SOFT INTRODUCTORY MUSIC
Maddie
Hello, and welcome to Treatment Talk, a podcast episode dedicated to expanding the conversation around healthcare for the homeless population. I am your host, Maddie Gauthier. This semester, I was introduced to the topic of accessible healthcare through my nonfiction writing class, which centers around homelessness. As a young person in college, I have often found it very difficult to navigate the current American health care system. Managing my insurance, paying co-pays for office visits, and trying to get prescription medications have all been very difficult for me. However, the tangled web of health care is much harder for the 1,605 unhoused individuals currently living in Reno. The unhoused face many more barriers to healthcare than the average housed individual. Many unhoused individuals do not have insurance, disposable income for office co-pays, or pharmacy access for prescription medication. Additionally, most unhoused individuals do not have transportation to appointments or identification to present to the staff. Because of these and other factors, unhoused people are three to six times more likely to become ill than the general population, according to the National Coalition for the Homeless. The question remains, what can be done to make healthcare more accessible to the unhoused population?
Here to shed some light on the circumstances that many unhoused individuals face when it comes to healthcare is Cameron Rose. Cameron is a senior majoring in philosophy here at the University of Nevada, Reno, and he owns his own business called Resold Auctioned Merchandise by Cameron. Prior to being a student, Cameron was considered chronically homeless. Since becoming a student at UNR, Cameron has focused on studying homelessness and was one of five people cited for protesting the Reno Homeless Sweeps in 2021 Cameron, welcome to Treatment Talk.
So, Cameron, as I mentioned in your introduction, you were formerly unhoused. Can you talk a little bit about what your experience with healthcare was like during that time?
Cameron
For me, it was difficult to get healthcare. I know I’m not the only one. For one, you have to have health insurance, and without health insurance, you’re pretty much left to just the emergency room. And because of that, there’s just not very many options. The other issue is, even with healthcare, you’re still stuck with limited options, because, like, you don’t get dental, you don’t get eye care, so even in that sense, you’re still just left to emergency care.
Maddie
Okay, so what were some of the most common medical issues that you saw going untreated because people didn’t have insurance?
Cameron
The major ones that I would say, are definitely broken bones. That’s definitely a big one. Mental illness is definitely another one, for, left untreated and trauma and stuff like that. And then those that we just don’t know. Sometimes we just wait and wait and wait until sometimes the body’s saying, hey, you need to go to the emergency room, and by then, you’ve only compounded it and stuff so, and that’s when it can be a variety of issues that you just didn’t know you had.
Maddie
So, by that time, I guess it’s too late to do anything.
Cameron
Sometimes it can be, yeah.
Maddie
Right, so, from what you’re saying, it sounds like it’s more a broken bone or a mental illness as opposed to, like, a seasonal illness, or did you have any experiences where there were certain times of year that people would be sick more often with, like, the flu or something?
Cameron
I feel, I know myself. I’m pretty healthy, and it takes a lot for me to get sick. Like, for example, I just recently got sick, and it was like three and a half years since I had been sick. When looking at it in that context, I think it’s because I have a high immune system, and I feel like a lot of homeless people, because of the conditions we’re living in, have higher immune systems, and we’re already in hard times, so we can—like, a sickness is not a hard time. Yeah, that’s an easy thing, usually, to get over. Plus, the difference between being homeless and the rest of the world that’s working is we can take that day off, and we will, I know. And if I’m sick, I’m taking that day off. I’m not going to go out, no, I’m going to rest every bit I can to make sure I’m ready to go, because it impedes me from being able to even function still in society. It makes it even worse. So, it’s just easier to get it done and over with, while people in society will just go to work,
Maddie
Right, and so you mentioned a little bit, if people had a broken bone or maybe an episode of mental illness, they would go to the Emergency Room to seek treatment. Did you ever know of anybody going to any other community health alliance or some other provider that wasn’t an emergency room?
Cameron
There are some more long-term treatment options. They just take longer to get into, more dedication. It’s not something I personally sought after, and I know I’m not the only one. I know there’s a lot of people that are, I won’t necessarily say afraid of hospitals, but they don’t like them. I’m one of those people, so I go to them if I need to, and only if I need to. And I know I’m a large, I’m not, I’m not the only one, there’s a large percentage of the population that just waits or doesn’t trust the medical community and waits till the last second to when it’s finally “Oh, well, I have to go because something’s not right”.
Maddie
Yeah. Can you talk a little bit more about some of the reasons that members of the homeless community might not be so trusting of healthcare providers?
Cameron
They’re treated like drug addicts right off the top, because they’re homeless. I’ve experienced this. The last time I was homeless, I went to Renown to just make sure I didn’t have Covid, because this was at the start of Covid. Got asked to do a piss test in a form that made me feel like I was being treated like a drug addict. And I don’t do drugs, like that’s not my thing, and I took offense to it, and when I took offense to it, then security got involved, and then when security got involved, my trauma lashed out, and next thing I know, I’m being put in handcuffs and being refused service. I know I’m not the only one that’s had experiences like this just because we’re homeless, where hospitals think they have a right to refuse you service when they don’t, and we just don’t feel comfortable being in there, because the security acts like they’re cops when they’re not, and they’re given more authority and protection when they shouldn’t. Like you need to treat the homeless just as just the same as you would any other individual that’s asking for treatment.
Maddie
So, what steps do you think that medical providers should take to ensure that their homeless patients feel comfortable receiving medical treatment?
Cameron
The number one thing is keep security mostly away from them. I know I’m not the only one that is traumatized or has trauma from the security. Like security needs to be a last resort, because the individual themselves is creating a disruption that can’t be maintained. And even then, there’s ways to mitigate this. Like, we have nurses and doctors that deal with this on the regular. Like, let them deal with it first, let them try to, if they are having a difficulty, there’s other nurses and other doctors. You know, I understand, once you’ve whittled all your options down, okay, then it makes sense, but a lot of them have a lot of trauma because of being homeless and then being hassled by the cops for being homeless, and that’s where a lot of the issue is. The second issue, I would say, is being treated like a drug addict. Just because they do do drugs, make them feel comfortable that they’re not going to feel like they’re going to be taken to jail, because it’s, again, it’s the first problem. That’s why they have the issue with the second part, because now they’re criminalized just for having some sort of drug use, and they shouldn’t be, because the issue isn’t if they’re on drugs, it’s what’s going on with them medically. Sometimes it’s the drugs that are causing this, and it can’t, it doesn’t need to be known. But it can be done in a way without making them feel like they’re inferior for their drug use or whatnot.
