UnsCripted Medicine
UnsCripted Medicine
Street Medicine Part 2: Cincinnati Initiatives
What does it take to provide healthcare on the streets? This episode follow up on our previous episode with Dr. Jim Withers, founder of the Street Medicine Institute. Join us as we explore the local initiatives of street medicine in Cincinnati with Keirsten White, Dr. Joseph Kiesler, Valerie Dowell, and Dr. Alexis Kimmel. Hear Valerie's moving journey to become a community health navigator and gain insights from Dr. Kimmel on addressing healthcare disparities for the unhoused in the emergency department. Finally, Dr. Kiesler discusses the intricate process of building trust with the homeless community and the importance of a consistent, multidisciplinary approach to care. Learn about the real-life obstacles faced by street medicine practitioners and how you can get involved.
Welcome to Season 5 of the Unscripted Medicine Podcast, a podcast created and produced by medical students at the University of Cincinnati College of Medicine. On the show we explore ideas in medicine you can't always find in a textbook From navigating medical education to exploring humanism in medicine and developing our physician identities we hope there's something for everyone.
Speaker 2:Check out the show notes or our website for more information, helpful links, resources and more. Please connect with us via email, on Instagram or on Twitter at unscripted underscore med. We would love to hear from you, we hope you enjoy. Welcome back to the Unscripted Medicine Podcast. Everybody, this is Andrew. I'm your host for today and this is kind of a continuation episode of a previous episode. Kirsten and I recorded Kirsten's one of my classmates. She's here with us. Do you mind saying hi, Kirsten?
Speaker 2:Hi yeah, we did a previous episode with Dr Jim Withers, who's the founder of the Street Medicine Institute, who talked about kind of the philosophy behind street medicine and the ethos that underlies the Street Medicine Institute, and so we have with us today some local advocates for street medicine and excited to hear about street medicine in Cincinnati and what kind of local efforts are going on to kind of carry on those ethos and the philosophy that Dr Jim Weathers set for us. So I have three guests with us in addition to Kirsten today Dr Joseph Kiesler, who most of our listeners probably know he's a faculty member at University of Cincinnati College of Medicine, and I have Valerie Dowell and Dr Kimmel. I'll let each of you introduce yourselves. We'll start with Dr Kiesler.
Speaker 3:Hello everybody. So yeah, joe Kiesler in the Department of Family and Community Medicine and I also serve as the Medical Director of NeighborHub Health, which is the healthcare for the homeless program. So I've been working with them probably the past 12 years or so, and so happy to be here.
Speaker 2:Yeah, thanks for coming on, valerie.
Speaker 4:Hello, I'm Valerie Dow, community health navigator for Neighborhood Health. I work primarily with individuals who are HIV positive and homeless.
Speaker 5:My name is Dr Alexis Kimmel. I am a social emergency medicine fellow at the University of Cincinnati in the Department of Emergency Medicine and recently started working with Neighbor Hub Health with the Street Outreach Initiative.
Speaker 2:Awesome. Thank you, and Dr Kiesler and Valerie, you know each other correct. Many years yes, can you talk about that relationship?
Speaker 3:Yeah, so you know we've, as I said before, been working with Neighbor Hub Health. It wasn't a health network, they just kind of rebranded it as Neighbor Hub Health to kind of be a hub of services for the community. And so Valerie and I have been kind of working with the same organization over these years and Valerie had been working with the organization before me and, as I said, this has been the organization for those experiencing homelessness really for the past. You know they've had the grant for the past 25, 30 years. It started as just a bread truck converted into a medical van. Dr Bob Donovan is the original physician working with a nurse practitioner on that van going to the shelters. Dr Donovan is still a physician with our group and so I've been fortunate to work with Valerie, who's been kind of a great advocate for our patients and for our community. And so Valerie goes out and sees our patients, our clients who are out around our building, around our community, and try to get them into care. So it's been wonderful to be able to work with.
Speaker 5:Valerie over these years.
Speaker 4:It's amazing, dr Kiesler took me wow all the way back to when we had the one van and we had to pray at the start and we would go to the men's shelter and everyone who were on the street they knew what day that van came and if it didn't come, you knew it because they raised sand. But the work is so for me. 23 years ago I was homeless and all of it's due to drug addiction. But the director of Cincinnati Health Network, she saw me one day. She said I like how you communicate with the patients. If I write a grant for a patient navigator, will you come and work for me? I'm like yeah, and don't know more about it. Two years later she came and got me, so it's where I am today.
