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Living on the streets

University initiatives improve health care for Minnesota’s homeless—challenging assumptions along the way

It’s a Monday evening, and the Phillips Neighborhood Clinic is busy as usual.

The clinic, which opened its doors in 2003, is housed in the basement of Oliver Presbyterian Church, located in one of Minneapolis’s poorest neighborhoods. One night a week it offers health care at reduced or no charge to uninsured patients, a significant number of them homeless.

But there’s no feeling of deprivation here. A pair of Native American toddlers races down the brightly lit halls calling and laughing. Meanwhile, in a room that during the day serves as a preschool nursery, a lively group of University of Minnesota students chat as they prepare to see patients.

The students are here because the Phillips Neighborhood Clinic (PNC) isn’t just a clinic—it’s an innovative educational facility staffed by social-work interns and first- and second-year students in medicine, nursing, pharmacy, and physical therapy. Under the guidance of faculty preceptors, the students not only manage patient care—they also manage the clinic itself. It’s an invaluable hands-on experience in the day-to-day realities of clinical care.

“As a medical student, I have courses in other disciplines, like nursing and physical therapy, but this is a robust opportunity to work in a multidisciplinary setting very early in my career,” says Kristen Kleven, a second-year student who volunteers at the clinic and cochairs PNC’s administrative board. 

“PNC is unique in that it’s student run, so we look at operations, patient flow, and what can be done to improve care,” Kleven says. “Working here, we can already see how teamwork affects patient care and how communication and coordination between disciplines affect outcomes.”

The Phillips Neighborhood Clinic is just one public face of numerous University research and clinical initiatives aimed at helping underserved populations, including the state’s growing number of homeless people, which today is estimated at about 20,000 individuals, up from 15,000 in the mid-’90s.

Offering HOPE

On the University’s Duluth campus, medical students and faculty are working on plans to establish their own PNC-like clinic for their city’s homeless adults.

Although the HOPE clinic—for Health of People Everywhere—is in its earliest stage of development, Duluth students are already hard at work laying the groundwork for the facility. Last year, Amanda Noska and Tria Lor, then second-year medical students, began looking at potential sites, developing a mission statement, doing community assessments, and exploring just how such a facility would help local residents. Another pair of second-year students, Hope Pogemiller and Tessa Pierson, continues that work this year.

“We are in the infancy of exploring a student-run facility that would be supervised by faculty here at the University,” explains Ruth Westra, D.O., M.P.H., chair of the University’s Department of Family Medicine and Community Health, Duluth.

Like the Phillips Neighborhood Clinic, the Duluth site would be open one night a week for two or three hours at a time and staffed by student volunteers from a range of disciplines. Currently, Duluth faculty and students are collaborating with Central Hillside United Ministry (CHUM), a homeless shelter in Duluth where second-year medical students are taking blood pressure and giving health talks to help create a presence in the adult homeless community.

While the students are providing an important community service, they clearly benefit as well, says Westra. “There’s a big learning curve when it comes to caring for an underserved population and finding out their needs rather than coming in with preconceived notions,” she says. “The HOPE clinic will provide our students with an opportunity to learn not only about this particular group of people but also about how the health-care professions work together to provide treatment.”

Dignity at life’s end

Other University initiatives are charting new territory in caring for homeless populations, and the National Institutes of Health (NIH) is taking notice.

John Song, M.D., M.P.H., a faculty member in the University’s Center for Bioethics and cofounder of the Phillips Neighborhood Clinic, has a longtime interest in helping homeless people. Today, Song is about to embark on a new three-year, NIH-funded study that will combine research with clinical intervention to see whether homeless people will create living wills and whether those wills have a positive effect on their end-of-life care.

“We want to see not only if homeless people will fill out living wills but also whether they will do so at a higher rate if they have some counseling,” Song explains. Ultimately, the study’s goal is also to discover whether the existence of advance directives will help the homeless preserve personal autonomy over the treatment they receive at the end of life.

To conduct the study, Song and his research team, including bioethics center colleagues Dianne Bartels, R.N., Ph.D., and Edward Ratner, M.D., will work with Minneapolis homeless shelters, health-care agencies, outreach programs, and soup kitchens—eight organizations in all. It will begin with baseline surveys of homeless patrons to establish attitudes toward end-of-life care. Half of the group surveyed will be provided with living will forms and information about how to fill them out. The other half will in addition be offered advance directive counseling by staff members at Heartland Hospice and Hospice of the Twin Cities.

“We’d like to see if there is any difference between the two groups because of the intensive intervention,” says Song. “We expect that the group that receives counseling will be more likely to make a living will, but we don’t know that at this point. If this turns out to be the case,” he says, “shelters might be encouraged to offer advance planning counseling to their clients.” Song says he is also interested in other changes the counseling might elicit. “We expect some psychosocial outcomes [among our subjects], like reconnecting with families and friends because of this.”

In its final stage, the study will examine local hospital records to discover whether study participants have been admitted for end-of-life care and, if so, whether their living wills were accessed and had an impact on treatment.

Trying to improve end-of-life care for a population struggling to survive day-to-day may seem counterintuitive at first, but the new study builds on research showing that issues surrounding death and dying are a major concern among the homeless. In a way, that should come as no surprise. Nationally, the average life expectancy of a homeless individual is 40 years. Many, if not most, homeless people have experienced the death of friends living on the streets and have many fears about how they themselves will be treated both at the end of their lives and after they have died.

