GPIN Members in the News
In the woods and the shadows, street medicine treats the nation’s homeless
November 22, 2017
Nurse Laura LaCroix was meeting with one of her many homeless patients in a downtown Dunkin’ Donuts when he mentioned that a buddy was lying in agony in the nearby woods.
“You should check on him,” said Pappy, as the older man is known. “But don’t worry, I put him on a tarp, so if he dies, you can just roll him into a hole.”
LaCroix called her boss, Brett Feldman, a physician assistant who heads the “street medicine” program at Lehigh Valley Health Network. He rushed out of a meeting, and together the two hiked into the woods. They found Jeff Gibson in a fetal position, vomiting green bile and crying out in pain from being punched in the stomach by another man days earlier.
Feldman told him he had to go to the hospital.
“Maybe tomorrow,” Gibson replied.
“Tomorrow you’ll be dead,” Feldman responded.
Months later, the 43-year-old Gibson is still in the woods, but this time showing off the six-inch scar — for a perforated intestine and peritonitis — that is evidence of surgical intervention. He greets Feldman warmly. “You’re the only person who could have gotten me to the hospital,” he says. “You’re the only person I trust.”
Pappy and Gibson are “rough sleepers,” part of a small army of homeless people across the country who cannot or will not stay in shelters and instead live outside. And LaCroix and Feldman are part of a burgeoning effort to locate and take care of them no matter where they are — whether under bridges, in alleyways or on door stoops.
“We believe that everybody matters,” Feldman says, “and that it’s our duty to go out and find them.”
Most of the time, members of his team provide basic primary care to people who live in dozens of encampments throughout eastern Pennsylvania’s Lehigh Valley. During their street rounds, they apply antibiotic ointment to cuts, wrap up sprains and treat chronic conditions such as blood pressure and diabetes.
But they also help people sign up for Medicaid, apply for Social Security disability benefits and find housing. Three or four times a month, they deal with individuals threatening to commit suicide. After heavy rains, they bail out “the Homeless Hilton,” a campsite under an old railroad tunnel that frequently floods — and where two rough sleepers once drowned. Many days, they simply listen to their patients, trying also to relieve emotional pain.
Street medicine was pioneered in this country in the 1980s and 1990s by homeless advocates Jim O’Connell in Boston and Jim Withers in Pittsburgh. Yet only in the past five years has it caught fire, with a few dozen programs becoming more than 60 nationwide. A recent conference on the topic in Allentown drew 500 doctors, nurses, medical students and others from 85 cities, including London, Prague and New Delhi. Most programs are started by nonprofit organizations or medical students.
Even as it comes of age, street medicine faces new challenges. A younger set of leaders is less interested in cultivating a bleeding-heart image than in establishing the approach as a legitimate way to deliver health care not only to the homeless — whose average life expectancy is about 50 — but also to other underserved people. Backers say street medicine should be considered a subspecialty, much like palliative care is, because of the unique circumstances of treating its target population.
Proponents also are pressing for much more financial support from hospitals, which can benefit greatly when homeless individuals receive care that helps keep them out of emergency rooms. Feldman’s program — which includes the street team, medical clinics in eight shelters and soup kitchens, and a hospital consultation service — has slashed unnecessary emergency room visits and admissions among its clientele. The result, to the surprise of Lehigh Valley Health Network officials, was a $3.7 million boost to the bottom line in fiscal 2017.
Perhaps the biggest issue facing street medicine, however, is figuring out how to provide more mental-health services. About one-third of homeless people are severely mentally ill, and two-thirds have substance-use disorders. Long waiting times for psychiatric evaluations delay needed medications and, in some cases, opportunities to get housing.
Psychiatrist Sheryl Fleisch is working on that problem. In 2014, she founded Vanderbilt University Medical Center’s street psychiatry program, one of a few such initiatives in the country. Every Wednesday morning, Fleisch and several medical residents visit camps in Nashville, handing out shirts, blankets — anything that can build trust.
Then they split up to talk one-on-one with people waiting on park benches, at bus stops and in fast-food restaurants, providing a week’s worth of prescriptions as needed. Fleisch says these homeless patients seldom miss an appointment.
Many “have been thrown out of other programs or are too anxious to go to regular office sessions,” she said. “We have some patients who will get up and sit down 15 times during our appointments. We don’t give up on them.”
