The 14-year-old, the daughter of undocumented migrants from Mexico living in a homeless shelter in Phoenix, wasn’t just shy. She was also hiding a secret — an extra digit on one of her hands that she kept out of sight in her pocket.
“Teenagers often feel like they don’t fit in, but she literally had six fingers,” says Gary Kirkilas, DO, a general pediatrician at Phoenix Children’s Hospital, who heads its Homeless Youth Outreach program.
Once the extra finger was discovered during an exam at one of the hospital’s mobile medical units, doctors were able to arrange surgery to correct the problem at no cost to the family.
“When I saw her the next year, she was beaming,” he says. “It made all the difference.”
The teen’s medical condition may not be typical, but her story illustrates the program’s ability to respond to the disparate needs of children in difficult circumstances. For 23 years, the outreach program has served thousands of children on the streets or in shelters in the Arizona city.
It is just one example of the ways hospitals across the nation are addressing the acute and preventative medical needs of youth who are unhoused.
Daunting needs
Young people who are unhoused experience higher rates of chronic health concerns, nutritional problems, and trauma-related injuries than their peers living in conventional residences, research shows. As many lack access to health care, even small problems can fester until they become medical emergencies. A 2016 study found that youth experiencing homelessness have a ten-fold higher risk of death than those who have a place to call home.
Behavioral health issues are common. Young people who are unhoused have high rates of depression and anxiety due to myriad past traumas, such as physical or sexual abuse — and others that may develop as a result of experiencing homelessness, says Luis Manriquez, MD, community health equity director and assistant clinical professor at the Elson S. Floyd College of Medicine at Washington State University in Spokane, who runs a street medicine program for people who are unhoused.
“Youth on the street are at higher risk of physical assaults and sexual assaults, particularly women and girls,” says Manriquez.
Upwards of 60% of youth who have been unhoused experience alcohol or substance dependency or addiction, research shows.
There are other barriers to care. In addition to a lack of health insurance and transportation to health facilities, there are the particular burdens of being unhoused, Manriquez says. For instance, people who are experiencing homelessness likely lack a safe place to store prescription medications.
Medical care on the move
Hospitals are employing a variety of strategies to solve these problems, typically partnering with community organizations and local health and housing agencies. The Phoenix Children’s Hospital program, which started in 2000, has grown from one mobile medical unit hosting four weekly clinics to three units offering 30 half-day clinics a week. Medical care is also provided at several fixed sites across the Phoenix area.
On a typical day, Kirkilas may see four or five patients in the morning and another few in the afternoon in one of the 34-foot-long medical units or clinics.
“Visits tend to be longer because they often haven’t had access to care in a long time,” he says. “We take a holistic approach rather than a problem-based approach.”
For instance, a child may come in with a cold, but the team discovers the presence of a speech problem that needs to be further assessed and will need to connect the child to hearing and speech therapists. They may need to manage poorly controlled asthma and get a child started or restarted on asthma medication or refer a teen to a behavioral health specialist for depression. Or they might see an adolescent girl for a regular physical and realize she’s never been screened for sexually transmitted infections or is missing recommended vaccines.
The program’s providers can access a state-wide electronic vaccine tracking system to see what vaccines a patient has previously received and what vaccines are needed as well as recording those that they give. Fortunately, the mobile medical units have hospital-grade freezers to store temperature-sensitive COVID-19 vaccines.
The key to effective care in the unconventional setting is thinking outside the box, Kirkilas says.
“If you’re working with a family that’s experiencing a lot of barriers, you have to anticipate where some roadblocks might appear and know how to help,” he says. “So if the family doesn’t have transportation, just sending that prescription off to CVS is a poor idea.”
Housing first
Unconventional thinking is also behind the Center for Housing and Health in Chicago, which coordinates efforts by housing agencies, social service agencies, and city hospitals to end homelessness as a first step in improving health outcomes among the city’s youth who are unhoused.
“What we see is that if people don’t have a home, that overshadows any of the health conditions that people might be presenting with,” says Peter Toepfer, the center’s executive director. “The home really is the foundation for people to begin to even engage in their health care and their overall wellness.”
