Nurse practitioner

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

Pre-existing barriers for patients

• 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

Effect of COVID-19

• 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

Effect of Shift to Virtual Healthcare

• 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

Providing Healthcare

• 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

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

Partnerships

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

Co-design

• 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