Speaker 2:Wow, little did you know. Yeah, that's what this would turn into. So can you anybody here? Can you talk about the need for street medicine in Cincinnati?
Speaker 4:I can, because one of the reasons why I feel like I've been doing street medicine forever Whenever you're those boots on the ground and you're out there and you're sitting with the patients, individuals, whether it's under the bridge or on the square, wherever to me that is street medicine. And I just have to hold back my tears because there's an individual living on the streets now and I'm just it's like getting that call. Oh, you know, they found so-and-so dead and it's all because we can't get him to come to the doctor. And so it's like, what do you do? And I talked to him yesterday about coming to the clinic and he said I'm just waiting to die. You know, those are the reasons why we need street medicine. That's the reason.
Speaker 2:Very powerful. Dr Kimmel, can you talk about what your role is and how you as an emergency medicine doctor and what role you're playing in this?
Speaker 5:Yeah, I think a lot of what Valerie mentioned is that from the emergency department, we see a lot of the effects of this in our unhoused communities people who waited to go to the doctor until things were really bad, and for a good reason. I think there's a lot of stigma in the healthcare system that patients face. There's a lot of coexisting addiction that either doesn't get treated or that they face. There's a lot of coexisting addiction that either doesn't get treated or that they face additional stigma for. And it's really frustrating from an emergency perspective to see that, you know, this is really all kind of the downstream effect of a larger need, which is a presence of street medicine in the community, paired with, you know, training and attention to how we treat patients when they do come to the emergency department.
Speaker 2:So how? How do we bring, how are we attempting to bridge that gap right now? Thank you.
Speaker 3:Thank you.
Speaker 3:I think you know, for the past two and a half three years what we've been doing so far has been partnering with Greater Cincinnati Behavioral has their PATH team, or Pathways to End Homelessness, which is their mental health outreach team, goes and they work with those who are experiencing homelessness on the street to engage them into mental health services, identify people, call to say, hey, I'm trying to find shelter but I'm staying on the street.
Speaker 3:They'll go, identify where they're staying and then they go through a vulnerability index scoring to find out, okay, do they qualify for permanent supportive housing potentially, or rapid rehousing, but also, do they have mental health needs? That team then identifies also, do they have medical needs? And then puts on currently what they've been doing. They put them on a list and then a couple times a month and I've been going out with that team to go around and to locate those individuals to try to provide them medical care. But we know right now that's just a limited approach because it's only you know, it's only a couple times a month, and so what we're doing right now is trying to build really a street medicine team with, you know, a broader, more providers, a broader team approach, and so that's what we're hoping with this, potentially with this grant and now bringing in more providers with our emergency medicine colleagues.
Speaker 2:So what are the challenges of that? Is it the funding itself and the grants?
Speaker 3:I mean, funding is one thing.
Speaker 3:I think it's also going to be part of that team and then really having a consistency of being able to go out, because I think the idea of consistency is it really develops those relationships.
Speaker 3:Because I think being able to, Because I think, you know, being able to, people who you know are experiencing homelessness, have they're so often one you know told no, so often, you know not, you know, oftentimes not lose respect by people just not acknowledging them, by people just not acknowledging them, but then oftentimes, like Valerie said, people are just not going to come into a brick-and-mortar facility.
Speaker 3:So unless we have the capacity to really bring care to where people are living, this is their current home, then we just, you know we're going to be able to. You know, what I've found is part of it is really developing that relationship with an individual who is, you know, staying on the street and being able to you know that's the first part is really developing that relationship. And then, at some point in time, patients you know that's the first part is really developing that relationship. And then, at some point in time, patients, you know sometimes will come into the brick and mortar building, but a lot of times it may be. What can we do for that individual while they're staying in their space in their current home on the street?
Speaker 4:I agree. I think it's meeting the people where they are, versus we keep trying to move the people out of their space to our space and I don't know.