On a muggy fall morning, Feldman’s team makes its way from the Hamilton Street Bridge in downtown Allentown to a swath of mosquito-infested woods between the railroad tracks and the Lehigh River. A few blocks away, an extensive redevelopment project, complete with a luxury hotel and arena for the minor-league Phantoms hockey team, is revitalizing parts of the long-depressed area.
Bob Rapp Jr., who has worked extensively with homeless veterans and knows the location of many campsites, is the advance man. “Good morning! Street medicine!” he calls out.
Feldman carries a backpack full of medicines. LaCroix uses her “Mary Poppins bag” to try to coax people out of their tents: “We’ve got supplies — socks, toilet paper, tampons!”
A thin woman with striking blue eyes pops out of a tiny tent, pulling at her wildly askew blonde hair as she glances in a mirror propped against a tree. Her toenails are painted gold. A Phillies cap and a Dean Koontz book, “Innocence,” sit on one of her two chairs.
“Tampons!” exclaims the woman, who identifies herself only as Duckie. “I just turned 60. I don’t think I need tampons!” She hugs LaCroix, with whom she bonded after the nurse helped her get new clothes and emergency treatment for a virulent, highly contagious skin infestation called Norwegian scabies.
Feldman kneels in front of Duckie with his stethoscope to check her lungs; the last time he saw her, the longtime smoker had bronchitis. No breathing problems this time, but Feldman tells her he wants a psychiatric evaluation. If the doctor confirms that she has bipolar disorder, depression or post-traumatic stress disorder — all diagnoses Duckie says she has heard over the years — she will be able to get the drugs she needs and perhaps transitional housing.
“I self-medicate,” she shrugs. But she likes the idea of moving inside with winter coming.
“It stinks out here,” she says. “It’s cold. I have to watch out for rats and raccoons and people.” She agrees to see a psychiatrist — a volunteer who comes out once a month — at her tent the following week.
Later in the day, the team goes to see a favorite patient. When the group approaches his plastic-covered hut in the woods, Mark Mathews frantically orders them to stop. “I don’t want to be caught with my pants down!” he yells from within.
Moments later, khakis on, the 57-year-old emerges. The son of a successful Allentown actor, the grey-bearded Mathews spent years playing Santa Claus in malls. He also worked for a high school theater department and in the 1980s was part of a local cable comedy show, “Sturdy Beggars.”
He became homeless after having a falling out with his sister four years ago. “The money ran out, and I couldn’t get another job,” he says.
LaCroix takes his blood pressure. The reading is high, something Mathews blames on not having taken his blood-pressure medicine that morning. The team will be back in two days to do a recheck, which is fine with him. “I enjoy their company,” he says.
Once, LaCroix carried a mattress across an old railroad trestle and up a steep hill to deliver it to his hut. Like other patients out here, Mathews has the team’s cellphone numbers. He frequently texts LaCroix to tell her jokes or alert her to someone’s possible health problem.
Mathews is sure his life has purpose. “I try to help other people,” he says. “I lend people phones if they don’t have them. I help them get to their appointments. I should be nominated for sainthood.”
About 550,000 people in the United States were homeless in 2016 on a given night — according to the most recent estimate by the Department of Housing and Urban Development — and about a third of them were sleeping outside, in abandoned houses or in other “unsheltered” places not meant for human habitation. In Santa Barbara, Calif., so many people live in their cars that the local street medicine team provides care in automobiles.
Federal and regional estimates for the number of homeless people in the Lehigh Valley — which includes the cities of Allentown, Bethlehem and Easton — range from more than 700 to almost twice that number. But that’s likely a big undercount.
A research study of people who sought care at three area emergency rooms during the summer of 2015 and the following winter identified 7 percent as homeless. Feldman, who led the study, said the finding suggested that more than 9,200 of the health system’s emergency room patients were homeless sometime during the year — in communities with no permanent emergency beds for couples and fewer than two dozen for women.
The LVHN Street Medicine program, which he founded, takes care of about 1,500 people a year. Since 2015, it has pursued its mission relentlessly, taking laptops into the woods to get homeless patients insured, usually through Medicaid; today, 74 percent have coverage. Over the same period, emergency room visits by the program’s patients have fallen by about three-quarters and admissions by roughly two-thirds.
