‘Astonishment and comfort’ from unhoused patients: ‘This suits me’

Mobile phones are ubiquitous, even in the possession of people experiencing homelessness, a demographic among America’s most vulnerable — with an average lifespan of merely 51 — and one of the most difficult for healthcare professionals to reach.

This demographic is not typically linked with technology, which often involves utility expenses, internet services, and mobile plan costs. However, an innovation born during the pandemic — telehealth for those without homes — continues to present a solution for modern providers to connect with unhoused patients more often and reliably than conventional office appointments.

Katherine Koh, assistant professor of psychiatry at Harvard Medical School and a psychiatrist at Massachusetts General Hospital along with its affiliate Boston Health Care for the Homeless Program, authored a recent article in the journal JAMA Internal Medicine showcasing the method’s efficacy in enhancing access and diminishing barriers to care.

In this modified dialogue with the Gazette, Koh mentioned she has observed the positive impact in her practice, and she along with co-authors from MGH, BHCHP, Boston Medical Center, and Brown University aim to further investigate this method and highlight its achievements for others aiding this elusive population.

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How did your endeavors in this field commence?

As is common with many healthcare organizations, BHCHP transitioned to telehealth during the 2020 pandemic. Initially, many, including myself, believed it would not be effective. However, the rate of missed appointments in my telehealth clinic was lower than during in-person days, which I found both intriguing and paradoxical.

Telehealth for individuals without homes might seem contradictory, but on closer examination, it makes sense. Many are grappling with substance abuse, mental health challenges, and executive functioning struggles while attempting to meet their essential needs. This situation complicates their ability to attend clinic appointments punctually. They often need a transportation pass or funds for public transit. Telehealth simplifies access to care without these obstacles.

Despite a high rate of missed appointments for in-person visits, around 80 percent of patients engaged with telehealth by answering their phones. For instance, I connected with one patient weekly for about half a year, while in-person, he would attend at most once a month. This article emerged from these clinical insights.

A preliminary analysis revealed that during the initial six months of the pandemic, 76 percent of behavioral health consultations occurred through telehealth, and 26 percent of medical visits did as well. Perhaps more compelling is that telehealth is still being utilized now, even when it’s not necessary. It continues to be a prevalent practice within BHCHP, and I believe it should be refined as an innovative means to engage this often elusive population.

Is it utilized more for specific conditions?

Visits for behavioral health particularly adapt well to telehealth since a physical exam isn’t essential in numerous cases. We’ve also received feedback from our physician colleagues that it’s especially effective for follow-ups on diabetes, COVID-19, and other infectious diseases, and suboxone appointments for opioid use disorder. While it may not suit every condition or individual, we have discovered that 50 percent of behavioral health patients have participated in at least one telehealth visit in the past year.

Do you feel you’re connecting with patients during telehealth appointments as much as you would in person?

Generally, yes, but I’ve noticed there are subtleties in how telehealth functions for varied patients. Most find it straightforward to attend an audio visit, as it simply involves picking up the phone. However, video consultations can be more challenging due to the need for a stable internet connection and a certain level of tech literacy. One effective approach we’ve employed is having a staff member set up an iPad for a remote consultation while patients are at our respite center or clinic, which has eased the use of video technology.

For first-time meetings with new patients, audio visits can be less effective for establishing rapport compared to in-person or video sessions. However, if I am familiar with the patient, audio visits frequently fulfill their needs quite well. I often hear patients express astonishment and comfort regarding the televisits, stating, “This suits me.” I believe it empowers them and inspires further engagement in their medical care.

What are the most significant healthcare challenges confronting homeless individuals today?

There are numerous issues. Few demographics carry a heavier mental health burden, which is my focus as a psychiatrist. When people consider homelessness and mental health, their thoughts often turn to those experiencing schizophrenia, who may be disconnected from reality.

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That is indeed widespread, yet a significant portion of what I manage involves the aftereffects of trauma. Numerous individuals have endured unspeakable trauma from a young age, impacting their capacity to trust, regulate emotions, and withstand stressful scenarios. Substance use disorders are highly common: opioid use disorder and alcohol use disorder rank among the most prevalent. Additionally, there exists a vast array of both acute and chronic health conditions, such as cardiovascular disease, respiratory disorders, and cancers. These ailments significantly contribute to an appalling mortality rate and a mean age of death that is nearly 30 years less than that of the general populace.

Are there health outcome metrics linked to this research?

Telehealth seems to enhance participation and access—typically two significant obstacles—for the homeless demographic, though we do not yet know if this leads to a reduction in emergency and inpatient admissions. This represents a crucial area for future investigation.

This investigation also promotes utilizing technology to encompass homelessness on a broader scale. For instance, I am engaged in a study employing AI to assess outcomes for our patients, which I find to be an intriguing new field. Traditionally, homeless individuals have been marginalized from technological advancements, but I believe the telehealth instance demonstrates that technology can and should be innovatively applied to advance research and care for those without housing.

Homelessness has reached unprecedented levels in America. What elements are contributing to this?

Rising housing expenses, along with stagnant wages, play a significant role. Additionally, there is an influx of migrants without sufficient systems in place to manage their arrival, compounded by the cessation of pandemic-related rental protections. Natural calamities also serve as an undervalued factor in escalating homelessness. For instance, in the 2024 count, individuals displaced by the Maui wildfires were identified as a factor in the increased rate of homelessness.

A few years ago, the Mass and Cass homeless encampment — located at Massachusetts Avenue and Melnea Cass Boulevard in Boston — was dismantled, with individuals being directed to shelters, temporary accommodations, and some relocating to various parts of the city. There have been reports indicating that individuals have returned to that locale. What is your evaluation of the situation there?

Addressing this crisis must also involve preventive measures, as even if we were to house everyone currently experiencing homelessness today, the issue would remain unresolved. There exists a continuous funnel of individuals descending into homelessness, with insufficient affordable housing and facilities capable of accommodating them. My understanding is that the current population at Mass and Cass includes not just returning individuals, but also newcomers. The aggregation of services in that vicinity—treatment programs, BHCHP, and shelters—renders it an attractive spot for gathering.

Confronting homelessness, which has numerous origins, within a large metropolitan area and budget limitations is exceedingly complex. Every major city contends with encampments and a deficit of funding or support for sustainable resolutions. At the individual level, I believe it is essential to acknowledge that many unhoused individuals find themselves in that situation due to decades of trauma, adversity, and suffering. Their scars cannot be mended in a matter of weeks or even months. Thus, identifying means to finance temporary housing sites for a more extended period until individuals can transition into permanent supportive housing, along with increasing the availability of affordable housing and emphasizing prevention for those at elevated risk, is crucial to rectifying this crisis.

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