Unmet needs: Bringing physical rehabilitation to people experiencing homelessness

A huddle of people are gathered around a doorway in downtown Pittsburgh, arriving to claim a bed before the shelter fills up for the evening. This shelter is temporary, with staff contracted by the county to operate in the basement of a church during the cold winter months. Although seasonal, this shelter has been a fixture in the city for the past 25 years. Hand-painted murals trace the stairwell walls leading down to the church basement, revealing a gymnasium floor lined with plastic mattresses. The quiet gymnasium will soon be filled with the voices of people of all walks of life and situations that have led to homelessness. Among the chatter of people outside waiting in line to enter the shelter, one woman sits on the curb away from the group with her head in her hands. Angela, 34 years old, became homeless 3 years ago when she was fleeing domestic violence. She escaped an environment in which she experienced emotional and physical abuse resulting in multiple traumatic brain injuries (TBI) and posttraumatic stress disorder. People with disabilities were recently designated as a population experiencing health disparities, 8 years after Krahn et al. raised awareness of the unrecognized disparity.1, 2 Within this vulnerable population, the impact of disability on navigating basic and instrumental activities of daily living (ADL) in the absence of adequate support, adds increased risk to an individual's health and safety. People with disabilities are at significantly greater risk of homelessness, and people experiencing homelessness (PEH) have significantly higher rates of disability compared to the general population.3, 4 The exacerbated risk of poor health outcomes at the intersection of disability and homelessness warrants effort to address the unmet rehabilitation needs for PEH. This disparity is further elevated for individuals of intersecting marginalized groups such as racial and ethnic minorities, sexual orientation, and gender identity.5-8 According to the U.S. Department of Housing and Urban Development Point-in-Time (PIT) count, an annual count of the homeless population on a single night, an estimated 582,462 people experience homelessness in the United States9, 10; 30% of the individuals surveyed experienced repeated or extended periods of homelessness combined with a physical, cognitive, or mental health disability, which is categorized as “chronic homelessness.”9 Variation in definition and methodology of counting physical disability in the homeless population limits the consistency of detail captured in current PIT counts and homelessness research. Current PIT counts and homelessness research focus on chronic health conditions, diseases, and functional impairments, but no body of research discretely addresses characterizing disability in the homeless population that would benefit from rehabilitative services.11-19 TBI is particularly important to address in homelessness services. Over half of PEH have had TBI—four times the prevalence in the general population.20 PEH with TBIs have an increased likelihood of unmet health care needs, emergency department use, and contact with the criminal justice system.21 Daily life challenges are exacerbated in homeless shelter settings when people with cognitive impairments are not taken seriously, risk being exploited, and have their symptoms overlooked or misattributed to noncooperative behavior or alcohol misuse.22 The health risks, functional challenges, and inequity faced when experiencing homelessness with a brain injury make TBI awareness, screening, and treatment necessary to improve outcomes. Tonight, Angela has a headache, worsened by the loud volume of a crowded shelter. These headaches are frequent, along with near constant fatigue, stress, hypervigilance, and memory issues. Angela's symptoms started after her second brain injury 3 years ago. She was briefly unconscious after she was hit and went to the emergency department but was told her injury was mild and sent home. She has not had any treatment for the physical, cognitive, or emotional impairments experienced following her brain injuries. Access to rehabilitative services is often absent or insufficient for PEH.23 For those who do access rehabilitation services, it is through a patchwork across settings including postacute care, respite care, community-based rehabilitation, federally qualified health centers, and street medicine. Postacute rehabilitation settings focus on restoration of function following stabilization in an acute hospital stay and include physical, occupational, and speech therapy in inpatient rehabilitation and skilled nursing facilities. However, rehabilitation facility admission rejection due to homelessness has not been considered discrimination due to lack of status as a protected group.24 Even for PEH who do access postacute rehabilitation, their discharge to the street in more strenuous environments without caregivers poses a need for higher level of function at discharge than the general