Nurses Driving Innovation in Community-Based Care
Even before the COVID-19 pandemic and current economic crisis, the number of people experiencing homelessness in the United States was trending upwards. Research suggests that there are over 550,000 people experiencing a state of homelessness in the United States, which often coincides with both physical and mental health challenges. The current crisis is also demonstrating the essential, tireless and innovative spirit of health workers in ensuring strong, resilient health systems for everyone, everywhere. Healthcare organizations and professionals are stepping up in ways we could have never imagined. At Johnson & Johnson, we are committed to supporting frontline health workers, their patients and the community as we navigate the unprecedented challenges of COVID-19.
As the most trusted healthcare profession, nurses are in a unique position to lead in community-based care and improve health outcomes for our most vulnerable populations. The Johnson & Johnson Notes on Nursing team recently spoke with five nurses to hear how they are continuing to deliver care in the midst of COVID-19 and learn more about the innovative solutions they are driving to improve access to care and help advance racial and ethnic health equity in their communities.
(Joy Fernandez de Narayan pictured right in the first image)
Dr. Joy Fernandez de Narayan, FNP-C, decided to pursue nursing because she’s always been passionate about helping the underserved. In 2013, realizing she didn’t need to travel far to find a mission, Joy joined Mercy Care, an Atlanta-based healthcare for the homeless program that has returned to its “Street Medicine” roots by providing primary care, psychiatry, substance abuse counseling, transition services and more to those in need. Now acting as Mercy Care’s Street Medicine manager, Joy and her small but mighty multidisciplinary team are adapting to challenges presented by COVID-19 and helping improve health outcomes for Atlanta’s most vulnerable.
J&J: How has COVID-19 affected your team and work?
Joy: We estimate there are more than 800 people experiencing homelessness in our area, but our program only sees around 300 unique clients a year. This year, due to COVID-19, that number has dropped to almost half—not because our populations decreased, but because we paused close-contact outreach in the spring and are now experiencing less operational support from volunteers and universities. There was already a feeling in this work that there weren’t enough people and resources to go around to everyone we wanted to reach. And now, during COVID-19, having less operational support has meant seeing and charting fewer clients.
I will say a silver lining of having to chart less has been that we are able to stay out on the street longer, doing more outreach and canvassing the city. After resuming operations in July, we’ve donned heavy personal protective equipment (PPE) in the summer heat and handed out educational flyers on COVID-19, provided masks and hand sanitizer, refilled medications for chronic patients, and ensured that people have had something to eat. As local soup kitchens have shut down, volunteers have leveraged the donated food to create over 500 meal kits per month, which we distribute on the streets. I believe due to our efforts to inform our clients about COVID-19, Atlanta’s homeless population wasn’t affected as severely as other populations across the country.
Now as winter is approaching and the temperatures start to drop, we’re concerned about potential new surges of COVID-19 and the effect that may have on emergency shelters that often protect dozens from the wind chill. Our team is now working to coordinate sub-zero sleeping bags that will keep individuals both safe and comfortable.
J&J: What’s something you wished people knew about your work and mission?
Joy: As healthcare has moved toward a clinic-based model, part of what makes our work innovative is that we’re embracing almost a “house call” model, actively seeking out those who may be resistant to care. We don’t have a lot of the same barriers other health systems face, and therefore can focus on relationship-based and culturally competent care. I think part of the reason we’ve been so successful and programs like ours are starting to spread internationally is because of the good relationships we have been able to build with our clients, many of whom have a large mistrust of health systems. We understand the importance of affirming dignity and humanity for those we interact with and making them feel like we are all in this together. Nurses especially have a lens that allows them to see the full person and understand what health and well-being means for them. Homelessness if something that is easy to fall into, but really hard to climb out of. I would love for more people to be curious and empathetic, and to imagine what it must be like for our clients. We often judge because we don't understand.
A community nursing internship during her undergraduate work in Boston, Massachusetts inspired Pooja Bhalla, DNP, RN, to focus her nursing career on helping those experiencing homelessness after she saw first-hand the connections nurses were able to make with people they touched. Now as the Chief Operating Officer of the Illumination Foundation, a non-profit organization in Orange County, California dedicated to disrupting the cycle of homelessness, she’s overseeing the foundation’s innovative operations for medical care and housing and leading local efforts to help mitigate the COVID-19 challenges facing those experiencing homelessness.