Maddie
Well, this brings up a really interesting topic, and we’ve talked about this a little bit in our English class, the idea of trauma informed design. And we’ve seen that trauma informed design has been really effective in homeless shelters. Do you think something similar would be effective if we tried it in a hospital setting?
Cameron
Definitely, because I think that’s the example with what I’m talking about with keeping the security away. It’s the trauma that’s going to cause that agitation. And it’s not necessarily an agitation. I know myself. I suffer from manic, and I come off to some people as aggressive, especially those in authority figures. Because the way I personally look at it, I have authority over me. I’m the only one that has authority over me. Up until the point I’ve shown that I can’t control myself and speaking loudly, getting frustrated, none of that is indicative of not controlling myself. Like, I have the right to those emotions, and I have the right to even be frustrated, and telling me to calm down never calms down the situation, because you’re telling me my emotions when you might not know my emotions. I could be annoyed. I could be frustrated because I don’t know how to express that, maybe you’re the one in the wrong. Because not every authority figure’s putting down their foot, and they’re in the right like, you don’t just get to put down your foot.
Maddie
Yeah, so do you think, like, extra education and training for healthcare providers on how to interact with the homeless community would be helpful?
Cameron
Definitely, exactly. Especially, for example, like manic, I think manic’s widely misunderstood, and manic is associated with several disabilities. It’s associated with schizophrenia. It’s associated with bipolar disorder, which is where I am associated with it, and also PTSD, where I’m also associated with it. One of the symptoms of mania is psychomotor agitation. Psychomotor agitation is the urge to keep speaking. So that’s when you keep going on and on. And so, it might sound like they’re rambling, but to them, they’re not. And so, these individuals “don’t have time”. But I’m sorry, when you’re dealing with an individual with psychomotor agitation, they need to get this stuff out, because they feel that you’re not understanding. And there’s a whole lot more to the issue than, oh, it’s just black and white. Like, I believe in black and white, but sometimes there’s more issues that are being ignored that we’re acting like, well, it’s black and white, but we’ve ignored all this stuff. And it’s important, I think, also with like manic, you’re not just so much with the psychomotor agitation, the urge to take keep talking, but it’s noticed, like you’re going to be loud and come off as agitated. So, if we have this manic disorder that we understand makes people come off as aggressive, don’t tell them that they’re being aggressive, because they’re not being aggressive. And it’s the miseducation in this that not understanding that, oh, well, you need to calm down. When technically you’re telling somebody who internally is calm, who’s externally not presenting is calm, to calm down.
Maddie
Yeah, it’s like a symptom, they should be treating the symptom. So, you and I have also talked about the role that a lack of access to affordable health care can play in creating homelessness. So, what was your experience, if any, with people whose medical issues may have caused their unhoused situation?
Cameron
So, I mentioned earlier broken bones. That’s the number one example I’ve noticed. If I were to give a second, I would probably say cancer, but I feel like cancer, the problem with the cancer– I won’t necessarily say problem, I’ll say the difference–is those that get diagnosed with cancer eventually can get on disability. It just takes some time. So, for the beginning of it, they’re hard up. On the broken bone, they’re just hard up all the way around. They don’t get to get disability, because usually within six months, your bone’s gonna be broken, but in six months you can be completely broken out on the streets. So, just by getting a broken bone, you’re really held back from anything that you can do, and it’s something that we all can suffer at any moment in time. And the one that’s actually shocked me the most is it’s, it’s, I won’t say it shocked me the most, because it makes sense, once you get older, your bones become more brittle. But it’s the ones that are older that are suffering this, becoming broken-boned, and then just on the streets, because the young mend quicker and stuff. And so, it’s harder for the older to then lose their job, go get another job, and deal with all of that. And we don’t recognize that problem, we don’t discuss it, I feel like. But like a broken bone is not something that should leave you homeless.
Maddie
Yeah, especially if you’re right on that edge of, you know, having enough money to afford somewhere to live and not. Something as simple as a broken bone can be the one thing that pushes you over. I didn’t even consider that.
Cameron
Yeah, no, that’s the one that’s definitely surprised me the most. I’ve seen so many examples of people that, especially in construction, I think all of them were construction workers. I feel the difference, at least for a lot of them, is the younger ones, especially, are in the construction, they get back into it. But it’s a hard period of time that they shouldn’t have to go through. And that’s again, the difference is, if they’re older, they don’t have that option. And that’s why I feel like we see a lot more older generation on the street than we do see younger generation, because they just get jobs easier and they mend quicker.
Maddie
They can bounce back. Yeah, I get it. So, switching gears a little bit. For our English class, you had proposed a project that would help homeless people get into college where they would have wraparound services. One of the services for students at UNR is the Student Health Center. Is this something that you think could be helpful to the homeless population? And if so, how?
Cameron
I definitely do. I feel that a lot of homeless have various health issues which has contributed to their homelessness. I’ll give it an example of using myself, I have actually two hernias. Yeah, no, they’re not major. They’re nothing, you know, life threatening. They can be. But when you have hernias, you’re only meant, you’re only technically permitted to carry 25 pounds. And when you’re homeless, well, you’re going to be pretty much carrying everything you own, and it’s going to be more than 25 pounds. So, it’s not just little ailments like that that the homeless could be able to start taking care of. It’s the health care for the mental illness. If they break a bone, if they’re in school, they’re not going to have to be like, oh my gosh, I’m back out on the streets. And the difference between the university and a lot of places with wraparound services is some of the wraparound services are provided by another provider. Yes, and that’s, that’s a huge difference, because, yeah, they’re doing it. The university is doing it. This is all covered by the university and taken care of by the university, which you don’t have to jump through all the hoops. You don’t have to have the conflict in setting up appointments. I know I’ve had that happen, because you’re just you’re working through more hands, right?
