For people experiencing homelessness, getting help with a substance use disorder can be tough. Many are isolated from the health care system, often with no way to get to a point of care or pay for treatment. That’s why, in Chicago, providers are going to them.
“We often just start with a bagged lunch and a bottle of water…and we’ll see what happens from there,” said Stephan Koruba, the Senior Nurse Practitioner at The Night Ministry, a street medicine clinic based in Chicago, Illinois. “What happens from there” might include helping someone secure housing or a legal I.D., or offering them wound care and treatment for substance use disorder – all out of a van.
When providing care to people experiencing homelessness, Koruba and his team of medical providers and social workers focus on establishing relationships first. “We try to offer a non-judgmental human connection,” he said. For many, distrust of medical providers can be a barrier to treatment. “Other humans are often the biggest threat to people out on the streets,” said Koruba.
The vehicle allows providers to “look in all the nooks and crannies” for those living in tent encampments, under bridges, and on street corners. In addition, the team operates a bus they use to provide nightly care to homeless individuals across six Chicago communities.
For those with an opioid dependency, Koruba is able to provide medication-assisted treatment. A typical treatment involves prescribing Suboxone, an opioid-based medication that prevents overdose and withdrawal, and behavioral health support.
While Koruba can write the prescription, getting patients the medication can be difficult.
Many don’t have insurance and can’t afford to buy Suboxone at a pharmacy, according to Koruba. Others don’t have a vehicle or money for public transportation, making it difficult to get to a pharmacy. To bridge the gap, The Night Ministry works with a local community health center to provide patients with free transportation to and from their appointment. At the health center, they can get treatment for their substance use disorder at no cost to them.
But treating a substance use disorder requires more than one visit to a doctor’s office. Patients must follow a strict medication regimen, which involves multiple trips to a pharmacy and consistent follow-up appointments. For those living on the streets, this kind of high-contact care is not always possible. “We do make plans to meet people at a certain time, at a certain place, and sometimes they’re there and sometimes they’re not,” explained Koruba.
Because the success of substance use treatment depends on having some degree of stability, those experiencing homelessness face an uphill battle. If an opioid medication isn’t taken consistently, people can fall back to using stronger, more addictive drugs.
This can lead to overdose, especially after a period of detox, and ultimately land a person in the emergency room. From there, a dangerous cycle begins: “We have seen lots of folks get very expensive, great care for a week or two at the hospital but be discharged out onto the street and then they miss all their follow-ups and they get sicker and they end up back in the ER a few weeks later,” said Koruba.
According to Koruba, “breaking that cycle” begins with changing emergency room culture: “The institutional inertia is to disregard drug addicts when they come into the ER for visits,” he said. Often, providers assume they are “just searching for more drugs.”
But considering an individual’s personal circumstances can have profound effects on their long-term outcomes. For example, Koruba said, most ERs don’t ask about a patient’s housing. “It’s not part of the internal culture,” he explained. Instead, they treat patients for the acute issue they were admitted for, such as an overdose. But because housing status can have “a big impact on [a patient’s] medical care and their ability to follow up,” it’s a critical piece of information. For some, it can be the difference between recovery and the need for additional emergency care.
To encourage better coordination among providers, The Night Ministry has been taking ER doctors on outreach trips to provide medical care on the streets. Doctors “can see the realities that our folks face” and “change the resources available to them in the hospital,” said Koruba.
While this kind of coordination isn’t happening on a mass scale, there’s been improvement. Recently, an ER doctor recognized a patient they had treated while volunteering with The Night Ministry, who had been admitted for an overdose. The doctor notified Koruba and he was able to “help them initially on their follow-up regime,” preventing the need for emergency care down the line.
While “the ball gets dropped a lot” said Koruba, “we’re trying to change the culture little by little.”
Through the Fund for Health Equity, Direct Relief has awarded The Night Ministry $250,000 to support their mobile outreach program, including funding to provide medical care and social services to those sleeping on city trains, in tent encampments, and on streets across Chicago.