COVID-19 cases in the United States are continuing to rise, with some regions of the country entering a stage of peak infection. Despite growing resources allocated to our public health response, a substantial gap exists in our approach to the care of homeless patients at this time. Various solutions have been proposed to improve access to care and temporary sheltering in this period of turmoil. However, an important consideration remains: at a time when we find the world of medicine lauding the potential of telemedicine in pandemic response, there is a disconnect in how to benefit homeless patients and communities with this emerging technology.
The appeal of using telemedicine to triage and monitor COVID-19 patients is multifocal. Given the serious risk that health care workers face of being infected during patient intake and care, distanced evaluations minimize potentially dangerous exposures. Beyond minimizing risk to frontline professionals, research on telemedicine has provided evidence that it may be safe and effective in screening patients. When combined with effective triage algorithms and integrated with existing call procedures, these factors illustrate the qualified feasibility of telemedicine for handling our country’s anticipated patient surges.
Despite growing integration into traditional health care infrastructures and continued enthusiasm for expansion, telemedicine presents clear pitfalls when applied to homeless patients. As it stands, various outdated and bureaucratic laws exist which limit this tool. For example, some states require an initial in-person medical examination prior to allowing prescription of controlled substances in telemedicine visits — an added difficulty for many patients in the best of circumstances, let alone for those who may lack stable homes or personal transportation.
Perhaps most crucially, homeless patients without smartphones may face substantial difficulty in accessing telemedicine. While one study from UCSF showed prevalent cell phone ownership among older homeless persons, smartphone ownership accounted for only about a third of that cohort. Even among younger homeless persons who may more commonly have smartphones, poor internet access may severely restrict their ability to receive remote triage or treatment.
These concerns are especially relevant, given the unique vulnerability of homeless patients during the pandemic. Homeless persons without stable shelter are largely unable to effectively carry out social isolation.
Compounded with a lack of access to basic supplies or facilities necessary for hygiene and sanitation, they are at a considerably higher risk of contracting COVID-19. And, of deep concern, homeless patients may be more likely to have poorly managed comorbid conditions, which may predispose towards worse outcomes in the event of a COVID-19 infection.
With an awareness of the potential of telemedicine to reshape our approach towards proactive diagnosis and treatment, it’s clear that there are areas of key consideration necessary when applying this model towards the care of homeless patients.
Effective telemedicine requires access to a mobile device or computer with a stable internet connection, a challenge for many homeless patients. However, given recent efforts in California and across the country which seek to provide shelter to homeless patients in trailers, motels, and hotels, the integration of a novel telecommunications network may be highly feasible.
To increase accessibility for homeless patients who possess digital devices, we propose integrating internet access at these new sites for shelter and at standing meal distribution sites. Patients without devices may ideally benefit from expanded device donation programs. However, the number of available devices for distribution is limited, and public device access hubs provided by shelters, fire departments, or police stations may offer an immediate alternative.
And of course, such interventions should be accompanied by a continued re-evaluation of the federal and state regulations, which may unduly limit telemedicine. Recent federal expansion of Medicare reimbursements for telemedicine through revised Centers for Medicare & Medicaid Services (CMS) guidelines hopefully offers a foreshadowing of such efforts.
Telemedicine has the unique strength of leveraging our country’s existing communications infrastructure at a time when face-to-face contact is considered hazardous. The limitations of this modality are perhaps most obvious when considered with regard to our homeless patients. As we begin to lay the foundations for a new age of long-distance medical care, it’s critical that we remain aware of the unique circumstances of our vulnerable populations, and that we construct systems that will maximize our ability to care for all patients.
Matthew A. Crane, Tiffany Lian, and April Banayan are medical students.
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