Maddie
And so, I was wondering, with your experiences, are homeless people aware of different options for medical treatment? Or do you think that there’s room for improving public knowledge about healthcare services?
Cameron
I definitely think there’s room to improve it. I feel like that for a lot of services. I’ll give a good example, the Lions Club provides eye care. That’s been their big one for years. A lot of people don’t know that. Most homeless don’t know that. It can be used. It should be more talked about. There’s other forms of medical care that are just not so talked about, but there’s also limited forms because, for example, I mentioned earlier, it’s hard to get dental. Well, there are dental places that do free, potentially, or low-priced dental procedures, but it’s always just removal.
Maddie
Oh, okay, so nothing like a dental, like a routine cleaning or something,
Cameron
Yes, and that’s, and we don’t discuss this enough. And I think this is a huge problem, because what happens when you start to lose your teeth, you don’t look as presentable. And now that you don’t look as presentable, it’s harder to get a job. And that’s one of the issues that a lot of these homeless are having is they don’t have any means to take care of this tooth issue, which is a major health issue, like you can die from an abscessed tooth. It can just be an abscessed tooth that it’s decayed so much that they have to have it removed or whatever, and they don’t have any other way until they get to dentures to fix that. And I came to feel like there needs to be more options than just tooth removal or basic, generic glasses similar to like what the military would give to its new recruits. We live in the modern age, I wear contacts. I don’t like glasses. Why can’t I get contacts? Because it’s not offered, it’s not covered, it should be. It’s not much of a much more price. In fact, in the long run, contacts are a lot cheaper if you break your glasses. You lose your glasses, you have to go get them again. I mean, if you lose your contacts, which is really hard to do, because you’re pretty much going to keep them in your bathroom. So, like, that’s a cost expense every single time you have to go get your glasses, and homeless sometimes can’t afford it, and that’s why I went to contacts. But yet, I’ve always had to cover that out of pocket.
Maddie
For our last question today, what do you think would be the best way for a provider to promote their services to the unhoused population, just to kind of get that knowledge out there and encourage more people to seek medical services?
Cameron
Definitely a good question. I think it’s hard to reach out to the homeless, because there’s just, they’re not going to go to you until they need it, and even then, in some instances, like glasses, there are plenty of people in the country and all across the world that need glasses but don’t have glasses because it’s just not convenient for them, or they just might not know, or they might not even have access to the knowledge. Because, I know myself, some of the services, I feel like they’re living off of me. And so, if they’re living off of me, to provide these services, I don’t want to go to you, because like—
Maddie
You can be taken advantage of.
Cameron
That’s what I feel like, I’m being taken advantage of, like you’re living off of me to get these services when these services could, should be provided already. Especially when it comes to health care. I’m in the belief that like, you have a right to life, and if we have a right to life, that means you have to have a right to medical care. If I don’t have medical care, I can’t sustain my life. So how can I say I have a right to life if I’m not able to sustain that life? But it’s also what I feel like is the same for being homeless. I deserve a home, because if I have a medical emergency, how am I going to rest and mend up? If I break my foot and I’m homeless, I still have to be on my foot every single day, and then that’s going to create a compounded issue where I’m not going to be able to work as, like I used to. I’m not going to be able to heal properly. Or if it’s mental health issues, like, sometimes you need to have your own space just to get away from people, so you don’t do something stupid like punch them, stab them, do who knows what. Just to get away. Because we all need a place to get away that’s our own private place to also keep our own property. And I think that’s another issue for a lot of homeless, is we don’t have, necessarily, access to the health care that other people would use that’s not going to like the hospital and stuff like that. The over the counter treatments, because you go to most anybody else’s house, they’ve got a whole cabinet full of various remedies for various issues that the homeless don’t get that unless it’s basically donated to them, and that’s not one of the main things that’s donated.
Maddie
Interesting. I never thought about, you know, a donation for common medicines.
Cameron
Yeah, like, cough drops and stuff like that. Like, yeah. Like, they love that, and they need it all the time, especially when you got a headache, it helps.
Maddie
Well, Cameron, thank you so much for helping to contextualize the conversation from the perspective of someone who has experienced these struggles firsthand. I really appreciate you talking to me today.
Cameron
Thank you.
SOFT TRANSITION MUSIC
Maddie
Although many unhoused people find it hard to access healthcare services, there are providers here in Reno actively working to change that. One such provider is the Northern Nevada Hopes Clinic. Hopes was founded in 1997 as a single room HIV and AIDS clinic but has since transformed into a 38,000 square foot community health center that treats everything from chronic diseases to addiction. Joining me now is licensed practical nurse, Julia Cross. Julia is the director of Hope Springs, which is a program offered by Hopes specifically for the unhoused community, and she specializes in street medicine. Julia, welcome to Treatment Talk.
Julia
Thanks. Glad to be here.
Maddie
We are so happy to have you here today. So, Julia, as I mentioned in your introduction, you are the director of Hope Springs, which is a program offered by Hopes for the unhoused community. Can you walk me through a typical day in your life as director?
Julia
Wow, a typical day probably doesn’t actually exist. The demands of this job are dynamic, just as dynamic as the population that we serve. Even though I work, you know, Monday through Friday, nine to five, we are a seven day a week, 24-hour facility, so things happen sometimes in the middle of the night, sometimes in the wee hours of the morning, and so it’s pretty dynamic. But for the most part, the team, I work with an amazing team, and part of my day is spent looking at applications for prospective residents in our program. As a nurse, I look primarily at the medical information that we need to determine if they’re medically stable for the program. With the assistance of the rest of the team, we also look at their psychiatric state, their chemical use situation and other factors that allow us to look at them holistically to see if they’re actually ready for our program and ready to make that change as they exit homelessness, incarceration, and a variety of other scenarios.
Maddie
So, yeah, So I mean, besides all of these intake forms, what other ways do you interact with the unhoused community?
Julia
At the facility, we have a gate, and twice a week we have orientation where prospective applicants will come to the gate and meet with the team to do an initial screening. And so pretty much all day, every day, that doorbell, or gate bell, as we call it, is ringing, and whichever staff member gets to the gate first has an interaction with the individual. So yeah, we get a kind of an ongoing parade, if you will, of people that really want to exit homelessness, that come to our gate for more information. So we’re able to chat with them and get a better idea of their background and assess their readiness for the program, and then we ask them to come back on a Thursday or Saturday for a sit down face to face interview.