J&J: What are some of the innovative ways the Illumination Foundation helps improve access to care and resources for those experiencing homelessness?
Pooja: We understand when individuals experiencing homelessness come into our care, they have likely experienced years of trauma and have no access to services– including healthcare or housing. They also often have untreated chronic health issues, as well as mental health issues. In addition to providing them with appropriate medical care, our focus is getting them into housing to help disrupt the cycle of homelessness. We assign them to a multidisciplinary team of healthcare workers, case managers, social workers and housing navigators who get them started on a continuum of care by addressing their health needs, helping to obtain any missing identification document and connecting with critical resources such as job training and housing.
We have an evidence-based system that has helped place more than 1,300 people in the right level of housing, and for many this means shared housing and a support system. We work with partners to purchase single family, multi-bedroom homes where we can place people based on their mental and physical health. By creating these micro-communities, we’re offering an innovative solution that helps provide our clients recuperative care as well as a support system. Residents in our micro-communities receive comprehensive services designed to improve housing retention, health and well-being, food security, safety and address social isolation while increasing economic opportunity, resulting in restored hope and housing stability. Our communities help our clients look after themselves as well as each other, and better sets them up for long-term success. Illumination Foundation addresses the social determinants of health by providing integrated system of care to meet each individual wherever they are in that continuum of care.
J&J: How has the Illumination Foundation been helping those experiencing homelessness amid COVID-19?
Pooja: This March, the Orange County Health Care Agency reached out to ask if we could run the COVID-19 program for people experiencing homelessness for the entire county. We were uniquely suited execute the program and get it up and running quickly because of our experience responding to crisis events and our deep relationships with the local nursing community. We turned hotels and motels into patient sites that have seen more than 1,900 patients to date. As we were constantly taking in new patients, our rapid response team assessed needs on the street.
Our team has faced quite a few challenges over the past few months, such as overcoming stigmas within the community and keeping up with the influx of people coming in for care. We also had to quickly figure out how we were going to separate presumptive positive from positive COVID-19 cases so the patients wouldn’t be on the same floor. We developed a screening system that helped us keep up with the influx of new patients and establish rounds that could best address patient needs. Our COVID-19 rapid response program began with six sites and is now down to three covering Orange County. But our mission hasn’t slowed down. As rates begin to rise again and restrictions loosen, we’re still focused on containing the virus within our vulnerable communities.
(Bre Loughlin pictured left and Tracy Zvenyach pictured right in the first image)
Frontline nurses Bre Loughlin, MS, RN, and Tracy Zvenyach, PhD, APRN-NP, combined their passion for technology and expertise in health policy to create Nurse Disrupted, a pandemic management response start-up that is striving to identify fast, technology-based healthcare solutions for vulnerable populations. When Bre and Tracy heard that Porchlight, their local men’s shelter in Madison, Wisconsin, needed help screening for COVID-19, they sprang into action to develop a virtual screening system and help mobilize volunteers to ensure safety for both guests and staff.
J&J: What was the inspiration behind your virtual screening tool and how has it helped improve health outcomes at the shelter?
Tracy: Bre and I have always been passionate about helping our community, and the community’s need at the time was screening for COVID-19. Early in the pandemic, homeless shelters were sending anyone showing potential COVID-19 symptoms to emergency departments and it was overburdening our health systems. There were women and men who needed to be screened before entering shelters, but there was no solution in place that could screen them effectively and properly while keeping volunteers and staff safe. At the same time, opportunities for nursing students in our state to complete their clinical practicum hours were depleted, as many programs were paused. It was both a challenge and an opportunity for us to implement a virtual screening solution for our local shelters and support the future nursing workforce.
Since April, Nurse Disrupted has completed over 9,400 virtual screenings for Madison’s homeless population and connected nursing students from four different nursing programs to this work. We started with two donated tablets and four nurse volunteers. Now we have over 160 nurse volunteers and have helped nursing students fulfill over 550 practicum hours. As Bre has been working to constantly innovate our virtual screening technology, I’ve been working to grow our academic partnerships, onboard new nurse volunteers, and keep updated on the latest COVID-19 guidance and regulations. In over seven months, we have had no major outbreaks at the women’s and men’s shelters that we support.
J&J: What are some of the challenges you faced when trying to implement your virtual screening tool?