A study by Song, Bartels, and Ratner published early in 2007 was the first to canvass these concerns in a systematic way. The study, “Dying on the Streets: homeless persons’ concerns and desires about end of life care,” asked homeless clients at a half dozen facilities in the Twin Cities to describe a good death and asked such questions as, “What kinds of services would you say would be needed so that homeless people might die in comfort and dignity?”

The answers elicited by these queries often surprised the researchers.

“Homeless persons’ level of sophistication and understanding of end-of-life concerns and the threats they face living in the streets was a revelation to me,” admits Bartels, whose background is in nursing and family social science. “Because death is so pervasive in their everyday life, they know what they do and don’t want. A number have already appointed someone to serve as their advocate. You’d think that if they didn’t know where they were going to sleep tonight, they probably wouldn’t have a living will—but some do.”

Over and over again, the homeless individuals interviewed for the study emphasized two things: They wanted to die with dignity if possible—no machines keeping them alive—and they wanted their bodies tended to and their lives commemorated in some way after they are gone.

Those who died homeless in Minnesota last year were remembered during a silent vigil and march December 20 in downtown Minneapolis. Photos: Stephen Geffre

With this research in hand, Song’s team convened a conference and invited homeless individuals, service providers for the homeless, end-of-life care experts, and representatives from the Medical Examiner’s office to ask what they thought would be an effective intervention study. “They came up with the same recommendation we did,” says Song: “living wills.”

“Homeless people tend not only to be sicker than the rest of us but also to suffer the greatest disparities in health care, with poor access to treatment and even poorer outcomes,” Song observes. “Advance directives may be their one practical means of preserving their voice when they no longer are able to speak for themselves.”

The tools to quit smoking

Kolawole Okuyemi, M.D., M.P.H., associate professor in the Department of Family Medicine and Community Health on the University’s Twin Cities campus, is also challenging assumptions about homeless populations.

“There’s a general feeling that quitting smoking should not be a priority for homeless people and that, in fact, it’s an okay way of dealing with the stress of homelessness,” Okuyemi observes. “There’s also a presumption that because of competing demands for food and shelter, the homeless are in no position to quit smoking.”

Okuyemi, who came to the University in 2006 to create and direct the Medical School’s Program in Health Disparities Research, is out to prove both assumptions wrong. Not only is smoking a top health concern for homeless people, but a pilot research program he conducted at the University of Kansas has already shown that homeless people want to quit smoking and can, if given the tools to do so.

Although trauma of one kind or another—accidents and homicides—ranks much higher as a cause of death among the homeless than among the general population, the reality is that, just like everyone else, homeless people are most likely to die of chronic illness—cancer, cardiovascular disease, diabetes, and AIDS. Smoking, of course, is a major contributor to at least two of those illnesses. Meanwhile, smoking among the homeless is much more common than among the general population. An estimated 70 percent of this country’s 4 million homeless smoke cigarettes, as opposed to 25 percent of the population at large, and homeless smokers on average consume more cigarettes per day than other smokers.

“Smoking is perhaps the leading preventable cause of disease among the homeless,” Okuyemi says. “And part of the tragedy of this tobacco use is that these are the people who can least afford it.”

In the Kansas pilot program, Okuyemi’s team conducted six focus groups with 62 homeless individuals to find out why they smoked, whether they wanted to quit, and what kind of program they would like, and be willing, to participate in. His methodology was informed by one of his fundamental principles of working with underserved communities: to conduct research with these communities and not on them by enrolling participants in studies as collaborators rather than as passive subjects for study. Okuyemi used findings from the focus groups to design a pilot intervention with a six-month follow-up. Although the sample size was relatively small—50 participants—the results were highly encouraging.

“Contrary to expectations, the people who agreed to be part of the program showed up for their appointments, and about 70 percent of those enrolled finished the program—the same completion rate as that for the general population,” Okuyemi says. By study’s end, the success rate—the proportion who quit smoking—among homeless participants was identical to that of the general population.

“It was mind-boggling,” Okuyemi says.

Now he’s using those results to launch a major research study/intervention to see whether they hold true with more subjects over a longer time period. He’s confident that they will. So is the NIH, which recently awarded Okuyemi and his research team a four-year, $2.8 million grant to find out.

The new study will be based in Twin Cities homeless shelters. Already several organizations that serve the homeless, including the Dorothy Day Center, Listening House, People Serving People, and Healthcare for the Homeless, have signed on to the project. Okuyemi is planning to enroll some 400 homeless individuals in the study, which differs from the pilot project because, in addition to offering a traditional smoking-cessation program that includes the use of nicotine patches, it will provide participants with motivational interviewing counseling, which Okuyemi calls “a special kind of counseling that encourages individuals’ inner motivation to drive their decision-making.”

Of his new research, he says, “This is the first full-scale study of its type anywhere in the world. If, as we are hoping, about 20 to 25 percent of the participants quit smoking long-term, the policy implications are significant. It would serve as a model for shelters and agencies around the country to offer programs to their homeless clients who are interested in quitting smoking.”

By Richard Broderick

Photos By Scott Streble

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