There’s no such thing as bed rest when you don’t have a bed. And there’s no preventive care when your doctor’s office is the emergency room.
People who are homeless struggle with several intractable problems when it comes to accessing health care: lack of preventive care, fragmented care from a patchwork of sources, and logistical problems that come with being homeless.
One Arizona organization is working to find a solution.
Student Health Outreach for Wellness (SHOW) is a student-run clinic that treats the underserved and homeless population in downtown Phoenix.
According to SHOW Director of Operations, Mary Saxon, the clinic tries to be a “one-stop shop.”
Fragmented care can lead to conflicting diagnoses and prescriptions so the clinic works to provide holistic care to people who usually are unable to find treatment for all their medical issues in one place, she said.
“Our patients will come in and they’ve seen so many doctors, so they’ve had so many different prescriptions, and some of them are the same prescription at different doses,” said Saxon. “So it’s really hard for them to adhere because they’ve been told so many different things.”
Finding consistent preventive care is complicated by an array of problems that often accompany homelessness: lack of identification, medical records and transportation along with unstable mental health and inconsistent access to phones — making it hard to keep and track appointments.
This leads people to go to an emergency room, an urgent care or call 911 for medical issues that either could have been prevented or treated before they became life-threatening, according to Bonnie Ervin, an Arizona State University social work professor who works with the SHOW clinic.
“Emergency departments, unfortunately, bear a lot of the weight of providing care for homeless people,” Ervin said.
The group’s primary way of reaching patients is a Saturday morning clinic, which sees about a dozen patients each week.
When a person needing services comes in, a volunteer “navigator” pairs up with the client, talks to him or her one-on-one about their needs, and then presents the information to a team of students and professionals from different disciplines who then decide on a treatment plan.
Unlike many student-run health service organizations, SHOW is directed primarily by undergraduates, something clinic leaders consider a huge plus because undergraduates can stay with the program for longer, are more numerous and often have more time to dedicate to the program.
Saxon says the SHOW clinic has had some undergraduate students who have gone on to medical school and then volunteered again as medical students or licensed health professionals.
The three Arizona State University student leaders in charge of the clinic are Saxon, Christy Thomas and Faiz Khan. All three said working with SHOW has affected their future plans.
“Slowly I became more and more invested in what SHOW’s mission was and what SHOW had to offer,” said Khan, a junior. “It really opened my eyes and showed me that anyone can go through this and anyone can get out of it.”
SHOW’s partnership with Health Care for the Homeless, the non-profit that owns the facility where it offers services at the intersection of Third and Taylor streets, allows for more cohesive care. The two organizations share medical records and often treat the same individuals.
The partnership allows patients to receive care at the same facility six days a week, with Health Care for the Homeless handling weekdays and SHOW carrying out the weekend extension. Together, they also work to provide preventative care.
“[Patients] might not even come in for, say, a foot issue, but it’s brought up in the visit and it’s treated right there,” said Saxon. “So I think it’s just kind of treating the patient for all their needs in one sitting rather than having to go to a bunch of different places, being referred.”
This approach has special impact when working with homeless populations.
“There’s not a lot of public funding for routine preventative maintenance for that population,” said Amanda Davisson, a unit supervisor at the Arizona Department of Child Safety who has been a social worker for 10 years. “They just live crisis to crisis.”
Although SHOW strives to address barriers that arise, some of the problems they face are inherent to working with a homeless population.
While she said that SHOW is “absolutely in the right direction,” Davisson still has questions.
“We need regular preventative care, but how do we do that with people that don’t have a regular residence or ability to maintain records, or maybe don’t even have an ID?”
“The solution to homeless health care is end homelessness,” Davisson said.
Robyn Leach, who has lived on the streets in Phoenix for more than a decade, said that clinics for the homeless are often similar to “walking into an urgent care.” One reason for that is the transitory nature of people who are homeless.
“I really think they’re doing everything they can do,” Leach said.
