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Khan wants patients to feel more comfortable having serious health complications addressed in the hospital... "There’s a lot of misinformation floating around regarding the treatment of opioid use disorder and how to provide opioid replacement therapy. So providers will either not know the rules or regulations or protocols, or patients will think there are regulations and protocols in place to stop them.” |
We'd like to be more formal connections between health care institutions and people on the street, so that we're able to prevent diseases from manifesting because people (don't) follow up or are never seen," said Waggerman |
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The Street Medicine program... has reduced 30-day readmission rates to Lehigh Valley Hospital from 51 percent to 13 percent.. [and has raised] the rate of insured homeless from 24 percent to 73 percent |
For many drug addicts, street medicine, also called "reality-based medicine," is the only way to get healthcare. The number of programs like Chicago Street Medicine have grown so widespread across the world that it has its own International Street Medicine Symposium |
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For hospital both private and public, recuperative care also has the potential to lower overall costs and decease the rate of hospital readmissions. Health officials estimate that each day in a bad at LA County's safety-net hospital costs the county more than $3,000, while a bed at a recuperative care facility averages about $150 per day |
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The only difference between the homeless women I regularly hear from and the women who are now coming forward and having their stories believed is that when homeless women speak, no one listens... women experiencing homelessness already live at the margins of society. in the margins of society, in the margins of the MeToo Movement, and in the margins of our minds. At the very least, we must see and acknowledge their reality |
"MILLION DOLLAR MURRAY"
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"MR. G AND THE REVOLVING DOOR"
"A patient with complex needs returns to the hospital again and again, despite his care team's efforts to reduce readmissions"
~Carolyn Dickens, Denise Weitzel, and Stephen Brown Read more... |
"Opportunity starts at home. our advocacy starts now."
"Articulate the goal and the broad strategy for achieving it...identify and work with all parties affected...set specific objectives...organize all the related interests in support of those objectives."
Read more... |
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What is the Issue? There is currently no protocol for the assessment of capacity when practicing Street Medicine. Ethical Considerations: Street Medicine organizations work to address the health and social service concerns of the unsheltered homeless by engaging individuals in their spaces of residence and gathering. This population consists of marginalized and vulnerable individuals, who despite living with more chronic illness than the general population, are less likely to utilize primary care or outpatient care services. Additionally, this group is disproportionately affected by mental illness and substance use disorders. As such, caring for these patients and assessing capacity can be very complex. Persons experiencing homelessness, especially those with mental health disorders, are generally assumed to have diminished capacity, thus making them increasingly vulnerable to exploitation and manipulation.4 Therefore, it is important to facilitate trust and to only escalate care against protest when medically appropriate. |
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Assessing Capacity on the Streets (2018)
Our Aim:
Many studies have highlighted the increased complexity of assessing decision-making capacity among individuals experiencing homelessness. However, no official protocols have been developed to address the complex needs of the population to ensure that appropriate medical care is given in a respectful manner. As such, our aim is to propose a streamlined protocol which could be used by street medicine practitioners to enhance the ability of providers to assess capacity and thus deliver higher quality health care.
Existing Protocols:
Chicago EMS Protocol
When an adult patient who is alert, oriented, and able to communicate refuses care or transportation, it is the responsibility of the EMS provider to advise the patient of his/her medical condition and explain the necessity for care or transport. If the patient continues to express steadfast refusal, online medical control should be contacted while on scene, and all events should be documented.
Alternatively, if the patient demonstrates behavior and/or has a medical condition that impairs decision making capacity, EMS should continue treatment and transport in the best interest of patient. Patient capacity may be impaired in trauma, intoxication, hypoxia, dementia, and psychiatric or behavioral emergencies, including suicidality and inability to care for self.
Inpatient Protocol
Clinicians often have to assess for capacity while treating patients in an inpatient setting. The main principles guiding capacity assessment include obtaining informed consent prior to initiating treatment and ensuring that patients are able to make informed decisions for themselves. There are many tools to assess mental capacity including the Mini Mental Status Exam and MacArthur Competence Assessment Tool for Treatment. To demonstrate capacity, patients and clinicians must work together to establish that patients can:
Many studies have highlighted the increased complexity of assessing decision-making capacity among individuals experiencing homelessness. However, no official protocols have been developed to address the complex needs of the population to ensure that appropriate medical care is given in a respectful manner. As such, our aim is to propose a streamlined protocol which could be used by street medicine practitioners to enhance the ability of providers to assess capacity and thus deliver higher quality health care.
Existing Protocols:
Chicago EMS Protocol
When an adult patient who is alert, oriented, and able to communicate refuses care or transportation, it is the responsibility of the EMS provider to advise the patient of his/her medical condition and explain the necessity for care or transport. If the patient continues to express steadfast refusal, online medical control should be contacted while on scene, and all events should be documented.
Alternatively, if the patient demonstrates behavior and/or has a medical condition that impairs decision making capacity, EMS should continue treatment and transport in the best interest of patient. Patient capacity may be impaired in trauma, intoxication, hypoxia, dementia, and psychiatric or behavioral emergencies, including suicidality and inability to care for self.
Inpatient Protocol
Clinicians often have to assess for capacity while treating patients in an inpatient setting. The main principles guiding capacity assessment include obtaining informed consent prior to initiating treatment and ensuring that patients are able to make informed decisions for themselves. There are many tools to assess mental capacity including the Mini Mental Status Exam and MacArthur Competence Assessment Tool for Treatment. To demonstrate capacity, patients and clinicians must work together to establish that patients can:
- Clearly communicate their understanding of their medical condition
- Clearly communicate the available treatment options
- Clearly communicate the result of not receiving treatment
- Clearly communicate their choice of treatment (or refusal of treatment)
Medication assisted Detoxification in the Emergency Department (MAD-ED): A Policy Proposal for Safety Net Hospitals (2018)
What is the issue?
There is currently no protocol for initiating Medication-Assisted Detox in the Emergency Department (MAD-ED) in safety-net hospitals in Chicago
Why is this is an issue?
Patients suffering from opioid-use disorder have very complex medical needs that are not currently being addressed. Chronic drug users utilize 30% more emergency healthcare services than the general population and are at higher risk for hospitalization, but due to fears of withdrawal and stigmatization, these patients frequently delay care and leave AMA far more often than the general population. This leads to increased costs for their care and increased morbidity and mortality after hospitalization.
There is currently no protocol for initiating Medication-Assisted Detox in the Emergency Department (MAD-ED) in safety-net hospitals in Chicago
Why is this is an issue?
Patients suffering from opioid-use disorder have very complex medical needs that are not currently being addressed. Chronic drug users utilize 30% more emergency healthcare services than the general population and are at higher risk for hospitalization, but due to fears of withdrawal and stigmatization, these patients frequently delay care and leave AMA far more often than the general population. This leads to increased costs for their care and increased morbidity and mortality after hospitalization.
Details from: D’Onofrio, G, et al. “Emergency Department-Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial.” JAMA, vol. 313, no. 6, 2015.
Key Further Reading
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Data to support
When compared to Screening and Referral (with or without Brief Interventions), initiating medication assisted treatment in the emergency department was significantly more effective in:
Establish a Medication Assisted Detox in the Emergency Department (MAD-ED) in Chicago’s safety-net hospitals 
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Association of Medicine and Psychiatry, 2018 Annual Meeting
International Street Medicine Symposium, 2019 Annual Meeting