Maddie
Very cool. And so, you have mentioned to me that your specialty is in street medicine. Would you mind defining what street medicine is, and maybe how that’s different from quote, unquote, “regular medicine”?
Julia
Yeah, so street medicine is the idea of bringing the necessary medical care out to the people. A lot of folks are resistant to coming indoors and seeking their own medical care. So, we take the medicine out to them. Growing up in the backwoods of Maine, my dad was one of the first cancer specialists north of Boston and pre-EMTALA (Emergency Medical Treatment and Labor Act), so he would go out on the snowmobile and visit people in their homes, and literally take medical care to the people. So, that’s kind of where I get it from. So, it’s somewhat in my DNA. The way I got started, I was in Los Angeles, and kind of got started on two prongs, but I partnered with a doctor who was making her rounds on Skid Row in downtown Los Angeles. So, I said, can I tag along? And she taught me everything I know now, and it grew from there. I did street medicine in Orange County and bicycle medicine and rode the riverbeds looking for people that had unmet medical needs.
Maddie
That is really interesting. I didn’t even know that that was a route that you could take. You’ve talked a little bit about what street medicine is. So, how have these experiences with street medicine taught you about the ways to approach medical services for the unhoused population in general?
Julia
Well, again, there’s a lot of unmet complex needs among the folks experiencing homelessness, and what these experiences have taught me mostly is to just listen to my patients and be very slow to rise to judgment. Until you’ve walked in someone’s shoes, you don’t really know them, and this population typically has many layers of trauma contributing to their current situation. Probably, over the past dozen or so years, I’ve seen a tremendous number of patients in situations that are unimaginable to folks that are, you know, housed, and unimaginable for people that actually live in a developed country such as the United States is. So yeah, listening to patients, the layers of trauma that they’ve experienced contribute to their hesitancy in seeking out medical care.
Maddie
So, that actually brings up a good point, because earlier in the podcast, I spoke with Cameron Rose, who is a formerly unhoused student here at UNR, and he mentioned that a lot of unhoused people don’t seek out medical services because they distrust the healthcare system. So, you’ve kind of mentioned that trauma may be preventing people from seeking out medical care, but is there another issue that you see maybe that prevents people from seeking out medical care?
Julia
Yeah, they don’t trust that where they go is, that the medical care medical community is actually going to listen to them, believe them. I mean, I could tell you dozens, maybe even hundreds of stories where folks have sought out medical care and been either arrested in the hospital, kicked out of the hospital. Yeah, it’s, it’s the trust factor. Just because I wear a stethoscope and scrubs doesn’t mean they’re going to trust me. You have to really show them that you are, you know, intentionally listening to them and give them a reason to trust you back. I learned a long time ago to never just drop off a patient at the hospital and expect that they’re going to get their care taken care of, because it’s just not that simple. I’ve stayed in the emergency room with patients overnight waiting to be seen. A couple of hospitals eventually just gave up and gave me a hospital access badge so that I could just go back with them through the hospital and be able to navigate their care with them. One of my sayings is, you know, friends don’t let friends go to court alone. Why would you let someone go to the hospital alone? Everyone needs an advocate. Everyone needs someone that they can trust, that will help them, you know, navigate those complex waters. So, yeah, trust is a really big, a big part of it.
Maddie
What methods do you think we should be taking to increase that trust between healthcare providers and the unhoused community? We kind of mentioned before, maybe increasing education for healthcare providers. Do you think that’s something that would work? Is there another approach that we should take?
Julia
Yeah, educating the healthcare professionals is huge in my book. In all of the settings that I’ve worked, as Program Manager for an 85-bed medical shelter in Los Angeles to now working at Hope Springs, I find a lot of value in having interns, nursing students, medical students, social work students, doing some of their clinical time in our programs, and being able to really teach them before they get out into their profession and get entrenched into, you know, maybe some bad habits and that sort of stuff. So, giving them the opportunity to test drive their profession and really understand what this population is all about, who they are, and to really, sort of, I guess, fall in love with this population. I find it’s a beautiful population. I really appreciate working with the folks and, yeah, and showing other people that kind of compassion is, and teaching them from the beginning how to listen, it’s pretty important.
Maddie
Yeah, I totally agree. So, switching gears just a little bit. Could you tell me about some of the services that hope springs offers specifically for the unhoused community, and maybe how these services differ from what we might see in a regular clinic?
Julia
Yeah, so the Hopes, Northern Nevada Hopes is a federally qualified health center, and their mission is to serve the underserved, whatever that looks like. In some cases, it’s providing food, clothing, transportation to medical appointments and beyond. I mean, there’s just there’s so much. They have a wide array of staff that are trained in housing case management that can help folks find housing, that can help them apply for benefits from disability income to signing up for Medicare and food stamps and other social benefits. Another thing that Hopes does is, as a federally qualified health center, they have a wide array of diagnostic services to help reduce the number of times that patients have to go to the hospital first. They can come to the clinic, get an x-ray done there, get, you know, ultrasound done and other diagnostics done so that they don’t have to rely on the emergency room for their primary care.
Maddie
And do you treat broken bones? Because after talking to Cameron, it sounds like that is a huge issue among the unhoused community, and that’s one of the primary reasons that people are going to the emergency room, is broken bones.
Julia
Yeah, I would say, in my experience, the potential for broken bones infection and wounds are right up there. And if you’ve got a clinic like Hopes that can, you know, do a quick x-ray and rule out a broken bone and save a trip to the emergency room, that’s extremely helpful in cost savings to the entire community. But yeah, broken bones, orthopedic injuries, getting hit by a car, trip and falls, assaults, that type of stuff definitely leads to broken bones. And again, if not broken bones, wounds and wound care is huge. I was traveling with a street medicine team recently down in Southern California, and it seemed like everybody we saw had incredible, almost unimaginable wounds. This population is prone to things like, you know, here in Nevada, Northern Nevada, frostbite, maybe getting toes amputated, fingers amputated from frostbite, and combined with diabetes, one amputation often leads to another, which leads to another, and it just seems to kind of grow out of control with the, with this population.
