The United States is seeing a troubling rise in homelessness, which has led physicians and healthcare teams across the country to innovate new ways to reach and support individuals experiencing homelessness.
One promising solution being explored is telehealth.
When we think of telehealth—seeing a healthcare provider over the phone or video—we usually imagine doing it from the comfort of our own home, with stable internet and enough privacy to have the consult.
But what if the patient doesn’t currently have a home?
Katherine Koh, MD, MSc, a psychiatrist at Mass General Brigham and street physician with the Boston Health Care for the Homeless Program (BHCHP), is part of a team exploring telehealth options for people experiencing homelessness.
Koh has been involved in street psychiatry for some time, and through her experience working with individuals experiencing homelessness across Boston, she has gained deep insight into how to meet the healthcare needs of this marginalized population.
Koh is the first author of a new viewpoint in JAMA Internal Medicine, Telehealth for Patients Experiencing Homelessness—An Unexpected Opportunity, which highlights how telehealth can serve as a way to increase access and engagement for those often excluded from traditional healthcare systems.
“People experiencing homelessness are often dehumanized within medical systems, which are not well set up for them," Koh says. "These systems rely on patients to be on time, attend appointments regularly, and navigate a complex medical system on their own—challenges that are compounded when someone is struggling to meet basic needs like food, shelter, and hygiene.”
Telehealth was a Powerful Tool During the COVID-19 Pandemic
In the JAMA IM Viewpoint, Koh and team reveal that despite initial doubts, pivoting to telehealth was a powerful tool for keeping the patients served by the BHCHP connected to care during the COVID-19 pandemic.
In the first six months, 76% of the team’s behavioral health visits and 26% of medical visits with patients experiencing homelessness were conducted via telehealth, and attendance rates for HIV primary care appointments were higher than before telehealth implementation.
Five years later, telehealth is still an effective tool for delivering healthcare services such as diabetes and buprenorphine follow-up appointments, and 50% of behavioral health patients among the homeless population have had at least one telehealth visit over the past year, Koh and team write.
Other programs across the country are seeing similarly beneficial results in using telehealth to provide care to individuals experiencing homelessness.
Veterans Affairs clinics, drop-in centers, and shelters are using telehealth to reach more people, and patients are responding positively. In one South Carolina program, 93% of patients said they were satisfied with their virtual visits.
One reason this approach is working is that many people without homes now have access to mobile phones.
Telehealth also removes major barriers to accessing care, such as securing reliable transportation to medical appointments, and allows patients to stay connected to their care teams.
Challenges and Next Steps in Telehealth Care
While telehealth shows promise, challenges remain. “Phones can be lost or stolen, and data plans are expensive,” Koh explains. “But solutions like lower-cost phone programs, Wi-Fi hubs in shelters, and support from clinicians and peer navigators can help to bridge the gap.”
With the homelessness crisis worsening, there is a critical need for more research on how telehealth affects downstream health care use, such as emergency department visits and hospitalizations.
If researchers can demonstrate that telehealth appointments provide downstream cost savings medical costs and insurance reimbursements, this could help to garner more support from Medicaid and other payers.
“By understanding how to better deliver care directly to those living on the streets, we can reshape access to crucial health services,” Koh says. “Telehealth can be a creative tool to give unhoused people the care they desire and deserve.”
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