|Year : 2014 | Volume
| Issue : 1 | Page : 99-102
Street outreach and shelter care elective for senior health professional students: An interprofessional educational model for addressing the needs of vulnerable populations
Cynthia Arndell1, Brenda Proffitt2, Michel Disco3, Amy Clithero4
1 Department of Internal Medicine, University of New Mexico School of Medicine, New Mexico, USA
2 Writer, Healing Hands newsletter, National Health Care for the Homeless Council, Albuquerque, New Mexico, USA
3 University of New Mexico College of Pharmacy and Director of University of New Mexico Health Sciences Center Interprofessional Education, New Mexico, USA
4 Department of Family Medicine, University of New Mexico School of Medicine, New Mexico, USA
|Date of Web Publication||11-Jun-2014|
Prof. Cynthia Arndell
Department of Internal Medicine, University of New Mexico School of Medicine, 1 University of New Mexico, Albuquerque, NM 87131
Source of Support: In the form of grants, equipment, drugs or all of these: La Tierra Sagrada Dean’s Endowed Scholarship Award, "Metropolitan Homeless Project: An Opportunity For University of New Mexico Homeless Patients", 2008, Conflict of Interest: None
Background: University of New Mexico Health Sciences Center (UNMHSC), located in Albuquerque, New Mexico, USA, has an international reputation for developing and implementing curricular initiatives addressing health inequities. The Street Outreach and Shelter Care elective is designed to provide interprofessional service learning opportunities for senior pharmacy and medical students addressing the needs of our nation's most marginalized population-those experiencing homelessness. Methods: Our institution collaborated with multiple community partners serving the homeless to develop, implement and teach a 4-week senior elective for health professions students. During this elective, senior pharmacy and medical student teams provide individualized health care to men in local homeless shelter facilities. Students also participate in street outreach programs across a continuum of homeless populations. Weekly interprofessional education (IPE) faculty-facilitated sessions allow students to reflect on their experiences and learn from other discipline perspectives. Results: Student evaluations uniformly reflect the transformative nature of the rotation since its inception, April 2009. Our outcomes corroborated the findings of similar service learning models developed to sensitize health professions students to the complex challenges of homeless populations. Discussion: Academic centers can play a central role in health education reform by instituting curricula focusing on the primacy of population welfare and just distribution of resources. Senior year is an opportune time to reinforce social accountability among health professions before graduation. This elective is based on adult principles of learning and can serve as an international educational model for developing interprofessional curricular innovations addressing the healthcare needs of vulnerable populations.
Keywords: Academic medical centers, health professions students, health inequities, homeless, homelessness, interprofessional education, service learning, vulnerable populations
|How to cite this article:|
Arndell C, Proffitt B, Disco M, Clithero A. Street outreach and shelter care elective for senior health professional students: An interprofessional educational model for addressing the needs of vulnerable populations. Educ Health 2014;27:99-102
|How to cite this URL:|
Arndell C, Proffitt B, Disco M, Clithero A. Street outreach and shelter care elective for senior health professional students: An interprofessional educational model for addressing the needs of vulnerable populations. Educ Health [serial online] 2014 [cited 2020 Sep 24];27:99-102. Available from: http://www.educationforhealth.net/text.asp?2014/27/1/99/134361
| Background|| |
Central to the education of all health professions is the commitment to address health disparities that exist among our most marginalized populations worldwide. , Improved health outcomes among underserved populations can only be achieved through an interdisciplinary, integrated systems approach that works not only to deliver quality health care but fights the injustices perpetuating health inequities across societies. Traditional medical models of care that focus on the individualistic, biomedical disease model are inadequate for addressing the complex needs of these populations. 
Several studies indicate that care models employing a comprehensive team-based approach result in greatly improved health outcomes for marginalized populations.  Yet, few curricular innovations exist in health professions education nationwide that model collaboration among disciplines, academic centers and community partners to address the complex challenges these populations face. Research supports the fact that US medical students lose their altruism throughout their medical school education. Inadequate training in interprofessional education (IPE) and lack of collaborative service learning opportunities addressing the needs of vulnerable populations contribute to siloed physician practices that perpetuate negative attitudes toward indigent populations and substandard care delivery. 
The University of New Mexico Health Sciences Center (UNMHSC) has an international reputation for implementing curricular initiatives addressing health disparities. Our mission to enhance the health of New Mexicans and their communities is realized through education, research and service. Aligned with this mission, UNMHSC implemented a fourth-year elective for senior medical and pharmacy students addressing the needs of our nation's most marginalized population, those experiencing homelessness.
Homelessness has a strong negative effect on health resulting in mortality rates three to four times higher than the general population. Poor nutrition, exposure to violence, crowded shelters and competing needs for food, housing and income take precedence over healthcare needs and contribute to higher levels of ill health. Not only burdened with inadequately treated chronic diseases, many homeless persons also experience mental illness, substance abuse and fractured social and healthcare networks. Often, mistrust of the healthcare system fosters further marginalization. 
