Serving the Vascular Care Needs of the Homeless Population
In This Article
- People with housing instability are at higher risk of serious vascular conditions but often don't receive the timely care necessary to prevent limb loss and other adverse outcomes
- Massachusetts General Hospital responded to this challenge by launching the nation's first—and still only—comprehensive vascular surgery clinic for people who are homeless
- The clinic takes place on a Saturday every three months and is staffed by volunteer physicians from vascular medicine, vascular surgery, and many other specialties
Diabetes, poor hygiene, and inconsistent access to primary care are among the myriad risk factors that leave people with housing instability more susceptible to serious vascular conditions such as peripheral artery disease (PAD). All too often, individuals don't receive the timely care necessary to prevent limb loss and other adverse outcomes.
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Massachusetts General Hospital responded to this challenge by launching a comprehensive vascular surgery clinic for people who are homeless in 2023. Still the only program of its kind in the United States, it provides a wide range of services, from diagnostic testing through surgery.
"Excellence in clinical care, research, and education are essential factors to being an academic center," says Anahita Dua, MD, a vascular surgeon at Mass General and director of the homeless clinic. "But there's also a fourth aspect that sometimes is neglected: social service. Mass General was founded in 1811 in response to a social need. With this clinic, we're going back to the institution's roots."
LEAPP Is the Foundation
The homeless clinic builds off the success of Mass General's Limb Evaluation and Preservation Program (LEAPP), which maximizes limb salvage for patients with PAD through evidence-based and comprehensive diagnosis, treatment, and care. Dr. Dua is the program's co-director.
"LEAPP is designed to handle the entirety of each patient's multidisciplinary care," she says. "A nurse coordinator acts like a Sherpa, coordinating all the patient's appointments so that they get optimal care to reduce the likelihood of limb amputation."
Soon after founding LEAPP in 2022, Dr. Dua set out to bring the same care model to Boston's homeless population. The homeless clinic takes place at Mass General's Fireman Vascular Center on a Saturday every three months.
Care Spanning a Variety of Disciplines
Mass General primary care physician David G. Munson, MD, has been instrumental in spreading the word about the clinic among local homeless shelters. He also works with the shelters to identify individuals in need of vascular care.
On clinic days, Mass General offers transportation to and from the hospital for all patients. Around 30 patients typically attend.
At the clinic, volunteer physicians from specialties including vascular medicine, vascular surgery, podiatry, wound care, physical medicine and rehabilitation, and infectious diseases await the patients. A grant from two medical device companies supports additional staffing, including nurses, medical assistants, a vascular lab technician, and other healthcare professionals, as well as ancillary staff such as security personnel.
Each patient is assigned a volunteer medical student or pre-medical student who accompanies them during their visits to the appropriate specialists. Afterwards, the student joins the patient for lunch in the hospital cafeteria.
Before the patient leaves for the day, a nurse coordinator schedules any necessary follow-up appointments with the various specialties. Since Dr. Munson regularly sees patients who are homeless, he keeps an eye out for any individuals who miss appointments and attempts to get them back on track.
The goal for the clinic, Dr. Dua notes, is to ensure every patient gets the care they need that day and thereafter.
"We're trying to be practical and pragmatic. These patients aren't going to come back for 50 appointments," she says. "We want to be a one-stop shop where we can do most anything that doesn't require general anesthesia—even major debridements—right in the clinic. And then outside of the clinic, we also do bypasses and other complex surgeries."
'We Can Do Our Part'
The homeless clinic hosts a training program to prepare the next generation of providers and performs metrics-based research to assess its impact.
However, the clinic's primary focus is taking a new, more thorough approach to the vascular care of people who are homeless. Historically, Dr. Dua says, vascular teams have visited homeless encampments and administered treatments like creams for wound care.
"You can't just go out on the street and say you're going to provide someone with vascular care," she says. "There's only so much you can do without your ultrasound and your ability to operate."
Offering truly comprehensive vascular care, Dr. Dua asserts, must have a surgical component and requires partnerships with outside entities. For example, the PCP who sees someone with a slowly healing wound must realize they can refer the patient to the homeless clinic. After the visit, the clinic sends the PCP a note in Epic outlining a care plan to execute. A similar model applies for homeless shelters.
"We can't do this all on our own, but we can do our part," Dr. Dua says. "We have the funds, we have the space, and we have the people who are willing to come together on a Saturday to deliver the care in an organized fashion for a patient population that really needs it."