Ervin, the ASU social work professor who works with SHOW, said frequently the treatment option they want to recommend can be difficult or impossible for patients to implement. For example, Ervin said, imagine recovering from heart surgery and being released to live on the streets.
One SHOW client needed a daily foot bath, but she was not allowed by to bring a basin for her feet into the homeless shelter where she was staying, Ervin said.
“We’re trying offer them the same treatment option we’d offer anyone, but we have to look outside the box,” she said.
While SHOW is a relatively new student-run clinic, others in the United States have been around for decades. One such clinic is the University of Nebraska SHARING clinic, founded in 1997 by medical students and two faculty members.
Like SHOW, the clinic provides primary care for “underserved individuals,” according to Alexandra Schelble, a University of Nebraska Medical Center medical student.
The group has also opened a clinic that sees patients for STD/HIV testing, and another to treat Type 2 diabetes.
Schelble estimates that almost all UNMC medical students volunteer at one of the clinics and that in their 20 years, the clinics have served 12,000 patients.
SHOW, in contrast, has served 620 between August 2015 and March 2017, according to data collected by the clinic from their most recent cumulative tallies.
However, unlike SHOW, the SHARING clinic does not primarily serve homeless populations.
“The majority are not homeless,” said Nicholas Lambert, the public relations chair. “Our sole criteria is being ‘indigent’ and being uninsured.”
The clinic defines indigent as having an income 138 percent of the federal poverty line.
SHOW officials say they are comfortable with the number of clients it is serving.
Leaders say that they “hit their cap” quickly due to the nearly two years they spent preparing to open the clinic. Although the clinic began seeing patients in 2015, the group was actually founded in 2013.
“I think 10 to 12 patients [each Saturday] is about our sweet spot,” said Christy Thomas, SHOW’s director of development.
That number is dictated by the number of licensed professional volunteers, the amount of space in the clinic and the availability of student volunteers who can serve as “navigators” for patients.
They have served between 120 and 150 people each semester the clinic has been open, with the exception of summer attendance, which is under 100, according to data from SHOW.
Although in fall of 2016 they served 30 percent more clients than the previous spring semester, that’s not SHOW’s goal said the clinic’s leaders.
Leaders said at one point in fall of 2016 they actually tried to “slow down” the clinic due to fears that quality of care was suffering.
“It’s almost kind of selfish to want our numbers to rise [for the sake of research projects] when we’re not providing the same quality of care,” said Thomas.
One area where the patient numbers have shown growth is the annual health fair, which doesn’t face the same restrictions on space and weekly volunteers. The 2014 health fair was SHOW’s first event, taking place before weekly clinics were open to the public. Although there is no attendance count for that year, they say the clinic drew around 50 volunteers.
This year, the number of volunteers at the October health fair grew to more than 200.
The number of patients served increased 30 percent between 2015 and 2017, to a total of 234 people who received services that ranged from blood pressure checks and skin cancer screenings to foot washing stations and legal advice, according to data from SHOW. Clients also can receive free, clean socks and shoes and items such as sunglasses and hats.
“We’re expanding in different directions,” Thomas said.
One of those directions is increasing preventive-care and health-information programming on topics such as smoking cessation, mental health and dental hygiene.
That type of programming experienced about 10 percent growth from fall 2016 to fall 2017, and that’s before the final numbers have been tallied for this semester. More than 200 people have attended so far in fall of 2017, according to data from SHOW.
One of the most popular services is foot care, which is offered at the health fair and is also one of the weekly programming events.
Their last weekend foot clinic, which took place in October, drew 80 clients — almost three times the average attendance for programming events, according to numbers from SHOW.
“Feet are often times really neglected by people,” said Khan. “It’s one of the last things that we care after, it’s one of the last things we look at, and having them cared for by someone else is a nice feeling.”
Students who work with SHOW say the approach is both helpful to clients and deeply satisfying for them.“Hearing stories is what makes me want to keep coming back,” said Audra Emmersen, an Arizona State University junior who volunteers as a navigator. “You can find volunteer work anywhere, but this is unique.”
Contact the reporter at Anya.Magnuson@asu.edu.