In 2013, the US Department of Housing and Urban Development reported that on a given night, 610 042 people were homeless, with more than a third of this population living in unsheltered locations.1 People who experience homelessness encounter unique obstacles to receiving medical care, including lack of insurance, language barriers, no permanent address or telephone, and competing priorities including the necessity to focus on basic survival needs, transportation, and fear of social stigmatization. Dermatologic concerns are prevalent in the urban homeless population and are rarely reported in the literature.2,3 Therefore, providing timely dermatologic specialty care in an environment convenient for the patient and which reduces barriers is of utmost importance.
There are few published models of providing dermatologic care to this community. We sought to provide access to dermatologic specialty care through a patient-centered, service-learning model. Targeted training programs and service-learning models in the underserved community are effective, and useful in meeting specific needs, while teaching trainees particular skills and providing trainees with attending physician role models who exhibit a community service ethic.4 Our program's goals include providing high-quality care to underserved patients, educating primary care providers in basic dermatologic care, and teaching residents to deliver care in a resource-limited environment.
Boston Health Care for the Homeless Program (BHCHP), a unique community health center, provides access to high-quality medical care to people who lack housing. In 1998, Dr Ernesto Gonzalez began providing free dermatologic consultative services to BHCHP patients, and in 2009, a comprehensive experience with BHCHP was integrated into the Harvard Dermatology Combined Residency Program curriculum. Monthly, dermatologists and dermatology residents provided consultations in a medical respite program and outpatient clinic to avoid patient dislocation with transportation to tertiary facilities. Didactic sessions for primary care providers and teledermatology services were also integrated.
During an 18-month period, the impact of the BHCHP experience on resident participants (n = 10) was reviewed. Ninety percent of residents rated the experience as good or outstanding. All residents (100%, 10 of 10) stated that the program provided a unique and valuable experience and the chance to care for a population they would not have otherwise been exposed to. Additionally, all residents indicated that they would like to continue participating in community service activities or caring for underserved populations in the future.
This valuable educational program represents a collaboration between BHCHP and the departments of dermatology at Brigham and Women's Hospital, Massachusetts General Hospital, and Beth Israel Deaconess Medical Center. BHCHP has allowed for the education of both dermatology residents and primary care providers in the care of this population. Dermatology residents have learned about skin diseases common among individuals who stay in congregate shelter settings or sleep outside and they have seen firsthand the challenges homelessness presents to accessing health care services. Expansion over the past 2 years includes bimonthly clinics, basic procedural and dermatopathology services, skin cancer screenings, and a study investigating demographic data and program review. This collaborative, community-based model for delivering dermatologic care offers residents a unique experience in service learning, while providing patient-oriented care for homeless individuals with dermatologic conditions.