Goff M, Greene L, Harri A. Serving rural communities experiencing homelessness during the COVID-19 pandemic: adaptations of a student driven telehealth model HPHR. 2021;48.
The COVID-19 pandemic incited innovation across healthcare; at the Geisel School of Medicine, medical students launched a telehealth program in partnership with Good Neighbor Health Clinic (GHNC), a free clinic in Vermont, and The Upper Valley Haven, a homeless shelter and food bank, to serve people experiencing homelessness. This program pairs people experiencing homelessness with medical student volunteers who serve as healthcare partners. Medical students assist referred patients with issues related to the social determinants of health, such as registering for Medicaid, finding a primary care provider, and connecting with medical and mental health services. Since its inception, the telehealth program has matched over 60 individuals with volunteers, serving both as a conduit for healthcare assistance and as a means of connection in a time of isolation. This article discusses how the program has adapted throughout each phase of the pandemic and draws from program experience to emphasize telehealth as an essential tool in caring for people experiencing homelessness as the pandemic continues to transform healthcare.
The COVID-19 pandemic spurred innovation across all areas of medicine and medical education. At the Geisel School of Medicine, medical students launched a telehealth program to provide support and counseling to people experiencing homelessness in The Upper Valley of New Hampshire and Vermont. No models for telehealth initiatives serving people experiencing homelessness existed at the project’s inception; however, similar programs have since developed across the country.1-6 Our initiative originated from a collaboration between Good Neighbor Health Clinic (GNHC), a free non-profit clinic serving uninsured individuals, and The Upper Valley Haven, a homeless shelter and food bank. In 2014, Geisel students established a health resource clinic at The Upper Valley Haven to help address the medical needs of people experiencing homelessness. In 2019, a foot care clinic was added in collaboration with podiatry providers at Dartmouth Hitchcock Medical Center (DHMC) in response to surveying the needs of individuals accessing services at the Haven. In addition to providing foot care, medical students assisted individuals with issues related to the social determinants of health, such as connecting them with health insurance or with community resources to navigate housing and food insecurity. When COVID-19 restrictions shut down the in-person clinic in March 2020, medical student leaders sought a way to continue working with individuals that The Upper Valley Haven clinic served.
At the pandemic’s start, the state of Vermont instituted a GA/EA Emergency Assistance program to provide people experiencing homelessness across the state shelter in local hotels.7 For the White River Junction and Hartford areas, this program was coordinated through staff at The Upper Valley Haven. Utilizing the rapidly adopted modality of telehealth, students created a program to virtually communicate with hotel residents.8 Interested clients are paired with medical student volunteers who function as health partners for navigating social determinants. Data describing the number of volunteers and patients served is summarized in Table 1. As COVID-related policies remain in flux, our program continues to experience changes. Beyond pandemic restrictions, we believe telehealth functions as a valuable healthcare delivery system for people experiencing homelessness and intend to continue adapting the telehealth model as our program evolves.
Due to the flexibility of medical students’ schedules and the medium of telehealth, volunteers offer long-term support services to matched patients through the telehealth program. Medical student volunteers assist with enrolling uninsured patients in the Vermont Medicaid program, establishing patients with a primary care provider, and triaging urgent medical needs such as prescriptions for psychiatric medications, diabetes management, or management of other chronic health conditions that the GNHC can address while the patient is being established with a PCP. Mental health care presents a significant unmet need among this patient population. To meet this need, we developed a virtual mental health clinic based on the model created by the Boston Healthcare for the Homeless program.9 We staffed this clinic with psychiatry residents at DHMC and can now refer patients with mental health needs to a specialist that they can connect with over telehealth.
Through the telehealth program, pre-clinical medical student volunteers gain experience with interviewing, taking a thorough history, and practicing techniques in narrative medicine, which its founder, Rita Charon, defines as “medicine practiced with these narrative skills of recognizing, absorbing, interpreting, and being moved by the stories of illness.”10 Students are encouraged to practice a narrative approach in utilizing open-ended questions, to listen until patients finish their statements, and to focus on life narratives and psychosocial issues, with the goal of empowering patients in sharing their stories in future healthcare interactions. Medical students also gain practice charting and writing Subjective, Objective, Assessment, and Plan (SOAP) notes in our electronic medical record system, a skill that many students do not have the opportunity to develop until their clinical years. In the past year, we also held monthly grand rounds. At these sessions, medical student volunteers present to the group about a challenge they worked through when assisting their telehealth patient. Participating in grand rounds offers the opportunity for medical students to practice their presentation skills and allows listening students to learn from the resources and methods employed by the presenting student or guest speaker.
As most of our rural community’s population experiencing homelessness or housing instability had reliable access to a phone, we found that telehealth offered an effective means of communication. Though we set out to address urgent health needs during a global pandemic, we observed that our program also offered participants connection and a reliable support system. Students cultivate long-term relationships and build trust with people experiencing homelessness, as many have been poorly treated by the healthcare system in the past.11 Student communication with patients varies based on the participants’ health concerns and goals, with some students connecting with patients for a few weeks and others connecting weekly for a year. In our program, we have learned that repeatedly showing up for these patients may provide its own type of healing and that long-term contact and reliability are essential aspects of care.