population. Medical respite programs exist for PEH who are too sick to return to a shelter or street setting following hospitalization, but rehabilitation services are rare in respite settings.25 Despite updated standards of medical respite programs to “administer high quality postacute care” to PEH, disability recommendations solely mention physical accessibility of facilities and applications for disability benefits. Guidelines do not provide specific recommendations of rehabilitation to address disabilities nor outline rehabilitation staffing to care for people with functional impairments.26 Underrepresented among medical respite programs, rehabilitation staff are reflected with only six occupational therapists, or 4.48% of respite staff nationwide.27 Many respite admission criteria require people to be independent with all basic ADLs and complete all transfers independently. Patients are often rejected from medical respite due to rehabilitation needs being deferred to inpatient rehabilitation or skilled nursing facilities, yet these same people are rejected from these rehabilitation settings due to bias and the challenges of admission criteria that require a safe discharge. Unable to access either respite or skilled rehabilitation, these patients with higher levels of needs end up unsafely discharged to a street or shelter. Emerging efforts exist to increase access to rehabilitation services in homeless shelters and supported housing due to unmet rehabilitation needs in these community settings.23 Oosman and colleagues28 demonstrated that integration of rehabilitation services such as physical therapy into supported housing improves access, health, function, and wellness of people by removing barriers to care such as transportation, cost, and wait times. FQHCs are federally funded nonprofit health centers that serve underserved and marginalized populations regardless of ability to pay, often including PEH.29 Current rehabilitation care for PEH with TBI includes increased screening, environmental modifications, personnel training, and occupational therapy (OT) for strategy training in shelter and respite settings.30, 31 Training providers (behavioral health/housing support teams) in a FQHC allow them to identify many more PEH with TBI in the clinic and provide additional therapies and tools.32 Although awareness of TBI in PEH has increased broadly, there is yet to be a subsequent robust connection to rehabilitative and mental health services to meet these increased care needs. Street medicine is a mobile model to bring health care directly to PEH where they are located on streets and in encampments instead of in traditional medical offices or community-based clinics. Street medicine as it is now known has been documented in practice since 1992 in Pittsburgh and Boston.33-35 In 2008, the Street Medicine Institute was established to promote street medicine globally.36 A scoping review of street medicine programs found common elements across programs to include (1) direct medical care, (2) wraparound health services (eg, referrals, hospital consultation, medical respite), (3) harm reduction services, (4) psychosocial case management, (5) provision of life necessities, and (6) education/research/advocacy.37 Evidence has demonstrated that street medicine improved PEH engagement with health care services, increased well-being and placement into housing, and saved approximately $9000 per patient, annually, in health care costs.38, 39 Despite these cost savings, most street medicine programs have been supported by grant funding and government contracts. There has been an absence of funding mechanisms to support the long-term sustainability of these programs.40 However, effective October 2023, the Centers for Medicare and Medicaid Services created a new place of service code “outreach site, street” to enable providers to bill insurance for street medicine, facilitating an additional stream of funding to support programs nationally.41 Even within street medicine, PEH continue to have unmet health care needs, worsened in those with a higher burden of chronic disease, history of sexual assault, and serious mental illness.42 These unmet needs often arise from logistical challenges of homelessness, resulting in lost medications, missed appointments, and forced displacement by city officials, a practice that includes breaking down and moving people in encampments and can lead to increased illness, interrupted continuity of care, and increased mortality.43, 44 Beyond the benefits to health equity and housing outcomes, working in homeless health care programs such as street medicine is incredibly rewarding for clinicians. The deep patient-clinician relationships and trust building necessary for street medicine build compassionate, healing experiences for both patients who have had negative health care experiences and providers burnt out from working in large systems.45, 46 Street medicine eases the power dynamics of health care by restoring the focus on using skills to support others on a human level. The street medicine team has