By Amy Moore, PA-C, DScPAS, Patrick Muehlberger, MD, Hans Bruntmyer, DO, MPH

Street Medicine

San Antonio Inaugural Review

By Amy Moore, PA-C, DScPAS; Patrick Muehlberger, MD; Hans Bruntmyer, DO, MPH

Background

Dr. Hans Bruntmyer, a retired military emergency medicine physician, had a career that largely revolved around being comfortable with the uncomfortable and was no stranger to practicing medicine in austere environments. When he and his family relocated to San Antonio following his military retirement, he was moved by the obvious need for improved access to medical care for the most vulnerable in our society — those who lack shelter, transportation, basic safety and support. He was already familiar with the Street Medicine movement, originally founded by Dr. Jim Withers of Pittsburgh, and began networking with Dr. Withers and other Street Medicine program directors in 2015.

During the next few years, Dr. Bruntmyer began to see the reality of creating a Street Medicine — San Antonio program (SMSA) and, in January of 2019, Dr. Bruntmyer began leading “backpack medicine” teams onto the streets of San Antonio to care for unsheltered individuals. Since those first “Street Rounds,” the organization has grown in size and scope, beginning with a single physician and student volunteers to now including three emergency medicine physicians, advanced practice clinician-led teams, nursing teams and a behavioral health component – Street Smart, in addition to countless volunteers of varying levels of training and across a range of professions. Despite his experience to that point, Dr. Bruntmyer could not have imagined the relationships formed or personal and professional growth that would be experienced by himself and all of the volunteers.

Over two years have elapsed since the first backpack medicine mission by SMSA. The organization intends to publish regular research to support the development of future Street Medicine programs, educate the medical community on care for the homeless, and to help this program evolve in order to make a greater impact on its patients, San Antonio street sleepers, present and future. The authors believe that the first step in that process should be a 100% indepth patient chart review to systematically understand patient and organizational needs over SMSA’s first two years of service. Protocol approval was obtained from the University of the Incarnate Word Institutional Review Board on February 15, 2021 (FWA00009201). This study is an outcome evaluation design of Street Medicine — San Antonio from January 1, 2019 to December 31, 2020.

In preparation for the review, a Google Scholar search was conducted between December 1, 2020 and December 31, 2020 to identify Street Medicine program evaluations. Key terms included Street Medicine, Street Medicine review, Street Medicine program evaluation, Street Healthcare and Street Healthcare program. The literature review resulted in three distinct Street Medicine program capstone projects and/or publications1-3 and one case series obtained from the annual Street Medicine Symposium.4 Additionally, eight articles obtained provided additional research related to Street Medicine Programs, such as resident and patient experiences, and in-depth looks at current data and issues that are unique to providing health care for the homeless, both locally and nationwide.5-12 The authors are grateful to contribute to the limited existing field of Street Medicine literature.

Results

Paper charts were pulled for each patient seen during this timeframe and a single investigator scrubbed each chart for basic demographics (Figure 1), major ailments treated (Figure 2) and supplies utilized (Figure 3). Referrals to SMSA from local social work organizations including Centro San Antonio, Chris-

FIGURE 2 FIGURE 3

FIGURE 4 FIGURE 5

tian Assistance Ministries and SAMMinistries were also tracked, in addition to referrals Street Medicine made to the above social work organizations for assistance (Figure 4). Finally, the authors tracked SMSA provider referrals for follow-on medical care (Figure 5). Discussion

During its first two years of operations, SMSA provided care to 220 patients over 419 encounters. 71 percent were male. The majority of patients, 163, had one encounter with SMSA. Four patients were treated over 10 visits. The maximum number of visits

for a single patient was 45. Ages of patients ranged from 21 through 82 years. Ages were estimated by decade for 24 patients. 35 charts did not have ages or approximations.

The two most common ailments treated were infections/acute wounds and musculoskeletal pain, together making up 56% of total acute conditions. Osteopathic manipulation was performed by Dr. Bruntmyer, the sole DO physician, whenever possible. NSAIDS, Tylenol and triple antibiotic ointment were the most common medications administered. Wound care supplies were provided for 69 patients; three of these had incision and drainage performed. 19 patients received orthopedic supplies, including splints and braces.

Local social work organizations referred 46 patients to SMSA for acute medical conditions. SMSA referred 17 patients to local social work organizations for assistance, including ID card retrieval, housing and detox programs. Housing was achieved for nine patients during this two-year timeframe. 69 patients were evaluated at a local shelter, with all others being evaluated on the street.

Upon recommendation of SMSA providers, 10 patients went to the ER following a street encounter. Of these, four were escorted by SMSA providers or EMS, and three resulted in subsequent hospitalization and/or surgery. 11 patients refused ER evaluation. Specialty referrals included general surgery, dental, podiatry and ophthalmology. All evaluations, treatments and operations were provided pro-bono. PCM referral included pre-established PCMs at the community hospital and VA, in addition to public and church-run clinics.