It has taken Feldman years to get to this point. In high school, he began lifting weights after getting into a car accident and fracturing three vertebrae. In 2000, as a freshman at Pennsylvania State University, he won the National Physique Committee teen championship.
“It gave me laser focus, but I was the only person who was helped,” he said. “It was very unfulfilling, and I decided that whatever I did after that would be different.”
His close collaborator is his wife, Corinne Feldman, a physician assistant who is an assistant professor at DeSales University. When they first moved to the Lehigh Valley in 2005, the couple wanted to work with the homeless but couldn’t find them — until realizing they were in campsites in the woods. These days, one encampment is even in the shadow of a defunct Bethlehem Steel facility.
The Feldmans started by setting up free clinics in shelters where they worked without pay. But a 2013 Boston conference on street medicine sharpened their focus. They would go to wherever the homeless were.
“We thought, ‘This is all we want to do with our lives,’ ” he recounted.
By then a physician assistant at Lehigh Valley Hospital, Brett Feldman got a grant from a local philanthropy, the Dorothy Rider Pool Health Care Trust, that allowed him to do street medicine one day a week. Over time, he received more grants, as well as backing from the health system to set up a full-time street medicine program. It launched in 2014.
There have been numerous disappointments and heartbreaks: Two patients at an encampment in Bethlehem froze to death. A man with third-degree burns from sleeping on a heating vent fled rather than have his badly infected lower leg amputated. And before the psychiatrist could come out, Duckie disappeared.
At the same time, there have been poignant victories. When a 50-year-old man, living in a drainage pipe, was given a diagnosis of advanced colon cancer, he declined treatment but eventually was able to move into an apartment, where the street-medicine team provided him palliative care. When his symptoms worsened and Feldman said it was time to go to hospice, the man replied, “First, I have to clean up the apartment because the landlord was so nice.”
The team helped him do the cleaning and then took him to hospice, where he died a peaceful death.
“Most of our folks think they will die alone, that their future is canceled,” Feldman says. “Bringing hope is more important than any medicine.”
Fresh Food By Prescription: This Health Care Firm Is Trimming Costs — And Waistlines
May 8, 2017
The advice to eat a healthy diet is not new. Back around 400 B.C., Hippocrates, the Greek doctor, had this missive: Let food be thy medicine.
But as a society, we've got a long way to go. About one out of every two deaths from heart disease, stroke and Type 2 diabetes in the U.S. is linked to a poor diet. That's about 1,000 deaths a day.
There are lots of places to lay the blame. Calories are cheap, and indulgent foods full of salt, sugar and fat are usually within our reach 24/7.
So, how best to turn this around? Consider Tom Shicowich's story. It begins with a toe. His left pinky toe.
"One day I looked down and it was a different color ... kind of blue," Shicowich says. And he began to feel sick. "I thought I was coming down with the flu."
The next day he was on the operating table. A surgeon amputated his toe, and it took two weeks of intravenous antibiotics to fend off the infection.
All told, he spent a month in the hospital and a rehab facility. "Oh, I tell you, it was a bad year," Shicowich recalls.
But this wasn't just bad luck. His toe emergency was somewhat predictable. Foot infections are a common complication of Type 2 diabetes — often due to nerve damage and poor blood flow, especially when the disease isn't well controlled.
He racked up about $200,000 in medical charges from his toe emergency. The portion he had to pay out-of-pocket drained his savings account. "I did shell out $23,000 to the hospital, so that was a kick in the head," Shicowich tells us.
It was also a wake-up call.
Shicowich was more than 100 pounds overweight. He was was fighting nerve damage, high blood pressure and kidney problems — all complications of diabetes.
"So I knew it was time for a change," he told me. And last year, he found the help — and the motivation — he was looking for: a new food pharmacy program that has helped him overhaul how he eats.
Welcome to the food pharmacy
"Folks, good morning, and welcome to the ribbon cutting and opening of the Fresh Food Pharmacy," intoned Sam Balukoff, the master of ceremonies at Geisinger Health System's recent debut of a new food pharmacy located on the grounds of a hospital in central Pennsylvania.
At this event, Shicowich was one of the stars of the show. Over the last year, he and about 180 patients with Type 2 diabetes have been participating in a pilot program aimed at getting them to to change their diets and lose weight. They receive free groceries of healthy foods every week.