Bre: Healthcare technologies can be really complex, and we knew if we wanted our solution to be successful, we had to make it easy to use. We wanted to create a digital clinical decision support tool that was grounded in science and could quickly be deployed and allow us to collect data. We knew our screening had to be fast, so that it wouldn’t hold guests too long from getting a hot meal or place to sleep. We decided the safest way to conduct the screening would be to have the shelter guests walk up to the tablet upon entering the shelter and our volunteers conduct the screening on video in a remote location. We landed on a screening that averages under a minute and asks them 11 specific screening questions. As we’ve navigated remote access and a technology literacy barrier for many of the guests, it’s reinforced the importance of leaning into technology that is simple—and remembering to have compassion for the people we interact with. We made it a point to train our volunteers on how to communicate effectively and with compassion.
And I believe that as nurses, Tracy and I were uniquely suited to bring a solution like this forward. Nurses understand the importance of evidence-based practices. Nursing is the most trusted profession for a reason—we develop relationships with the people we interact with and see the full picture of a patient experience. We know that for this population there might be factors unrelated to COVID-19 that contribute to headaches or a cough. Overall, the staff and volunteers we work with really love the technology, and we have really laid the groundwork to expand our solution to help more communities in need. Our next focus is working with K-12 school districts. We can help schools with a simple software solution to ensure that COVID-19 screening, testing and contract tracing data are documented and reported systematically for administrators and to public health departments. We can also extend the reach of school nurses with our technology setup to serve more schools and students at once. We are in it for the long term to build fast and simple technology solutions to protect and improve the health of vulnerable populations.
When Dr. Adrian L Mesa, DNP, APRN, PMHNP-BC, FNP-BC, decided to work at Camillus House, a non-profit organization that helps provide healthcare, shelter and social services to vulnerable communities in Miami-Dade County, Florida, it changed the trajectory of his career. His experience inspired him to take healthcare “curbside” and implement a program at the University of Miami that paired nursing students with organizations working to address health and societal inequities. Now the founder of AMP Group-Mental Health Services, Adrian is leaning into his passion for delivering mental health care and working with the Miami Homeless Assistance Program to bring his insights to help those experiencing homelessness in Miami, nationally and across the globe.
J&J: How are you working to implement innovative models of care in your local community?
Adrian: When I joined the University of Miami, my project was based on ways that we could decrease lengths of stay and the utilization of emergency rooms in our local hospitals. The initiative we created leveraged nursing students’ talents in a new way to help the community and give the students a well-rounded educational experience that instilled empathy and compassion. COVID-19 has since frozen this program, but now I’m looking to apply this innovative thinking to my volunteer work with the Miami Homeless Assistance Program. We should be thinking about how we can use our nursing students who are struggling to make clinical hours, by offering their help in providing care to those who need it now more than ever. We should be partnering students with food pantries and other local organizations that already have strong community ties and trust.
Without being present, it’s hard for students to truly understand the cardboard box that the patient sleeps on, the highway over pass that shields them from the rain or the hundreds of other homeless individuals that huddle in the area. If more programs that connect nursing students with our vulnerable communities can spread nationwide, we’ll be able to build an empathy that will transform patient care moving forward. The work we are doing goes beyond delivering medications, it’s about the relationships we are developing with those on the street. It’s work that cannot be done without a team of passionate volunteers, students, case managers, nursing assistants, social workers, outreach workers and organizations coming together to help serve those who are pushed aside and marginalized by society.
J&J: What’s something about your work or about the populations you serve that you would like people to know?
Adrian: For me, this work is personal. I witnessed first-hand how my uncle battled with his mental health, and whenever I encounter a challenging patient, I think about him. I think there are times when people with a mental illness are mistreated in health settings because they are being seen during their worst states—so I always try to picture the person’s family or what they were like as a child. I wish people were able to rewind time to see the traumas, neglect and abuse the individual experienced so they could be more understanding. Similarly, I think many people attribute homelessness to drug or alcohol abuse, when really it can be caused by a wide array of factors such as lack of access to mental health care, unemployment and the high cost of living in these areas. I wish more people knew that individuals who live in a state of homelessness often experience depression, insomnia and anxiety, and that COVID-19 has really exacerbated the mental health crisis this country was already facing.
 The Council of Economic Advisers. (2019, September). The State of Homelessness in America. Retrieved from https://www.whitehouse.gov/wp-content/uploads/2019/09/The-State-of-Homelessness-in-America.pdf