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Background

nurse practitioner who works with individuals experiencing homelessness, or are street involved
primarily works from a pop-up, on-site, temporary clinic
- program created to help people unable to access traditional forms of healthcare
- close to where patients were so it was a familiar and comfortable setting
providing care similar to an urgent care centre
- wounds, infections, pneumonia
clinics ran evenings and weekends on a predictable schedule
- weekends and evenings so that patients don't lose their bed or spot at the shelter
provide a non-judgmental space and reduce barriers to primary care
patients can be existing patients or newcomers - a mixed bag

Difficulty in making appointments
Feeling stigmitized or unwelcome in healthcare settings
Unable to get to places to get healthcare, or specialist appointments
Time and place is a big barrier
Food security, no place to sleep, unsafe environment - personal health becomes a lower priority and difficult to manage

clinic was not available for 1.5 months as the pandemic / shutdown happened
during this time, noticed a decline in health of patients
- many patients did not have access to phone and internet
  - prescription refills weren't done
  - health conditions not cared for
encampments have increased as a result of the pandemic, although access use of the shelter ("congregate housing") system
change to the way the program ran may have caused a drop-off in usage
- highlights importance of trust and predictability

Many patients lack phones or internet access (hence phone numbers and email addresses)
- keeping track of passwords or login information would be a barrier
Shift to virtual care has caused a lot of problems
Virtual care can work for the population of interest, just needs more creativity in how it's implemented
Home clinic has two virtual healthcare rooms for appointments
- this can be a barrier as some do not want to be in a formal clinic setting
- requires a nurse / worker /staff to help patient set up the VH appointment
Very few shelters have facilities for virtual healthcare visits
- knows of only 2
Virtual health could work, but would take time to build trust
- computer literacy may be another issue
Combination of virtual healthcare and onsite service could work, but only if it isn't a burden
- might be a good way to offer other services such as counselling or therapy – this is all currently virtual and is inaccessible to patients
For the practitioner, the shift to VH has been an issue
- newness of technology
- technology literacy and familiarity
- privacy concerns
- workflow issues (lack of a predictable appointment process - more ad-hoc)
- preference for in-person practice
People in home clinic seem okay providing VH services and the outcomes seem to be good

people come to the pop-up clinic without prior appointments
- mostly acute episodic visits, occasionally some are scheduled
- support workers onsite to help - help with relationship building and harm reduction
rarely opportunity to provide follow-up as many patients don't have phones (although some do have phones)
- only way to follow-up is if they come to a clinic again on another occasion.
more major issues are sometimes surfaced during more minor meetings
- unsupported / undiagnosed conditions can come out during conversation
many patients have other conditions such as substance abuse, mental health
- shift toward harm reduction such as providing clean kits, naloxone
- hoping to have opiate agonists and safe supplies in the new year
access to specialists is currently only available through virtual and in the home clinic
- the person also needs to be willing to come to the home clinic (and not everyone is comfortable with that)
clinic sites are predictable and accessible
- given out using flyers - same stop every week
- With COVID, this has been more difficult as people have moved around
- location can be set up outside a shelter so it provides an easy opportunity for people to drop in
Not all patients have health cards or ID, may use an alias
- have funding to help provide some small diagnostics and tests for patients without health cards
Replacing health cards that are lost or stolen is part of the case worker's role

health literacy is all over the map
try to capture the same people over time to improve chances of health information is understood

partner with other organizations who have case managers - help people get appointments, phones, housing, etc.
less formal partnerships with shelters and drop-ins

Pamphlets, community boards, signs are good ways to get information out
Connect with case managers at organizations who know the individuals better
- trust is an issue - best to go through an org.
offering something back would be a good way to encourage people to get involved
- gift certificates for groceries and food
- supplies and clothes