team interviewed 19 program stakeholders, including patients and CBO staff, between January and May 2024. Though the research is government-funded, Adams underscored that the views expressed do not reflect the official views of the funders or the U.S. government. 

The evaluation largely affirmed the program's positive impact. The researchers found that patients appreciated the program, specifically citing provider reliability, care and concern, and the ease with which they could receive care without the burden of travel.

Adams noted that telehealth has enabled that degree of flexibility, which is essential to extending care to unhoused populations.

"There are a lot of barriers to medical adherence for everyone, but especially for the unhoused population," she said. "A lot of times folks are labeled as non-compliant...So, being able to meet people where they are, take care of them in their space, on their terms, and in partnership with people that are helping them to achieve their social needs as well is mutually beneficial and that it makes it more flexible for the medical provider, but also much more attainable for the patient."

In the interviews, CBO staff also described the program's myriad benefits, including the convenience it affords in offering essential healthcare for unhoused individuals and the comfort they can receive.

"We got a lot of really positive feedback across stakeholders," Adams said. "A lot of what we are trying to achieve seems like we are achieving it."

The interviews not only verified the program's benefits but also allowed researchers to identify themes for implementing and maintaining a hybrid care program for unhoused individuals.

One critical factor for successful program deployment is ongoing coordination with social services. Unhoused individuals' medical needs may go overlooked in favor of other, more pressing needs, like their next meal, Adams explained. Establishing and maintaining a close partnership with social service agencies in the community is critical to providing wraparound services, including healthcare, for these individuals.

Additionally, Adams highlighted the importance of being open to hearing each individual's goals for their health.

"Do not impose your own agenda on them and really be a person that is there to help them achieve their own goals," she said. "And that's important no matter who you're taking care of, but I think it's particularly salient in a population that does not interact in a traditional way with the medical system."

Further, the evaluation helped researchers determine and address care gaps within the program.

For instance, MUSC has added new members to its care team, including a dedicated community health worker to oversee the coordination efforts, which have expanded to include emergency medical services and the Charleston County Sheriff's Department. The program is also working to add dental and point-of-care testing services.

The highlight of this evaluation for Adams was also giving the unhoused a voice in how the program operates.

"We get a lot of anecdotal feedback along the way, but I think all of us in the program are researchers and scientists at heart," Adams explained. "So it's always important to make sure that the sort of feeling that you're getting, that things are going well, or maybe the suggestions that you've gotten are not just those that are being voiced by the people with the loudest voice -- that it's truly an opinion and a thought that's held by all of the stakeholders in a particular program."

Caring for the unhoused population requires unique care delivery models. As MUSC and other health systems continue to tweak and enhance those outreach models, it is becoming increasingly clear that telehealth will play a key role in connecting individuals to care no matter their housing situation.

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.