Homeless, Not Hopeless
Houston nurses play a vital role in providing health care to a forgotten population.

By Janet Kilgore
March 14, 2005

Marion Scott, RN, MSN, is under no illusions. As director of the homeless health care program for the Harris County Hospital District (HCHD), she knows her limitations in getting people out of the cycle of poverty and despair. She can’t give them jobs or homes or provide them a daily hot meal. She even knows an occasional checkup isn’t enough.

“You can’t fix their health problems and leave them homeless and still think you’re making an impact in an individual’s life,” says Scott. “We help by making them more aware of their health problems, by managing their diseases. After they leave us, they have access to health care and the information they need for prevention.”

Scott and other nurses are providing all the help they can in providing a none-too-minor assist in keeping Houston’s forgotten population as healthy as possible.

The homeless health care program came about in response to the homelessness crisis of the 1980s, when EDs filled up with indigent patients seeking nonemergency care. Since 1988, Harris County’s program has been offering medical, dental, and psychiatric services, as well as health care education, to people who are homeless in Houston, primarily through federal grants and working with community agencies in Houston. “We were one of the first grantees,” says Scott, “and our solution was nontraditional.”

The program, as well as a separate city-run initiative, is unique in that patients don’t come to a centralized location for care. Instead, they get it within their local homeless shelter. The HCHD has set up clinics at 13 shelters, each staffed with its own medical personnel made up primarily of nurses, nurse practitioners, and nurse clinicians.

Getting to those who are homeless

People who are homeless are accustomed to waiting from eight to 24 hours to be seen in an emergency center, health care on their doorstep is a blessing. They also don’t have to deal with the barrier of transportation or worry about getting back to a shelter where bed space may be limited (some run out of room as early as 5 PM).

Going to traditional providers or the ED sometimes isn’t an option for people who are homeless. Some may be turned away from clinics or offices that won’t accept them, and sometimes the patient who is homeless makes the decision to stay away.

“That decision often is, ‘Do I spend this money going to the clinic, or do I use this money to eat tonight or pay for a bed?’” says Scott. “Most of the time, basic needs win out.”

Scott adds that some providers turn away people who can’t pay or whose hygiene isn’t optimal. People who are homeless might also be excluded if they don’t look like the typical patient population. Another consideration, she says, is that “the homeless don’t always understand the importance of health care and preventive services.”

That’s why one of the biggest features of the clinics are some of the freebies they offer. The clinics provide over-the-counter medications and some prescription drugs to patients. The staff also distributes deodorant, toothpaste, combs, and socks that provide incentives for patients to come to the clinics.

The work at homeless clinics differs from a traditional center’s function. The clinics are operated primarily by nurse practitioners, nurse clinicians, and physician assistants. They are all “operating on set protocols that tell them exactly what to do for specific symptoms,” says Nina Davis, RN, special project coordinator with the HCHD homeless health care program. “We have medical directors, but we don’t have an MD on staff at the sites every day. It takes a different management skill.”

In 2003, the shelter clinics handled 108,000 appointments with a budget of $2.6 million. Collaboration helps stretch every dollar. “And that’s 108,000 appointments that emergency rooms didn’t have to accommodate,” Scott adds. Davis says the homeless clinics’ own patient surveys indicate that four out of five clients would go to the ED if shelter clinics weren’t available.

Also helping out this vulnerable population is the city of Houston’s separately operated Healthcare for the Homeless program. Run in cooperation with about 30 regional agencies, eight area hospitals, and four local universities, the program treats about 4,000 patients a year who make a total of about 14,500 patient visits, according the program’s annual report. Infor­ mation from the program’s website indicates that its services began with a partnership between the Baylor College of Medicine and the SEARCH Homeless Project in Houston. This led to the formation of the Homeless Healthcare Council, which in 1999 formed a nonprofit corporation to oversee the city’s homeless health care program.

A unique community

As project coordinator, Davis monitors clinics’ performance to learn of or verify health issues in the homeless community and to keep an eye on communicable diseases for the county’s health department. One initiative, for instance, is to identify patients who test positive for tuberculosis and make sure they follow up with the county. “Many of our patients have just come from the penal system, and in the shelters you also live in close proximity,” Davis says. “We see a lot of positive TB tests, and we identify patients who tested positive in the past.”

Davis has also arranged resources to address issues like smoking cessation among those who are homeless, an easily forgotten malady compared to the day-to-day health dangers that may take priority. “I had [homeless] cancer survivors come out to talk about quitting,” Davis says, “and I got one of our physicians to sign prescriptions for the patch or the gum.”

Shelter clinics see ailments similar to those treated in any clinic in the country, according to Davis, but there are added problem areas for these patients that health care professionals must account for. “We do see a lot of hypertension, patients on medications who forget to take them for weeks or months, or their meds get stolen,” says Davis. “A patient might mention he’s been out of his diabetic medicine, and the nurse will send him to our community health program for further evaluation.”

Scott says the clinics are working to integrate more primary care and mental health services, with counselors who will deal with a variety of issues, including anger management. The fastest-growing group of people who are homeless are mothers and their children, forcing clinics to begin adopting more immunization and women’s health education. One of the clinics brought on board an LVN who provides special safety and hygiene classes for women with small children.

Patient satisfaction

Like nearly all health care providers, the clinics are concerned with outcomes and patient satisfaction. And in a sampling of some patient feedback, according to the HCHD, many do feel they’re getting the service and — most important — the respect they feel they deserve:

“Y’all are the best in the world.”

“The staff is very professional and helpful. The nurse did a good job.”

“More staff is needed for longer hours, but the clinic is doing fine.”

“The visit was handled, as usual, in a very courteous, friendly, and professional manner. Thank you for caring.”

“I was treated real good and they were nice and explained everything to me where I could understand. Thank you for the clinic.”

Like many in Houston, Davis knew almost nothing about the health problems of those who are homeless before she began working for the program. Since then, she’s seen patients who suffer from mental illness, some who’ve never been educated, and others who are homeless despite having college degrees.

“After I started going to the clinics and getting to know the individuals living on the streets, their mental condition, and how they lived, I was glad I got into that program,” says Davis. “I felt there had to be something we could do.”

Janet Kilgore is a freelance writer.