Speaker 2:It's just, we just need to meet them where they are that sounds like a lot of trying to maintain just continuity of care, even if you do see them and you identify them as someone who needs care trying to continue that and build those relationships with them. Are there organizations I mean, obviously you, Valerie, help maintain that coordination and help maintain that continuity of care, but are there other organizations or is there sufficient organizations and support in Cincinnati to maintain that kind of continuity of care maintain?
Speaker 3:that kind of continuity of care. Well, I mean, I think there's so many, I think there's a lot of different pieces to it. I mean I'm just thinking about, like.
Speaker 3:I mean, you know, last month, lex and I got to go out together and we saw this one gentleman who's in a wheelchair, who's experiencing a lot of medical issues opioid use disorder, some mental health issues but he's trying to, you know, and living outside, trying to keep his stuff all in one spot and just thinking about just how he wants to get into care when he wants to get into care for his opioid use disorder, but thinking about just the transport issues, you know, and how he's going, how's he going to get to get to into care, worrying about how he's going to keep his, his stuff safe if he leaves where he's staying, and and so it's, it's all those other pieces that come into play.
Speaker 3:That, really, I think, and then people just have a lot of that creates a lot of fear. And then also, you know people he's trying to figure out how is he going to make? You know, sometimes it comes into play, you know, how are they going to make a living? So he's also panhandling, so he's I can't. You know, some individuals say I can't leave, I need to panhandle in the morning, but maybe I could do something in the afternoon, and sometimes those pieces come into play. So you have to kind of work, think about those things that will all come into the decision-making for and you just have to be willing to listen.
Speaker 2:That sounds like a very multidisciplinary problem.
Speaker 3:It is and that's why I think. That's why I think as we're trying to build this, you know right now we're kind of been doing, you know, at least from what we've been doing so far is outreach with you know, building so far our partner has been greater sensitive behavioral with with the path team. But as we're trying to think about building a street medicine team, we're trying to think about building a street medicine team, we're trying to go okay, well, how do we build a team with? Okay, well, you know we have what I have an, an advocate, or like valerie, how do we have mental health, mental health on the team? So I mean, who else needs to be part of that team that could potentially go out and then also kind of we talked before, we want to have a learner on that team. So I think those are different pieces as we kind of go.
Speaker 4:I think you've got to have people who really understand the people, not just our providers. You've got to have that. God, excuse me, I don't know what's going on with my voice. I've been talking too much. You've got to have enough people who can understand the individual, who's not afraid to get on the ground with them, sit down and just. Maybe they don't want nothing, Maybe they just want to talk. And that is to me the beginning of the relationship. And I think Dr Kiesler was saying about being visible and being available. Over and over again, you got to With this population, you have to. That's the trust.
Speaker 3:And I think and that's what I totally agree with you, because I think that's what I've found so much is it's really so important about just building that relationship.
Speaker 3:I mean, I think a lot of what you know it's not about that you're going to go out and you know and and you know, kind of, take care of this abscess. It's really about building that relationship. And it may be that the person may let you look at their, their wound, but if you don't, if if you don't kind of develop some relationship, and the relationship really comes from the outreach worker who knows them the best, and they're introducing you to, at least for me, introducing me to the person, and then the person then decides, okay, well, I trust this, I trust Valerie, so I'm going to trust I may, I may trust the physician, the provider, but it'd been over, you know repeated times and but I think that's you know. So really, it's that kind of that first person is really the outreach. The person they've met known the most is that you know whether it's the valet or it's the path worker. They've really developed that relationship. And then they develop the relationship with the medical provider.
Speaker 2:How do you, as a physician, build in that kind of flexibility into your profession to have the time to do that, to have the time to do this kind of work?
Speaker 5:Yeah, so right now, as a fellow, I have dedicated time. But the beauty of emergency medicine even though we work every day of the year and night shifts and all that is that, we do have the flexibility and so, um, I think my group has been very supportive of myself and hopefully a few of my colleagues starting this endeavor with scheduling flexibility and, um, you know, I think if it's something that you were really passionate about and you want to prioritize, they'll work with you.
Speaker 2:Is that true in primary care practices as well, in your experience?
Speaker 3:Well, I think it depends on what your practice is. So you know, as our department started, dr Donovan initially was the only doctor working with the program and then, about 15 years ago, as the program started to expand, they needed more physicians so the program started kind of working with our department for physicians and so I was one of the physicians.