Each year, approximately 17,000 New Mexicans-including single adults, families with children and unaccompanied youth-are homeless for at least part of the year. In Albuquerque, New Mexico's largest city, over 1000 homeless seek shelter every night. 
The overarching goal of the Street Outreach and Shelter Care elective is to provide transformative service learning experiences that enable students to (i) value an integrated team approach to addressing the needs of vulnerable populations; (ii) participate in interprofessional service learning opportunities; (iii) apply advanced practice and advocacy skills in the care of marginalized populations; and (iv) identify resources as well as gaps in current systems and public policies.
| Methods|| |
Faculty from across disciplines collaborated with multiple community partners to develop and implement a four-week senior elective for health professions students. Community partners include Albuquerque Health Care for the Homeless, Albuquerque Public Schools, the Albuquerque Police Department and the Bernalillo County Juvenile Detention Center as well as local shelters and agencies providing services for homeless men, families, children and adolescents. The rotation planning committee employed multifaceted teaching methods based on a literature review of best practices for educating health professions students on comprehensive management of vulnerable populations. ,
The rotation commences with an orientation covering topics on the healthcare needs of homeless individuals, shelter care, harm reduction principles, trauma-informed care, community resources and safety. Senior pharmacy and medical student teams round on patients in three shelters and provide ongoing individualized treatment plans. Student teams also conduct health education sessions and participate in street outreach across a continuum of homeless populations.
During the elective [Table 1], students engage in facilitated weekly IPE case-based discussions exploring interrelationships among homelessness, poor health outcomes and gaps in services and public policies. Reflection on the realities innate in caring for vulnerable populations creates opportunities for students to express frustrations and discuss strategies for preventing provider burnout and cynicism. Sharing perspectives with other health professions peers, faculty and community partners enables students to value each discipline's skills and witness the successes that can occur with an interdisciplinary team and integrated systems approach.  The rotation ends with an IPE session focusing on the health professionals' roles and responsibilities in addressing health inequities and solution-based strategies that promote ongoing advocacy.
|Table 1: Sample weekly schedule for the IPE street outreach and shelter care elective|
Click here to view
| Results|| |
Since its inception in April 2009, 59 health professions students-28 pharmacy and 31 medical students-have participated in this elective. We assessed medical student satisfaction with the elective using the school of medicine's standard evaluation form, which was completed by 90% (n = 28) of participants. Based on these results, outcomes are very positive and similar to comparable curricular initiatives addressing health disparities. ,,,
Using a five-point Likert scale, medical students were asked to indicate their degree of agreement with this statement: "I would recommend this rotation to other students." Responses were on a continuum from strongly agree to strongly disagree, where 5 = strongly agree and 1 = strongly disagree. The mean score was 4.7, indicating that almost all students taking the elective would recommend it to peers. On a continuum of poor to excellent, 93% (n = 26) of students completing the evaluation rated the rotation and faculty as being excellent.
At the rotation's conclusion, students were asked about its strengths; comments included:
- "I admire the medical, associated personnel, and volunteers that allow Albuquerque Health Care for the Homeless and other organizations to function"
- "As a pharmacist, I can advocate for the homeless by first identifying them, educating them on various aspects of their health, and encouraging them to be their own advocates, from housing to their medications to clean syringes"
- "This rotation allowed for diversity in the patient populations and helped me evaluate care plans based on the individual's larger life circumstances"
- "Priceless experience! Rounding with pharmacy students was awesome. They know so much about managing medications"
- "A wonderful rotation. In one month, I learned so much about Albuquerque and its people. It has prepared me to be much more open and understanding of those experiencing homelessness and of those using IV drugs. It will enable me to better care for all patients."
Suggestions for improving the rotation primarily related to the need for better communication with students in the event of last-minute meeting cancellations.
Faculty-facilitated weekly reflection sessions helped assess student reactions to their experiences and what they learned, as well as their plans for ongoing service and advocacy. Students uniformly reported improved confidence in caring for vulnerable populations, working collaboratively in teams, and knowing community resources. After their rotation, several graduate students spearheaded initiatives to address the needs of Albuquerque's homeless persons:
- Pharmacy graduates held a fundraising event for the Saint Martin's Hospitality Center, a day shelter providing services to assist Albuquerque's individuals and families out of homelessness
- Seven medical student graduates and one pharmacy graduate continue to volunteer in homeless shelters; one medical student graduate is developing a student-led homeless clinic during his residency
- Two graduates are developing an interprofessional homeless clinic that will be led by UNMHSC students.
| Discussion|| |
The primary limitation of this rotation is the lack of robust evaluation instruments to measure the short- and long-term changes in participants' attitudes and practice after graduation. Within the next year, we will modify and implement the validated Health Professionals' Attitudes Toward Homeless Inventory  pre-and postrotation. We expect the postrotation survey to reflect significant improvement in student attitudes toward homeless individuals, greater interest in working with homeless persons and increased confidence in self-reported ability to work with vulnerable populations within an interprofessional team. We also plan to develop a survey for postgraduates to assess any ongoing engagement with marginalized populations.
