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VA Docs Discovering Life on the Street

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Three doctors stand on a street corner in an old part of town

Street medicine: health care and related services that are delivered directly to persons sleeping on the streets, along the river banks, and in the abandoned buildings

by Tom Cramer, VA staff writer
Thursday, March 28, 2013

You’ve heard of street smarts? Street magic? Sesame Street? Now add ‘street medicine’ to the list, thanks to a new VA program that is sending teams of health care providers into the streets — literally — to find and help an invisible army of sick, discouraged Veterans who spend their nights under bridges, on park benches, or on the sidewalk.

It’s All About the Team

The technical term for this growing movement within the Department of Veterans Affairs is ‘H-PACT,’ which stands for Homeless Patient Aligned Care Teams. Currently VA has 31 of these teams across the country that are providing health care and other services to over 5,000 homeless Veterans. And counting.

“Our goal is to help homeless Veterans engage in care without a lot of the bureaucratic challenges,” explained Dr. Tom O’Toole, director of VA’s National Homeless Veterans PACT Program. “We want to provide the care they need, where they are, and when they need it. We also strive to provide those ‘wraparound’ services including mental health, social supports, benefits, and housing assistance — all with the intent of helping get them into permanent housing and stay there.”

Heading up one of VA’s 31 Homeless Patient Aligned Care Teams is Simha Reddy, a doctor at the VA Medical Center in Seattle. Rounding out Reddy’s ‘H-PACT’ team is a VA registered nurse and a social worker.

 So many of these guys are hard to find because they’ve become disengaged. These are the guys who are the most vulnerable. 

Going Where the Patients Are

“There are about 250 Vets that we see on a regular basis,” Reddy said. “We try to provide these homeless Veterans with the medical and psychiatric care they need to help them move beyond their current situation. We help them with their medical issues, mental health issues, housing issues…whatever it is they’re dealing with.”

Reddy, 32, said he and his team perform outreach at three or more sites each week. In addition to a clinic every morning at the main hospital, they visit Veterans in homeless shelters, ‘day centers’ (also called drop-in centers or hygiene centers where the homeless can shower, do laundry, or get something to eat) or any other location where tired, hungry people are likely to be found.

“When you go out into the community, seek these people out and treat them, they don’t need to rely on the emergency room as much,” Reddy observed. “Meanwhile, overwhelmed emergency rooms have less walk-ins to cope with. So everybody wins.”

Highly in Need

Dr. Reddy said the Veterans he treats on the street tend to be considerably sicker than the average person, with medical needs 50 percent more complex than the typical Seattle patient.

“We’re trying to take care of the ‘high needs’ Veteran,” Reddy explained. “These are the Veterans who have difficulty managing a chronic illness, the Vet who needs intensive outpatient care, the Vet who comes to the emergency room a lot. These are people with diabetes, liver failure, heart failure…people who need a lot of attention. The goal is to get them stabilized, help them avoid long waits at the ER, let them know they have a team watching over them.”

“Our primary goal at these drop-in centers and hygiene centers is to make ourselves visible and accessible,” the physician explained. “We want to reach our hand out to Vets who otherwise might not regard VA as an option.”

Easier said than done, in many cases, since Veterans not enrolled in any kind of health care system tend to be the most withdrawn, and distrustful.

“The most important thing we can do is to create relationships with these Vets,” Reddy said. “We’re trying to figure out how to meet people where they’re at, both physically and emotionally. We’re not always successful, but we try. We just want to create an atmosphere where people feel welcome…where they feel they can come to us for help with their medical troubles. We try to give them some support.”

He continued: “A lot of times these Veterans will tell me, ‘Right now I’m just in survival mode.’ Our goal is to make them feel comfortable enough to start thinking ahead so they don’t need to function in survival mode anymore. We want them to start thinking about their future.”

 I just pick up my black bag and go see people. It’s like 1950 again, only my black bag has a laptop in it. 

Off the Radar Screen

“We come across a lot of people who’ve just dropped off the radar screen,” said Brian Hopps, a registered nurse and member of Reddy’s H-PACT. “These are the people you can only find when you physically go out into the community. A lot of them aren’t going to show up at the VA medical center way up on the hill. You have to come down from the hill, you have to go out and find these Veterans…you have to go where they live.

“Until you start doing this work, you really have no idea how many homeless Vets there are out there,” he continued. “Homeless Vets with dementia, homeless Vets with multiple sclerosis, homeless vets with cancer…”

Hopps said the key to helping these forgotten Veterans is forming relationships with them.

“I met an elderly Veteran on the verge of losing his transitional housing and being back out on the street,” Hopps said. “He was in the early stages of developing dementia, and was very limited physically. He couldn’t take his medication on his own, and it would take him 30 minutes just to change his socks.

“Because I spent a lot of time with him I was able to ascertain just how incapacitated he really was. You can’t ascertain these things with only superficial contact with a person…you need to spend time with them. We ended up finding a place for him at the Soldier’s Home, where they’re taking care of him. He’s much happier there than at the shelter.”

Building Trust

Social Worker Megan Krampitz, the third member of Seattle’s H-PACT, agreed that getting to know someone is critical to providing them with quality care.

“There’s a Vet in his 70s, and he’s been homeless for years,” Krampitz said. “He’s blind in one eye, and he’s losing his vision in the other. He has all this crazy white hair, and this huge smile, but only one tooth. He’s so endearing when he smiles. He’s tiny and he’s frail…you don’t realize how small he is because he has all these layers of clothing on.

“When we found him,” she continued, “he was living in a shelter. His Social Security checks had stopped coming. So we got his Social checks coming again…we got him into transitional housing…we got him enrolled in VA health care…we got him connected with the blind rehab folks at our medical center. For now, he’s in a safe place.”

More detailed information on all of VA’s Programs for Homeless Veterans can be found at www.va.gov/homeless. If you or a Veteran you know are at risk of homelessness, contact VA’s National Call Center for Homeless Veterans at 1-877-4AID-VET (1-877-424-3838) to speak to a trained VA responder.