Maddie
So, yeah, so what you’re describing to me sounds a lot like wraparound services, which we’ve kind of talked about in my English class this year. And I know that Hope Springs offers wraparound services, including case management, health and wellness, substance use treatment, stuff like that. Could you explain how a wraparound approach is beneficial for the unhoused community?
Julia
Yeah, I look at wraparound services kind of like a warm blanket that you might not even know that you needed. Wraparound services are sort of, by definition, they’re gap filling services, because this is not straightforward, and sometimes we don’t know what the gaps are. And so it’s up to us to identify different barriers to care and then reducing or eliminating those barriers. I had a lady in Los Angeles area that was living on a riverbed, and her barrier to care was nine cats. It turned out she had end stage cervical cancer but wouldn’t come into my shelter for treatment because of nine cats. So, a doctor, a nurse, and I, we got literally paid to herd cats. We herded the cats. The doctor actually fostered them for about a year while she was initially in treatment, and then when she passed away. And so, understanding what those barriers are, and taking on sort of a whatever it takes attitude to reduce those barriers. So, if the barrier to care is transportation or finances or even a meal, if someone’s too hungry to go somewhere and get the care that they know they need, that’s a pretty easy problem to solve. So, yeah, wraparound services fill the gaps in people’s lives.
Maddie
I love that, filling the gaps. So, one of the biggest factors that we’ve talked about on this podcast that prevents the unhoused community from seeking medical help is the cost. So how does the Hopes Clinic work to make sure that the unhoused community can afford their services?
Julia
Yeah, cost is, is definitely, I think it’s the first thing we all think about. You know, I don’t feel good. What do I do today? I can’t go to the hospital. It’s too expensive. And, you know, is there an urgent care open. And so that you know this population is so busy just trying to meet their basic needs in life that going to the doctor is kind of overwhelming because they’re afraid of the cost. But Hopes receives grants and other funding streams that don’t necessarily cover the cost of patient care, but they will assist with other costs of doing business, which allows the clinic to charge less and allow people who can’t pay their bill to not have to worry about it, in many cases. So, and again, they utilize, they’ve partnered with UNR for a lot of students, for interns to help fill the sort of staffing gaps. So, we have medical students, nursing students, social work students, that can do their clinical time with us and assist the team again as a cost savings. And it gets them great exposure to this population.
Maddie
I love that. I didn’t even know that you guys had a partnership with UNR. That’s good information to know. So, when we’re talking about costs, we also have to talk about insurance, and a lot of unhoused people don’t have insurance. So, would you say that insurance is a necessary part of getting medical treatment, or is it not? And if it’s not, what does that process of treating an uninsured person look like?
Julia
I mean, yeah, insurance is definitely critical. Again, that’s one of the first things most of us think about is, I can’t go to that doctor because they’re not on my insurance plan. Not having insurance is, I think, from my perspective, is becoming less common as we become more aware of the financial implications of allowing folks to be un- or under-insured. You know, in LA we talked about million-dollar Murray, who is from Reno. And you know, when you look at the cost of Murray’s entire life, the cost of not keeping him housed, of not keeping him healthy, of not keeping him incarcerated, at the end of his life, it costs the Reno community a million dollars to keep him alive, and we could have done it for a lot less money. So, we can’t let people just be uninsured and untreated. A lot of folks don’t know that there is a lot of funding out there for the uninsured. Indigent care funds, hospitals provide that. So, if you can’t pay your bill, there’s often a way to figure out how to pay the bill. Yeah, and we can’t just let our neighbors, whether they’re housed or unhoused, we just can’t let them die of curable diseases. And you know, folks, everyone should have access to the same level of medical care whether you do or don’t have insurance, that shouldn’t matter. And many communities around the country have embraced and funded health insurance for the uninsured, and it’s working. It doesn’t work in communities that haven’t embraced it and that refuse to fund it. But the volume and complexity of paperwork and documentation needed to obtain insurance or even to reobtain health insurance once you’ve lost it can be mind-blowing. So, having, you know, like Hopes Clinic has case managers that can work with the population to help them, whether they’re illiterate or they, English as a second language, that can help them complete that paperwork and get insurance, or even partial insurance, help them apply for indigent care funds to help cover their medical needs and that sort of stuff. So, I think fewer people are uninsured in this modern times.
Maddie
Well, that is definitely good to hear. So, I had also previously spoken with Cameron about how medical bills can be a factor that causes people to become homeless. Do you often work with low-income people who may be on the verge of homelessness because of their medical costs? And do you approach their treatment any differently?
Julia
I personally haven’t had a lot of interaction with people who have, you know, lost their housing because of medical bills. What I find is, you know, typically, I meet this population when they’ve been unhoused for a time period, and being able to, you know, get back on top of life in general could include, you know, medical bills. But, you know, I’ve seen, I’ve seen patients come into my medical shelters with, you know, medical bills of a half a million dollars, and they pretty much sort of laugh at it, like, I can’t afford a cup of coffee. How am I going to afford at, you know, a quarter or a half a million dollars in medical bills? But again, one of the things that we do is we help them apply for charity care funds and indigent care funds to help cover those bills. The clinic, Hopes Clinic, partners with Legal Aid to assist with that as well. In 2022, Washoe County alone received $4.3 million in local indigent care funds, and knowing how to access those funds can help a lot of people get out from underneath a tremendous amount of medical bills and medical debt that they might have.
Maddie
Yeah. So, I mean, in addition to indigent care funds, how else do you see legal issues intersecting with your work with these patients?
Julia
A lot of my patients have complicated legal backgrounds, whether it’s evictions that are affecting their ability to reenter the housing community, again, medical bills that just that drop their credit scores, sealing of criminal records, there’s a lot. One of the first things that we do when we bring people into Hope Springs is connect them to Legal Aid to try to sort through all of that and figure out what can be sealed, what we can do with their background to improve their likelihood of employment and long-term housing.