Shicowich has lost about 45 pounds, and he's now much more active.
Each week, Shicowich and the other participants come to the food pharmacy. In its new incarnation, it looks more like a grocery, with neatly stocked shelves filled with healthy staples such as whole grain pasta and beans. The refrigerators are full of fresh produce, greens, low-fat dairy, lean meats and fish.
The participants meet one-on-one with a registered dietitian. They're given recipes and hands-on instruction on how to prepare healthy meals. Then, they go home with a very different kind of prescription: five days' worth of free, fresh food.
Shicowich says it's a huge change from his old habit. "I would stop at a Burger King or a McDonald's or buy a frozen Hungry-Man dinner, basic bachelor food, you know, heat and eat."
But those days are over. Now, he and his girlfriend cook meals at home. He says now it's much easier to climb a flight of stairs or take a walk with his girlfriend.
Shicowich's health has improved. His blood sugar and blood pressure have dropped so much that if he keeps on track, his doctors say they'll reduce his medications.
"It's life-changing," David Feinberg, the president and CEO of Geisinger Health System, says of the results they've seen.
He says, so far, all the patients in the pilot program have made similar improvements. "It's mind-blowing," he says. And he says the range of support patients are offered — everything from dietary counseling to wellness classes and workshops — can help them succeed.
Take, for instance, the significant declines in patients' hemoglobin A1C levels. This is a blood test used to track how well patients with diabetes are controlling their blood sugar.
A year ago, Shicovich's A1C was close to 11. Now it's down in the high-6 range. Anything under 6.5 is considered below the threshold of Type 2 diabetes, according to the Mayo Clinic. Feinberg says this means that Shicowich — and other participants in the program — have a much better chance of avoiding many complications of Type 2 diabetes if they can maintain their A1C levels down in this range.
"[They] won't go blind, [they] won't have kidney disease, amputations," Feinberg says. "The list goes on and on."
Cheaper than paying for complications
When this program started, some questioned the premise of giving away free, fresh food to patients with diabetes. But keep in mind, the costs associated with diabetes in the U.S. now exceed $240 billion a year.
Once you consider that price tag, Geisinger's program can look like a bargain. Over the course of a year, the company will spend about $1,000 on each Fresh Food Pharmacy patient. All of the participants in the program are low-income, so the gift of the food eliminated a key obstacle to eating well.
But would this lead to a reduction in health care costs?
Feinberg says as his team tracks hemoglobin AIC levels in the pilot participants, they're also assessing the number of medical visits, sicknesses and the overall cost of caring for these patients.
It's still early days, and they plan to fully analyze their first year of data. But here's what they estimate so far: "A decrease in hemoglobin A1C of one point saves us [about] $8,000," Feinberg says.
And many of the participants have seen a decline in hemoglobin A1C of about three points. "So that's [about] $24,000 we're saving in health care costs," Feinberg says. "It's a really good value." Geisinger is now in the process of expanding the program to new locations within Pennsylvania.
Is prevention medicine the future?
This program is an example of the booming interest in prevention-oriented medicine.
The current health care system in the U.S. is often more aptly described as a disease-care system. "It's reactive," says Mitesh Patel, a physician and assistant professor of health-care management at The Wharton School at the University of Pennsylvania. "We wait until people get sick and then spend lot of resources helping them get better."
But Patel says there are signs this is beginning to change. "I think the paradigm shift has already begun," he told us. Patel's take on Geisinger's new Fresh Food Pharmacy program: It includes the kind of financial and social incentives that can help motivate people to make changes.
For instance, the Fresh Food Pharmacy gives free, fresh food not just to the patients enrolled but to everyone in their household as well.
"The way we behave is really influenced by others around us," says Patel. So, promoting a group effort could "make the program a lot more sticky and more likely to succeed."
It's always a challenge to get people to maintain lifestyle changes over the long term. But, Patel says, "If you get the entire family to change the way they eat, you're much more likely to improve health."
The evidence that lifestyle-modification programs can reduce health care costs is starting to accumulate.
Earlier this year, researchers published findings in the journal Health Affairs that evaluated the medical expenses of Medicare patients with prediabetes. The patients had completed a one-year diabetes prevention program focused on healthy eating and increased physical activity. The researchers found, overall, the average health-care savings was about $300 per person, per quarter — compared with patients who hadn't been through the program.