Conclusion and the way ahead

SMSA has grown in size and scope over the past two years. This evaluation will be utilized to develop further training and build needed inventory. Future goals include wellness fairs for street sleepers which will focus on health education and preventive medicine. Additionally, SMSA plans to conduct training seminars for the medical community and potential SMSA volunteers to discuss lessons learned about how to best connect with and care for this unique population. In the summer of 2021, SMSA was approved for Americares Medical Outreach medication distribution program, which will greatly affect the ability of the organization to provide a broad spectrum of prescription medication to its patients.

The review has also highlighted the importance of streamlining documentation. Beginning in February of 2021, SMSA has transitioned to an EMR. This has already aided in building patient trust and ensuring continuity of care when seen by multiple providers. Furthermore, as a result of this review, SMSA intends to track more specific and consistent demographic information, diagnoses, past medical history, social work needs and referral status. Last, but not least, SMSA intends to keep its close relationships with community partners to both accept and refer those in need. The ultimate goal of the SMSA, to care for San Antonio’s most vulnerable, has not changed.

References 1. Edwards, A. L. (2017). Street medicine: A program evaluation. Georgia State University. https://scholarworks.gsu.edu/iph_capstone47 2. Waara, A., Abraham, K., & Mason, W. (2017).

Street medicine Detroit annual report. https://static1.squarespace.com/static/509c2caae4b0c7861e4 b4512/t/5ad93db9562fa7843a6cc941/15241865 80889/Street+Medicine+Detroit+Annual+Report+2017.pdf 3. Hemba, K. E., Simon, R., & Weinstein, L. D. (2013). JFMA street outreach: A resident-run street medicine program. A retrospective chart review examining the needs of a vulnerable population and services provided. Department of Family & Community Medicine Presentations and Grand

Rounds. Thomas Jefferson University. https://jdc.jefferson.edu/fmlectures/16 4. Howe, E. C., Buck, D. S., & Withers J. (2009, October). Delivering health care on the streets: challenges and opportunities for quality management.

Qual Manag Health Care, 18(4), 239-46. https://doi:10.1097/QMH.0b013e3181bee2d9 5. South Alamo Regional Alliance for the Homeless (SARAH). (2020). 2020 Point in time count report: San Antonio and Bexar County.

http://www.sarahomeless.org/wp-content/uploads/2021/03/PIT2020-OnePager-Updated03.05.2021.pdf 6. Doohan, N. & Mishori, R. (2020). Street medicine: Creating a "classroom without walls" for teaching population health. Med. Sci. Educ., 30, 513-521. https://doi.org/10.1007/s40670-019-00849-4 7. Maness, D. L. & Khan M. (2014, April 15). Care of the homeless: an overview. Am Fam Physician, 89(8), 634-40. PMID: 24784122. 8. DeVoe, J. E., Likumahuwa-Ackman, S., Shannon, J. & Steiner Hayward, E. (2017, April). Creating 21stcentury laboratories and classrooms for improving population health: A call to action for academic medical centers. Acad. Med., 92(4), 475-482. https://doi:10.1097/ACM.0000000000001385 9. Christensen, A. (2015). Patient satisfaction & knowledge of services: An evaluation of a street medicine program. Georgia State University. https://scholarworks.gsu.edu/iph_theses/423 10. Capelli, K. (2020). Is street medicine effective in improving access to healthcare? Student Research

Poster Presentations 2020. Misericordia University. https://digitalcommons.misericordia.edu/research_posters2020/43 11. Smith-Graham, S. (2017). Understanding the role street medicine programs play in the career trajectories of student volunteers who choose to work with underserved populations. Georgia State University. https://scholarwords.gsu.edu/iph_theses/503 12. Arndell, C., Proffitt B., Disco M. & Clithero A. (2014, January-April). Street outreach and shelter care elective for senior health professional students:

An interprofessional educational model for addressing the needs of vulnerable populations. Educ

Health, 27, 99-102. https://doi:10.4103/1357-6283.134361 Amy Moore, PA-C, DScPAS is an active duty Army emergency medicine physician assistant and faculty member of the Army-Baylor Emergency Medicine Physician Assistant degree/residency at Brooke Army Medical Center. She joined SMSA in January of 2020.

Patrick Muehlberger, MD, an emergency medicine physician, is an Assistant Clinical Professor at the University of the Incarnate Word-School of Osteopathic Medicine and faculty of the Uniformed Services Health Education Consortium Emergency Medicine Residency. He was one of the first team leads for SMSA and serves as one of the two Assistant Medical Directors and Emergency Department Liaisons within the organization. Dr. Muehlberger is retired from the U.S. Air Force.

Hans Bruntmyer, DO, MPH is an emergency medicine physician and is the founder and Medical Director of SMSA. SMSA is the flagship project of Imago Dei Ministries, of which Dr. Bruntmyer is a founding member and acting Secretary. He also serves as Assistant Clinical Professor and Director of Outreach Medicine at the University of the Incarnate Word-School of Osteopathic Medicine. Dr. Bruntmyer is retired from the U.S. Air Force and is a member of the Bexar County Medical Society.