Maddie
Right, I mean, it’s something that I wasn’t even thinking about when I started this project, that, you know, there might be some legal barriers too as far as medical treatment goes. But, something I also saw on the Hopes Clinic website was that Hopes offers a free money management program for patients. I would be really interested to know more about how improving money management can benefit someone’s overall health, if you could talk about that a bit.
Julia
Yeah, so, we have a program, it’s called Healthy Money Habits, and this program teaches the basics of financial literacy that many folks were either never taught or they might have learned so long ago that, you know, it’s not very helpful information today. At Hope Springs, the Healthy Money Management class is a requirement for all of our participants. Hope Springs is a six-month program, so month two and three, the focus is really on money management. What do you have in, for debt? What do you have, and what’s your income potential? That sort of stuff. And just looking at the very basics of finances. What’s a credit score? How can you increase it? How can you, you know, wreck your credit score? As they approach graduation, the conversations will change more to okay, now you’ve got a job, or now you’ve got an SSI (Supplemental Security Income) check coming in the mail. So, this is what your income looks like. What can you afford for housing? You got to keep the cell phone bill going. You’ve got to, you know, we’ll get rid of your storage unit that all your stuff is in, you know, those kinds of things. And looking at the lease, what are the hidden costs in the lease that you might not know to look for. Do you have to pay for a mailbox? Do you have to pay for a parking space? Do you have to pay for snow removal, lawn care? Like, what is your landlord actually charging you for? Yeah, the Healthy Money Habits classes are really important, and when it comes to health care, a lot of folks don’t know the difference between a deductible and a copay, between a coinsurance and your maximum out of pocket expenses. And so, the Healthy Money Habits class includes insurance literacy, so that folks can better understand how to maximize their health insurance benefits and minimize their out-of-pocket expenses. And you know, when they get a bill from a doctor, do you panic? If you don’t understand it, the insurance, then you might panic. Yeah. So, the classes are really helpful all around to help folks with financial literacy, to navigate the complex financial world out there.
Maddie
Yeah. That does sound like a really amazing resource. And so, after discussing all of these factors that go into treating the homeless population, I would like to know, what is the biggest issue that you see when treating homeless patients that needs to be addressed?
Julia
So, I really see two issues. First off, as I said before, I think everyone should have, you know, access to quality health care without that intractable, paralyzing fear of how much it’s going to cost. That shouldn’t be the first thought that we all have, but we do have that in the United States. Too many middle-income folks, low-income, and no-income people are forced to choose between housing and health care, between food and medication, between a trip to the ER for an infected wound or delaying it and maybe having a finger amputated because you waited too long. You know, too many people are afraid to seek proper medical care for fear of deportation, incarceration, and what’s the medical bill going to, what’s it going to cost me financially? Time off from work if you don’t have PTO, how are you going to, you know, we saw that with Covid, if you have to miss a week of work, are you going to lose your housing from it? And, you know, I once had a lady in my shelter with such advanced breast cancer that her breast actually auto-amputated before she ever even saw an oncologist. So, delaying medical care because of fear of these things, it just shouldn’t be that way. We should all be able to have equal access, regardless of our income status or our housing status. And the second piece to that is, I think that everyone should be treated with dignity by every healthcare professional that they meet. Someone experiencing poverty, homelessness, incarceration, who presents with a medical emergency should be treated with the same veracity and urgency that everyone else receives. I had a detached retina years ago, and I woke up that morning and I knew exactly what I had, and I called the eye doctor, and they said, oh, you know, this is a medical emergency. We need to get you into surgery right away. And yet, I’ve seen, I’ve seen folks walk around for a year with a detached retina because they can’t, the medical professionals don’t deem it as much of an emergency for a homeless person as they did for me. Or inmates that are incarcerated that have to wait, you know, a year after their retina is detached to see an eye doctor for it, and by then the damage is permanent. So, there, it shouldn’t be that because you’re part of this population, you don’t get the same, the same medical care with the same veracity and that sort of stuff.
Maddie
No, I totally agree. The whole guiding principle of this project is that healthcare is a human right, and I definitely think that everyone should be treated the same under medical care. So, finally, for our people listening at home who may be interested in volunteering, how would you suggest that the public gets involved? Does Hopes need volunteers, or are there other organizations and areas you know who could use help from the public?
Julia
Yeah, no, that’s a good question. A lot of people are overwhelmed with the need to help, but they don’t know how. Anyone interested in volunteering, should you know, reach out to any of the local nonprofits, like Hopes, Northern Nevada Hopes. There are existing programs that that are adept at serving this population that would greatly benefit from additional volunteers. One of the things that we discourage is well meaning folks with no real experience that try to go out and directly interact with the homeless, handing out supplies, tents, and things like that in the encampments. Those who truly need what you’re offering are often victimized by sort of the bullies who hoard the items and maybe even extort the vulnerable for them. We saw this a lot on Skid Row in Los Angeles. People would just dump a truckload of sleeping bags on the sidewalk, and the people who truly needed it never got it. By partnering with subject matter experts who’ve gained the trust and respect of this population, you know, is helpful. The goodwill of even one volunteer is greatly amplified when that one volunteer is added to an existing team that’s already doing it, already in motion. So, rather than risking going it alone, I would urge everyone to find a solid organization. There’s several around the community, including Hopes Clinic, and they’ll be able to guide you best in how your volunteerism can be amplified.
Maddie
Yeah, something we’ve talked about in my class this year is guerrilla activism, and how that’s something we want to avoid. So, this is a question I definitely wanted to help inform our listeners at home. Julia, thank you so much for bringing the perspective of a medical professional into our conversation, and thank you for the work that you do to treat the unhoused community. I really appreciate you making the time to talk with me today.
Julia
Well, thank you for inviting me. I really appreciate it. Thank you.
SOFT TRANSITIONAL MUSIC
Maddie
After listening to Cameron and Julia, it may seem like the issue of making healthcare more accessible to the homeless and housing unstable communities is too large for us to fix. You may be thinking, where do we start? What could we possibly do to help? Something I’ve learned this semester is that no action is too small in the fight to end homelessness, and the same principles apply to making healthcare more accessible to the unhoused community. By taking small steps toward creating routes toward healthcare, we can help to make medical treatment more accessible for the homeless community. One such organization taking these steps is Immunize Nevada. Immunize Nevada is a nonprofit that is committed to improving the health of the communities in Nevada by providing vaccines for preventable diseases. Their goal is to eradicate vaccine preventable diseases throughout Nevada. Joining me now is Jenna Wong-Fortunato, a community health worker for Immunize Nevada. Jenna, welcome to Treatment Talk.