The center serves young people ages 18 to 24 primarily through the Flexible Housing Pool program, which was designed in 2020 to provide housing subsidies and health services to young people at high risk of gun violence. Developed in collaboration with Cook County Health and the city of Chicago, the project’s goal is to break the cycle of homelessness and crisis.
The project has served 350 households made up of young people, most of whom are parents, Toepfer says, and also serves 400 dependent children.
“This has become a project that’s addressing the family as a system and trying to ensure that the children are experiencing homelessness for the last time,” he says.
After clients have secured an apartment through the system, the center operates somewhat like a clearinghouse, referring people to different community resources to ensure that they have access to primary care, assess their eligibility for various insurance programs including Medicaid, and connect them to a variety of behavioral health services. For young children, the focus is on well-child visits, including immunizations and other preventive care.
Health care for individuals is overseen by support case managers. “They meet with folks … and make sure that people have been able to follow up with their different appointments and getting connected to the care that they need,” says Toepfer.
One of the big challenges is getting their clients to accept care.
“There is a distrust that is very much based in reality, as many [patients] have not been adequately served by the health care system, by and large,” says Toepfer. In a 2020 survey, only 6 out of 10 Black adults said they trust doctors to do what is right most of the time, compared with 8 of 10 White people, and high percentages of Black people expressed distrust in the health care system even if they had not had negative experiences themselves.
“To try to overcome that and to get people into services that are more culturally responsive isn’t a small task,” he says.
To surmount that hurdle, the center has begun to engage peer navigators to literally walk with clients to appointments.
Says Toepfer, “There’s nothing like a peer who can say, ‘This actually does work,’ and can guide you.”
Meeting youth where they are
In the wake of the COVID-19 pandemic, doctors at Floyd College of Medicine mobilized to test and track people experiencing homelessness who might be affected by the disease and to monitor infection trends in the city’s homeless shelters. The Street Medicine program they developed has now evolved into a permanent health care entity in Spokane in which teams of providers help people with medical needs.
“The way that we’re structured is to go and provide care for people in their environment, on their terms,” says Manriquez. “That means going under bridges, going out to encampments in the woods, or doing clinics in the shelters.”
Before each day of providing care, an all-volunteer team, including a homeless outreach worker, a clinician, and a staff member or volunteer from the Spokane Regional Health District, meets and fills backpacks with medical supplies, then drives around the city looking for individuals who are unhoused and in need of immediate medical care. The program also connects those individuals to other health care partners like CHAS Health, a federally qualified health center providing medical, dental, pharmacy, and behavioral health services, regardless of their ability to pay.
According to Manriquez, the program’s director, the teams also respond to health needs at a young adult shelter for people 18 to 21 and one for children up to age 18.
“A lot of chronic or genetic conditions show up in youth, which is the reason we do well-child checks,” says Manriquez. “But the less stability you have in your life, the less likely that anything that’s going on is going to be noticed, whether that’s vision problems, juvenile arthritis, or being on the autism spectrum. Those things may not come to the fore, as well, if you’re moving through foster care, or you’re going through different transitional housing situations or different families.”
In addition to trying to catch such conditions early, when treatments are more likely to be beneficial, street medicine teams are also trying to provide COVID-19 and other vaccines such as for HPV.
“It’s hard to get vaccinated if you don’t have a consistent ability to come in to a clinical site,” Manriquez says.
Street medicine teams carry Narcan for drug overdoses and can provide buprenorphine to help people struggling with addiction until they can establish regular care with a community partner or when waiting for a follow-up appointment with a provider.
Such health needs often seem overwhelming, but “people do recover from their childhood trauma and from substance abuse,” says Manriquez. “What makes it difficult for people to be willing to put in that effort is that treatment doesn’t necessarily work the first time. It may be that eight times are going to be required for this person to get better.”
The long view helps Kirkilas to stay in the game. But he and others treating the needs of youth who are unhoused also take joy in the small victories.
“I come away with an immense satisfaction to know that at the end of the day someone receives care, whether it’s a physical, a hearing test, or a lifesaving vaccine that they wouldn’t otherwise be able to access,” he says.