gotten to know Angela over time with regular outreach visits providing basic needs and building a trusting relationship. The team includes a primary care physician, physiatrist, neuropsychologist, occupational therapist, and students of medicine and pharmacy, reflecting the team's university-based interprofessional collaboration. When the team approaches her sitting on the curb, she discloses her chronic headaches and traumatic brain injuries. This street medicine team works with her to schedule outpatient appointments in the physical medicine and rehabilitation (PM&R) and neurobehavioral health clinics for the following week. However, on the day of the scheduled appointments, Angela does not attend or answer phone calls. A few weeks later, the street medicine team finds Angela in an encampment that formed upon the seasonal closure of the winter shelter. She recounts to the team that she could not get to the clinic because her phone and ID were stolen. She is now staying outside and asks for a sleeping bag and some clean clothes. She has been on the county housing waitlist for 14 months and plans to meet with her housing coordinator soon. For PEH, efforts to access health care (eg, attending a scheduled medical appointment) are often at odds with the need to prioritize meeting their basic needs such as food, shelter, and safety.47 Disability further compounds the challenges for PEH, affecting emotional and physical health, and creates barriers to housing. Homeless adults often spend most of their day occupied with the task of meeting basic needs, making the complex task of navigating health care systems a lower priority than day-to-day survival. There are many barriers to engagement, such as attending an outpatient rehabilitation appointment, including competing priorities (eg, pursuit of food, shelter), transportation challenges, cognitive impairment limiting executive function necessary to get to the scheduled appointment, misunderstanding of the purpose of rehabilitative services, previous unpleasant health care experiences, and lack of space to complete home therapy programs.48 Although many people create adaptive strategies to manage disability on the street, the psychosocial impact of facing the injustice of homelessness can cause increased challenge to their health, and disabilities can exacerbate emotional distress. Feelings of despair, fear, anger, and powerlessness interact with the experience of chronic disease and homelessness.49 Poor sleeping environments exacerbate symptoms such as fatigue and pain. People with mental health comorbidities with their physical disabilities have additional cognitive and emotional challenges to managing their conditions including anxiety, decreased motivation, impulsivity, difficulty planning, and fatigue. When disability is unaddressed, it hinders people's ability to obtain and maintain housing. People with physical, mental health, and cognitive disabilities are at higher risk for homelessness and experience increased difficulty exiting homelessness due to disability.4, 50 For TBI, there is both a cause and effect with homelessness: the functional impairments from TBI make finding and retaining housing difficult, and risk of TBI occurrence increases with length of time homeless.51 Angela did not want to miss her appointments. That morning, she was in the public library using a computer to access housing paperwork. Frustrated with the difficulty she was experiencing using the computer, she got up to find a librarian for help, forgetting her backpack on the floor. When she returned to the computer, her bag was stolen along with her phone and ID. Angela searched frantically for her backpack. The cumulative effect of experiencing theft, self-blame for not grabbing her bag, frustration over her memory impairment, and emotional dysregulation built into a panic attack. As a result, staff removed her from the library for disrupting others. Overwhelmed, Angela knew she had an appointment sometime in the afternoon but was unable to recall where, what time, or how to get there. With county case manager phone calls required to stay on housing waitlists, her phone took top priority over health care appointments, and she spent the remainder of the day working to track down her belongings to no avail. Realizing that Angela's cognitive symptoms and competing priorities of homelessness make attending appointments unfeasible, the street medicine team meets her needs by bringing the services to her. She gets a new phone for free through federal programs and the team uses both phone and email to coordinate meeting times and locations that fit in her daily life. Despite its proven effectiveness in primary medical care, rehabilitation services are rarely included in the street medicine programs for PEH. The limited literature incorporating rehabilitation into street medicine is in the context of interprofessional student learning.52 Given the barriers to providing rehabilitation services to PEH across traditional settings, outreach to real-life environments via street medicine is a necessary