Jenna, as I mentioned in your introduction, you work for Immunize Nevada. Can you talk about what the organization does, and how do you go about eradicating vaccine preventable diseases?
Jenna
Yeah, of course. So, Immunize Nevada is a nonprofit organization aimed at expanding access to vaccines and providing education regarding vaccines. We do this by planning community vaccine clinics, and we provide funding to allow those who are uninsured or underinsured to receive vaccines at no cost. A common misconception people have about our organization is that we are the ones who provide the vaccines. We actually do not. We partner with different pharmacies that bring those vaccines. We have physical office locations in Reno, Las Vegas, and Elko. However, we travel everywhere in between. So, we go to places like Winnemucca, Gardnerville, Pahrump, pretty much everywhere in Nevada that you can think of, we will go to and provide vaccines if requested. We go about eradicating vaccine preventable diseases by providing the ability to get vaccinated to those who would otherwise go without due to either cost or location.
Maddie
That’s really great to hear, because I know a lot of, like, the rural communities need those vaccines, need access to those vaccines. So, from your experiences, what seems to be the disease that we should most worry about? Also, what are the most common vaccines that you see being administered?
Jenna
So, right now, we are primarily focusing on Covid and Flu. Immunize Nevada became more involved in planning community vaccine clinics when the Covid-19 vaccine became available back in 2021, and we have been continuing to make sure this vaccine is accessible. Additionally, we are also focused on RSV and providing vaccines for those who are eligible. RSV stands for Respiratory Syncytial Virus, and it’s a respiratory virus that can cause serious illness and hospitalization in infants and older individuals. However, during back-to-school season, we primarily vaccinate against meningitis and Tdap, as those are state mandated vaccines for seventh and twelfth graders.
Maddie
So, that definitely means you guys are in demand if there’s, you know, a government requirement for school for a vaccine, or what we’ve seen with the Covid-19 pandemic. So, Immunize Nevada regularly works with individuals who are uninsured or underinsured. That’s what you were telling me earlier. Could you explain what it means to be underinsured?
Jenna
Yeah, so underinsured means that a person has health insurance, however, it may not offer complete financial protection. An example of this would be vaccination coverage. So, an individual may have health insurance, but their specific health insurance plan does not cover the cost of vaccines.
Maddie
Okay, so it doesn’t cover costs. But then what options do underinsured or uninsured people have if they want to get a vaccine?
Jenna
So, an option for uninsured or underinsured children is going to a VFC provider. VFC stands for Vaccines for Children, and it is a federal program that increases vaccine availability nationwide. It provides vaccines at no cost to children who would otherwise not get vaccinated due to cost. On our website, immunizenevada.org, under the caregivers and families tab, there’s a drop-down menu that has “find a provider” as an option. If you click on that, you can search for the types of providers by ZIP code. Uninsured, or underinsured adults can visit a federally qualified health center or FQHC, where vaccines will be offered at low to no cost. And in Nevada, they can also visit our website to find community vaccine clinics near them in the event section at the bottom of our website.
Maddie
And so, Immunize Nevada regularly hosts community vaccine clinics. Can you talk about the process of setting up a community vaccine clinic? Maybe, how many people do you typically vaccinate during these clinics, and what are those costs like?
Jenna
Yeah. So, planning a vaccine clinic has several different steps. So, all of our community vaccine clinics are done in partnership with other community organizations, and we call these our community partners. There are many ways that community partners get in contact with us, but the majority is done through networking, usually at outreach events or conferences. Sometimes we’re introduced through an already existing partner. Sometimes they come across our website and contact us from there. Once a partner reaches out to us, we send them a clinic request form to fill out. This form just has basic information, such as the requested date, time, location, and which vaccines they’re looking for us to provide.
Once they submit this form, it goes to all the community health workers, which I am one of them, and someone from the appropriate region, so, we have community health workers in the north, in the south, and then we also have rural CHWs, who mainly focus on the rural areas, and someone from the appropriate region where that request came from will assume the lead position for the clinic. So, the lead of the clinic is basically the one who’s doing all the planning and setting everything up. And so, once someone takes the lead of a clinic, we make sure to reach out to the requester, introducing ourselves, letting them know that we are the one who is planning the clinic. Sometimes the requested date might interfere or conflict with another event that’s on our calendar or something that we already have on our end, and at that point, we work with the partner to find a date that works for everyone involved. However, this usually isn’t the case. Most of the time we can make the requested date work.
Once we have that date and time kind of set up, then our next step is to secure a vaccinator for the clinic. So, we have several vaccinators that we partner with, and these include commercial pharmacies such as Safeway and Smith’s, as well as federally qualified health centers, including Community Health Alliance. We reach out to one of these vaccinators, and if they have availability, we confirm the details with them, and then once everything is kind of all set in stone, we make sure the vaccinator has availability, we make sure that they know the time, the date, the location, as well as which vaccines they are bringing. We then add that event to our internal calendar to ensure that everyone within Immunize Nevada knows that that event is happening. Again, date, time, location, just to know that that time is busy in that particular location of the state. And then, we will also add this event to our Galaxy Digital site. All of our volunteers and interns are added to this, and this is where they’ll see their volunteer opportunities. So, anything that’s listed on our Galaxy Digital site, anyone who is a volunteer or an intern with us will be able to sign up for them on their own and attend as they wish. And so, as you can see, there is lots of communication involved with various individuals to make sure that the clinic runs smoothly.
And so, the number of people that we vaccinate typically depends on the time of year, the organizing partner, as well as the location where the clinic is being held. When the clinic is during back-to-school season, which typically runs from May through August, we often vaccinate hundreds of people, as Nevada requires all seventh graders, twelfth graders, and those entering kindergarten to have received specific vaccines, which I kind of touched upon earlier. Some clinics are closed, which means the person who’s requesting that clinic is wanting that clinic only for their employees or their clients, and so those ones typically have fewer individuals, since it’s only limited to that particular organization.