The lack of pharmacy student evaluation data limits our ability to measure outcomes among this cohort taking the elective. In response, future institutional rotation evaluations will incorporate feedback from all health professions students, not just medical students.
Another limitation of this elective is the small number of student participants. As currently structured, participating street outreach teams and shelter agencies cannot accommodate more students. Plans include expanding partnerships with agencies serving the homeless to accommodate more students, and we recently launched an interprofessional student-led outreach clinic, which will allow more students from other disciplines to participate.
As educators, researchers and clinicians, we can play a critical role in implementing curricula that cultivate social responsibility and introduce students to effective models of interprofessional collaboration. Despite the powerful potential to promote improved health outcomes and just distribution of healthcare resources, few educational models exist promoting these principles.
UNMHSC's Street Outreach and Shelter Care elective has created long-lasting, dramatic changes in the beliefs and practices of student participants. Since its inception, student evaluations uniformly reflect the transformative nature of this elective, which results in many graduates' continued work to address the needs of homeless populations. Furthermore, the elective offers a framework for effectively addressing the healthcare needs of vulnerable populations that any health professions' academic institution can implement. The framework's essential components include a solid orientation to the issues, a rich variety of hands-on service learning experiences, interprofessional collaboration, facilitated weekly discussions and input from key community partners.
| Acknowledgements|| |
It took a community to develop and implement this elective. The authors would like to thank the following faculty and community partners for their commitment and immense contributions: Matias J. Vega, MD, Medical Director of Albuquerque Health Care for the Homeless, Dennis Plummer, CEO, Albuquerque Metropolitan Homeless Project and Jessica Casey, Program Manager of Albuquerque Opportunity Center Men's Shelter. We also would like to thank Mary Ellen Gonzalez, MSW, Eduardo Alas, MD, Adrian Lawyer, Director of Transgender Resource Center, Holly Nelson, MD, Debora Bear, NP, Linda Smoker, MD, Katie Braziel, Associate Director of Albuquerque Public Schools Title I Homeless Project, Brother Gerard Sullivan, CEO, Good Shepherd Men's Shelter and Whitney Conyers, Director, Barrett House Women's Shelter. And finally, the authors want to thank all of the community partner agencies' staff for providing our students with rich, transformative learning experiences.
| References|| |
|1.||ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med 2002;136:243-6. |
|2.||American Pharmaceutical Association Academy of Students of Pharmacy/American Association of Colleges of Pharmacy Council of Deans Task Force on Professionalism. Student pharmacist pledge of professionalism. June 1994. Available from: http://www.aacp.org/resources/studentaffairspersonnel/studentaffairspolicies/Documents/pledgeprofessionalism.pdf. [Last accessed on 2014 Jan 13]. |
|3.||Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-58. |
|4.||Schneidermann M, Fernandez A. Case management/multidisciplinary care models. In: Shanahan J, Naglieri C, editors. Medical management of vulnerable and underserved patients: Principles, practice, and populations. New York: McGraw Hill Professional; 2006. p. 151-8. |
|5.||Buck DS, King BT. Medical student self-efficacy and attitudes toward homeless patients. Virtual Mentor 2009;11:32-7. |
|6.||Witte P. The state of homelessness in America 2012: A research report on homelessness [Executive Summary]. Washington, D.C.: National Alliance to End Homelessness; 2012. Available from: http://www.endhomelessness.org/library/entry/the-state-of-homelessness-in-america-2012. [Last accessed on 2014 Jan 13]. |
|7.||Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: A systematic review. Adv Health Sci Educ Theory Pract 2009;14:595-621. |
|8.||Furin J, Farmer P, Wolf M, Levy B, Judd A, Paternek M, et al. A novel training model to address health problems in poor and underserved populations. J Health Care Poor Underserved 2006;17:17-24. |
|9.||Ko M, Edelstein RA, Heslin KC, Rajagopalan S, Wilkerson L, Colburn L, et al. Impact of the University of California, Los Angeles/Charles R. Drew University Medical Education Program on medical students′ intentions to practice in underserved areas. Acad Med 2005;80:803-8. |
|10.||Crandall SJ, Davis SW, Broeseker AE, Hildebrandt C. A longitudinal comparison of pharmacy and medical students′ attitudes toward the medically underserved. Am J Pharm Educ 2008;72:148. |
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