strategy to remedy the disparity in access to rehabilitation services. Street-based care can reach people who need rehabilitation the most and have been excluded from accessing care through other “traditional care models.” Delivering rehabilitation care on the street or in encampments comes with the challenges typically seen in street medicine. Follow-up with patients can be difficult when patients have inconsistent access to communication devices, no permanent address, and ever-changing daily schedules to meet survival demands.53 The nature of street medicine in public settings makes privacy during therapy sessions challenging. Equipment and supplies for assessment and treatment are limited to what clinicians can carry. On the other hand, the real-life setting of street medicine elicits a pragmatic approach that aligns with the aims of rehabilitation. We can observe how a patient functions in their everyday environment, complete with the people, natural elements, and sensory and physical demands that affect task performance. PM&R, with a focus on interdisciplinary teams and patient-centered and goal-driven care, is uniquely prepared to care for this complex population. Common clinical concerns seen on the street closely align with PM&R training: chronic pain, arthritis, back pain, mononeuropathies, brachial plexopathy, spinal cord injuries, traumatic brain injuries, burns, amputations, and wounds. In a scoping review of street medicine program elements, 66% of programs have multidisciplinary teams of physicians, nurses, social work, and peer specialists.37 However, PM&R physicians are yet to be identified as a key part of street medicine programs in the literature and by the Street Medicine Institute.37, 48, 54, 55 Although street medicine facilitates direct care to patients, the transition to a home environment has the potential to further improve health outcomes. Occupational therapists are distinctly positioned to facilitate a sustainable transition from unsheltered living to permanent housing. OT housing programs with personalized modules on ADLs and health management can double the number of patients that transition to housing in 6 months.56 OT interventions can improve quality of life and coping skills, through engagement in meaningful activities protective against factors that drive substance misuse or relapse.57 More recent research demonstrates improvements in ADL function and mental health of formerly homeless adults that undergo the Community Aging in Place—Advancing Better Living for Elders (CAPABLE) model working with an OT, nurse, and handyperson to maximize accessibility in permanent supportive housing.58 OT has demonstrated efficacy in housing and health outcomes for PEH in shelter and housing settings but is still emerging in street medicine programs. Lloyd and Bassett59 call for greater outreach-based rehabilitation particularly for OT services and describes the key role OT plays on assertive community outreach teams. The community outreach-based OT program for PEH in Pittsburgh is among the few in the nation to deliver OT services in encampments, shelters, and housing placements. Instead of rescheduling the outpatient clinic appointments, the physiatrist and neuropsychologist meet with Angela in the shelter to complete further neuropsychological testing. The test results increase insight into specific cognitive domains most affected by her deficits, but it is distressing for her to realize the extent of her impairments. The physiatrist makes a referral for Angela to get Botox injections for her headaches. She is also referred to be visited by the community outreach-based occupational therapist, who collaborates with her to set goals for her daily life. Angela sets goals to maintain a schedule including calling her housing case manager regularly, navigate to health care appointments such as her Botox injections, keep track of her belongings, and develop coping skills to stay emotionally regulated during tasks in public places. The occupational therapist visits weekly for metacognitive strategy training in Angela's real life, her to create a daily a to keep track of her navigate public and develop coping skills to the 4 Angela has increased to manage her belongings, and She uses fatigue and management strategies in OT to and Angela has been staying in contact with her housing case manager and a phone call to of an in a The street medicine team with her the transition to her and maintain the housing is a out of injustice and over any one individual's or Disability with homelessness as both a risk and as an of the challenges to obtain and maintain housing. The high unmet rehabilitation needs of PEH be by rehabilitation as a key part of homeless health care, in street medicine outreach to the most vulnerable of the population. can current challenges in traditional homeless health care and human services, such as PM&R care and OT to improve daily life function in the transition to permanent housing. As street medicine programs across the rehabilitation providers are to and to homeless health care services.