And then the cost for each clinic kind of varies again, for each clinic, depending on the vaccinator we work with, as well as how many uninsured individuals we are expecting and how many we actually end up vaccinating. So, when communicating with the requesting community partner, we try to get a gauge on how many individuals are expected to be uninsured. When we get that information, we submit a funding request to our executive director, and this is the amount of money we are requesting to cover the cost of vaccines for those who are uninsured. So, when an uninsured individual gets vaccinated at one of our clinics, the pharmacy who is vaccinating at that clinic will note this down and send us an invoice after the clinic with the amount we’ll be covering. So, the cost of each vaccine varies from around $40 to $250, so we multiply these numbers by the number of expected uninsured individuals with each vaccine, plus some extra cushion, because, you know, sometimes estimates are a little high, sometimes they’re a little low, so just have that little bit of extra cushion to get the estimated cost of the clinic.
Maddie
It makes me really happy to hear that you guys have made allotments for underinsured and uninsured people. So, at these community vaccine clinics, do you regularly give vaccinations to members of the unhoused or housing unstable communities? And if so, what vaccines are they typically needing?
Jenna
So, unless we are in a location that assists the unhoused population, we typically don’t see many of this population at our community vaccine clinics. When we do vaccinate, it’s typically Covid and Flu vaccines. And I feel like this demographic is not necessarily attending our events for a few reasons. The primary reason could be that they don’t know the events are happening. And so, our events are typically advertised online, and if someone doesn’t have access to the internet, they won’t know that the clinics are going on. And in line with that, they may not have the opportunity to learn which vaccines they need and when they are eligible for them, for example, again, the newest Covid vaccine, so they might not know they are eligible to get that vaccine. Another could be a transportation issue. They don’t have a way to get to our vaccine events. And then they just may fear the stigma of being unhoused.
Maddie
Right, yeah. I mean, that’s something that I’ve talked about with other guests, is that among the unhoused community, there is a lack of knowledge about available healthcare services. I know that Immunize Nevada provides education at outreach events. So, how do you think that Immunize Nevada could go about educating the unhoused community on their options for getting vaccinated?
Jenna
Yeah, so I believe that we could go about educating the unhoused community by actually going into their communities and offering to provide resources if they’re interested. These resources could be on vaccine preventable diseases or the vaccines themselves, and we, the community health workers, could also be a resource, or they could ask questions that they may have. And if we gauge that there’s interest in receiving the vaccine in that particular community, we could partner with organizations involved with assisting the unhoused and host a vaccine clinic for them.
Maddie
So, a large part of Immunize Nevada’s mission is educating legislators on immunization and health issues in the community. To your knowledge, has Immunize Nevada ever advocated for legislation about healthcare for low income or unhoused people? And if not, what sorts of legislation might they advocate for?
Jenna
Yeah. So, our Executive Director, Dr. Sherilyn Duckworth, traveled to Washington, DC in September, actually, to speak with legislators about several topics. Some of these included improving Medicare coverage so more individuals qualify and improving interstate immunization records. And so, when someone gets an immunization in Nevada, it’s documented in their Nevada State immunization record, but if they go to another state, that state can’t pull up their records, it’s only in Nevada’s database. So, looking at improving interstate immunization records and improving funding for vaccines for low-income communities. And all of these are a direct benefit and improve the health of low-income and unhoused individuals.
Maddie
So, Immunize Nevada also participates in the Nevada Vaccine Equity Collaborative, which aims to promote the equitable distribution of the Covid-19 vaccine to socially vulnerable populations in Nevada. How have you seen this collaboration working to benefit the unhoused community?
Jenna
Yeah, so, Immunize Nevada co-authors the Nevada Vaccine Equity Collaborative newsletter to give digestible Covid-19 information, and the goal of that is to allow community partners to serve unhoused communities. And some of these community partners, like the Nevada Homeless Alliance, take these resources and apply them to their target populations. By providing up to date information, our community partners can then deliver the best up to date services, which allows equitable and quality care to reach our unhoused community.
Maddie
And so finally, for our listeners who may be interested in volunteering, how would you encourage people to get involved? Are there certain areas of your work that need the most volunteers? I know you mentioned that portal where interns can go to find opportunities. Talk a little bit more about that.
Jenna
So, I would encourage those who are interested in volunteering with us to email our info email, and that email is info@immunizenevada.org. From there, your email will be forwarded to the manager of the appropriate region, so either northern or southern. And then if you live in a rural area, that typically gets either moved to, not necessarily moved, but like you get sorted into northern rural or southern rural. And volunteering with us is an excellent opportunity to get out in the community and see the different types of people that make our state so unique. It’s also an opportunity to learn about different vaccines. And our volunteers primarily help out at clinics and outreach events by helping out with paperwork and answering the more basic questions that patients may have. And before I started working at Immunize Nevada, I was actually a volunteer with the organization for about a year, and that experience made me want to apply as a staff member and just get so much more involved with what we do.
Maddie
That’s an amazing story. I’m so glad to hear that that’s how it worked out for you.
Jenna
Yeah, a lot of the people who work here actually were previous volunteers or interns. So, a lot of people enjoy the opportunity and actually want to get more out of it.
Maddie
Jenna, thank you so much for speaking with me about the steps that our community can take to make healthcare more accessible to the unhoused community. I appreciate the work that you do to keep Nevada healthy.
Jenna
Yeah, and thank you for having me.
SOFT TRANSITIONAL MUSIC
Maddie
The issue of healthcare accessibility for the homeless community is very large and will certainly not be solved overnight. But after hearing from our three guests today, I’ve seen that good work is being done to make quality medical treatment attainable for our community’s most vulnerable people. There is no right answer to solving this problem, but the important thing to remember is that all steps we take forward are steps in the right direction. The conversations we have and the work we do now lay the foundation for more comprehensive and available solutions in the future. Thank you again to Cameron, Julia, and Jenna for helping me to further the conversation around healthcare accessibility for the unhoused. This was Treatment Talk.
SOFT OUTRO MUSIC
END OF PODCAST
JUMP+ 