One of the challenges we have faced in our program includes difficulty contacting patients and communicating effectively with volunteers. Occasionally, when we refer a patient to a medical student volunteer, the volunteer is unable to reach them by phone. To overcome this challenge, we work closely with service coordinators at The Upper Valley Haven to connect students with patients. Tracking each telehealth interaction also presented an issue, and to address this we created a system for volunteers to schedule telehealth visits in the electronic medical record as they would an in-person patient visit. Scheduling calls electronically allowed us to more effectively track telehealth delivery.
As in all clinical care, we have also experienced challenges in addressing needs for which there are insufficient resources in our area, such as dental care, affordable housing, and transportation. In our rural community, few dentists accept Medicaid reimbursement, and there is only one free dental clinic. This can make addressing dental needs a challenge for the population we work with. Lack of affordable housing presents another significant issue in our community. Individuals receiving shelter through the Vermont GA/EA Emergency Assistance program work with service coordinators at The Upper Valley Haven to apply for affordable housing through the state; however, the need for housing placement vastly outpaces the number of available spaces. Lack of affordable housing is linked to residential instability, which has been associated with numerous adverse health outcomes like poor health care access and mental health.12 People experiencing homelessness or living in poor or unsafe housing conditions often have increased exposure to environmental hazards and less exposure to community or neighborhood support, which is essential for mental health and healthy development. In our area, housing instability is also highly correlated with substance use disorders, mental health needs, and lack of basic medical care.
In addition to our rural location offering fewer dental and medical providers than might be available in more suburban or urban communities, we also face a significant lack of access to transportation, especially in public transportation that may be more available in more urban areas. Due to our rural location, transportation also presents a significant issue. Many patients do not have access to a car, and although we do have a local public transit system, getting to a bus stop can still be difficult, especially in the winter months. Although Medicaid can provide rides to healthcare appointments, the need to schedule appointments in advance and the Medicaid-established limit to the number of rides each client can access provides an additional barrier. This lack of transportation limits our patients’ ability to access the healthcare system for appointments or resources.
The innovation that spurred the Geisel-GNHC telehealth program’s beginnings foretold its trajectory, one of constant adaptation to current community circumstances and needs. As the pandemic evolves, we continue to experience changes. In May 2021, the state of Vermont began to shrink the GA/EA General Assistance Program to only include families and those living with disabilities. Initially, around 130 households were staying in local hotels in the Upper Valley; that number has now decreased to 60.
As a result of this downsizing, the number of patient referrals to our telehealth clinic has simultaneously declined. In response, we have expanded our program in other ways, one of which is through tent outreach. In our rural location, some people experiencing homelessness seek shelter by camping in tents, and the number doing so has recently grown after people were required to leave hotels. Staff members at The Upper Valley Haven regularly conduct visits to tenting sites to address any urgent needs. Medical students in our program have begun accompanying Haven staff members on these visits. Medical students joining tent outreach offers the opportunity to address health needs on-site and enroll interested participants in our telehealth program, where a student can help connect them with needed healthcare resources on a longer-term basis.
Although the rapidly expanded use of telehealth adopted during the early pandemic may decline, we believe that telehealth in our rural community fills a need in communicating with people experiencing homelessness. Building off of tent outreach, we plan to adopt a hybrid model in our telehealth program and to restart the in-person foot clinic. When seeing patients in person, we will offer enrollment in the telehealth program. We believe this will allow patients with complex needs, such as establishing long-term care or enrolling in insurance, to access assistance without the added burden of travelling to the in-person clinic. This hybrid model will allow us to retain the expanded access and means of connection that telehealth offers in our rural setting while adjusting to post-pandemic changes.
With increasing vaccinations, the altered Vermont GA/EA Emergency Assistance program policies, and the onslaught of new viral variants, the direction of our healthcare system remains in flux. In continuing the Geisel-GNHC telehealth program, we hope to reestablish an in-person component to the clinics, perhaps through student volunteers accompanying Haven housing coordinators through motel outreach, while concurrently offering telehealth services. Through offering telehealth services to people experiencing homelessness with limited access to healthcare, we observed the power of telehealth in forging long-term relationships, building trust, and implementing narrative medicine techniques. Moving forward, we will continue to implement telehealth and technology to shape our program around the changing needs of this community.
The authors wish to thank the following individuals and organizations:
The Upper Valley Haven; Good Neighbor Health Clinic; Kathrine J. Heflin, MSPH; Leah Gillet; Abigail Alexander, MD; Peter Mason, MD; James J. O’Connell MD; Joseph O’Donnell, MD; John R. Sanders, MD; Renee Weeks, MA, LCMHC, LADC; Nathalie Hebert, NP; Rebecca McKinnon; Caroline Watson; Katie Edwards; Sarah Matsunaga; Yiqiao Bao, PhD; Alice Liu.
The authors have no relevant financial disclosures or conflicts of interest.
Matthew Goff (he/him) is a second-year medical student at the Geisel School of Medicine at Dartmouth. His interests include health equity and community-based medicine.
Lily Greene (she/her) is a second-year medical student at the Geisel School of Medicine at Dartmouth. Her interests include health equity and political advocacy.
Adina Harri (she/her) is a second-year medical student at the Geisel School of Medicine at Dartmouth. Her interests include health equity and narrative medicine.