Speaker 3:that kind of started with a group of other physicians that started working. So I kind of went from you know my kind of one of the practice sites with you know kind of the other practice and then started working with the homeless program and then eventually I kind of moved over entirely to the homeless program and so now all my clinical time is with the health care for the homeless program. So I think it depends on where you end up practicing and how you spend your time. And so for me, you know we have multiple different clinical sites I was interested in within the homeless program, I was interested in street outreach. So that kind of drove my interest in saying like, let's try this, there's a need, can we go this route? And the Neighbor Hub Health was willing to support that, support that, uh, you know, I think, even though it's not you're not going to see, you know you're not going to see 10 patients in the afternoon, but they realize that, they realize that it's it's an important part of of how we care for this population I see.
Speaker 2:so to clarify is is that kind of work is not necessarily volunteer? That is, through your group, right?
Speaker 3:It's through, it's a fairly qualified health center for people experiencing homelessness, and so it's paid time for me as a primary care doc through my department. So it's not volunteer time, it is kind of supported time for me as a faculty, but it is you know. So I think it is carving out. That's how I carve out my time for that.
Speaker 2:But in the case of the emergency department, dr Kimmel, that is like that's your own time, correct? Or does the department actually support like that kind of, this kind of work?
Speaker 5:Yeah, some of it depends on like foundation funding, grant funding, things like that, but I mean I think there's plenty of providers who do also donate their time. I mean, we have several providers in our group that also volunteer at the MedVoc clinic and things like that. So there's certainly a range of options of how you want to get involved and help with care of unhoused populations.
Speaker 2:How can our listeners get involved, most of our listeners being students. This is a three-part answer right here from each of you.
Speaker 1:I think I don't have a great answer. I can speak as a student who's interested and I think I don't have a great answer. I can speak as a student who's interested and I think consistently. When I'm honest with myself, I realize I don't have the capacity to build the kind of consistency in relationships that would put me in a place of being able to actually participate meaningfully in street medicine. So I joined the Street Medicine Institute and tried to advocate at a more national level, just for and I say that I guess not national level Like I didn't really do any kind of like writing or anything like that Just like meeting with other student groups that are able to function as a street medicine team in other locations and help connect them to different resources and people, um, that are doing the work elsewhere.
Speaker 1:But, um, I think it's difficult as a student, like I had a mentor tell me within the street medicine institute that the best thing that I can do right now is learn how to be a really good doctor, and I really took that to heart because this is something that I do want to do, and so when I graduate I want to have the best skills that I can do it well, and so I keep that in mind.
Speaker 5:I know one of our groups of M1 students for their project was working on distributing like creating distributing xylose and wound care kits. So I think projects like that, if you don't have the time to really have continuity on a street outreach initiative, that's understandable. I mean, I remember being a medical student and it's not exactly easy, exactly easy. But I think projects like that if there's a group that has a need, you can always assemble a group of people to, you know, spend an afternoon putting wound care kits together or you know what have you?
Speaker 4:Another way they can donate their time is maybe you want to start a sock drive, or you might want to put peanut butter and jelly sandwiches together. It's just whatever your time and how you want to give, just let it come from the heart, yeah.
Speaker 3:Yeah, because I know that PATH is always looking for you know, because they give out sandwich bags or those type of things to the clients, and I know that we'll, as we develop this, we'll be looking for the same you know, because as we're hopefully going to be ramping up for just a
Speaker 3:couple times, a month, eight times a month and developing this team, and I think, as I mentioned before, as we do, that our goal will be to be able to, you know, to have a learner. So I think that's where we want to be heading with this. So we don't have that, you know, quite there yet, but that is our goal.
Speaker 5:And Kirsten, I think your thought on joining the Street Medicine Institute is fantastic. I know the membership fee for students is either free or very low. They have a lot of robust student programs and I mean the National Conference is in Kansas City this year, so you know driving distance and they, I believe, have pretty cheap registration for students as well. It's a great opportunity to network and really kind of just understand a little bit more about what street medicine initiatives look like nationwide or really it's worldwide.
Speaker 2:All right. Well, thank you you everyone for coming. I appreciate your time and sharing your stories and your thoughts and what the street medicine effort looks like in cincinnati, because I think it's a really cool movement and really important um for a large portion of our population. So thank you, thank you again for coming thank you for having us.
