Homelessness is a major public health problem in the United States.[1]
[2] According to the 2018 Annual Homeless Assessment Report to Congress, on a single
night in 2018, more than 550,000 people were experiencing homelessness in the United
States.[3] A recent study showed that 4.2% of individuals in the United States experienced
homelessness for at least 1 month at some point in their lives and 1.5% experienced
homelessness in the past year.[2] Eye health among the homeless community is of paramount importance, as poor vision
makes this population particularly vulnerable and adds, significantly, to the social
and health burdens.
The homeless population has been found to have high rates of uncorrected refractive
error,[4]
[5]
[6]
[7] cataract,[6]
[7]
[8] retinal disease,[6] and glaucoma.[7]
[8] Visual impairment has also been associated with unemployment.[9]
[10] Further, it has been suggested that screening for visual problems and providing
free spectacles may improve the quality of life and earning potential of homeless
individuals.[5] Despite this, there is a paucity of literature on the eye care needs of the homeless
population; little is known about how homeless patients access eye care[4] or if/how their eye care needs are met.
In 2017, we created a free eye clinic in San Francisco at a homeless shelter to help
bridge these gaps. The primary goal of our eye clinic is to meet the eye health needs
of its residents in an effective and sustainable manner. Secondary goals of the clinic
include teaching medical students basic principles about the eye examination and ophthalmologic
decision making, and increasing medical student exposure to ophthalmology and community
service as potential career choices.
As there are no papers to date on methods to develop a sustainable free eye clinic
for homeless patients, our purpose is to outline the methodology and strategies that
we employed to develop our free eye clinic. Our hope is that these strategies may
serve as a template that will catalyze further efforts elsewhere.
Key Steps and Strategies
The key steps and strategies to develop a sustainable, free eye clinic for the underserved
are described below.
Analysis of Needs
The first step to develop an impactful clinic is to identify the need. According to
the 2018 Annual Homeless Assessment Report to Congress, half of all people experiencing
homelessness were in one of the following five states: California, New York, Florida,
Texas, and Washington.[3] In 2018, California, Hawaii, and Oregon were found to have the highest rates of
homeless individuals with 50 or more individuals per 10,000 individuals.[3] Further, the highest rates of unsheltered homeless individuals in 2018 were California,
followed by Oregon, Nevada, Hawaii, and Washington.[3]
Homeless individuals are at increased risk for various adverse health outcomes and
are three to four times more likely to die compared with that of the general population.[11] Specifically, eye health among the homeless population is an important consideration.
Homeless patients also have poor rates of blood pressure[12] and glycemic control,[13] which highlights the importance of addressing these cardiovascular and ophthalmic
risk factors when serving this population.[14]
Homeless individuals are often high utilizers of the healthcare system.[15] Homelessness is associated with significantly higher emergency department use[16]
[17] and hospital inpatient use compared with the general population that leads to substantial
excess healthcare costs.[18]
[19] Taken together, this suggests that additional safety nets and services are needed
to support the healthcare needs of the homeless population. Given the high rates of
homelessness in California, the need for ophthalmic care in the homeless population
and its association with high healthcare costs, we addressed the need for a free eye
clinic in San Francisco at a homeless shelter.
After performing a literature search to better understand the eye health needs of
this vulnerable population, we identified a homeless shelter where we could offer
our services. We leveraged infrastructure at an existing clinic that already had a
physical space and the workforce in place to serve homeless individuals. Specifically,
we identified a homeless shelter that already had a relationship with our institution.
This homeless shelter had biweekly urgent care clinics and monthly podiatry and dermatology
clinics that were run by volunteers from the University of California San Francisco
(UCSF) Medical Center and School of Medicine. We approached the leadership of the
homeless shelter and confirmed that the shelter would be willing to add an eye clinic
to their services. We recommend a similar process of approaching the leadership of
a homeless shelter even if one does not have a preexisting relationship with a clinic.
We then conducted a preliminary qualitative study including informal interviews with
patients residing at this homeless shelter. The interviews consisted of a total of
three interview sessions over a 2-month period where the ophthalmology resident and
medical student volunteers canvassed shelter residents about their eye health. Specifically,
residents were asked the following: (1) their personal medical and eye health history,
(2) how they viewed the importance of their own eye health, and (3) barriers to access
eye care. This allowed us to further explore and characterize the ophthalmic needs
and potential obstacles to effectively provide care. Through these interviews, a total
of 36 residents were interviewed. We learned that people residing at the shelter had
high rates of uncorrected refractive error (67%), diabetes (83%), and hypertension
(61%). Seventy-five percent of those we spoke to did not know that untreated diabetes
and hypertension could affect their vision. Further, 22% reported that they desired
to apply for jobs; however, vision loss prohibited them from doing so.
We also identified several obstacles in meeting these needs, including difficulty
obtaining affordable spectacles and navigating the complex healthcare system. Many
residents did not know how to schedule an eye appointment, while others expressed
distrust in the healthcare system. Some believed that providers would not effectively
address their visual complaints, while others reported that seeking out eye care would
be fruitless, as they believed that their eye conditions could not be treated. By
interviewing residents at a homeless shelter, we highlighted the need to address ophthalmic
diseases at this specific shelter and identified barriers to care to maximize our
impact.
Identify Champions and Stakeholders
When identifying champions and stakeholders, it is critical to identify interested
parties who are invested in serving the homeless population. Once the decision was
made to open the clinic, we presented our idea to the UCSF Department of Ophthalmology
Program Director, UCSF Department of Ophthalmology Chair, and UCSF Department of Ophthalmology
Director at the Zuckerberg San Francisco General Hospital to solicit their support
for resident participation, department and faculty involvement, and patient referrals,
respectively.
The key leaders, volunteers, and partnerships to develop a sustainable, free eye clinic
at a homeless shelter are outlined in [Table 1]. In addition to finding a faculty and resident champion, it is important to identify
passionate volunteers who can realistically and regularly operate the clinic. Our
eye clinic is run by a combination of premedical and medical student volunteers. The
medical student coordinators were recruited first by a combination of sending list
serve e-mails to the UCSF medical students, those in the UCSF Ophthalmology Interest
Elective, and word of mouth. After confirming a 1-year commitment, the medical student
coordinators were selected and they in turn recruited the medical student volunteers
along with premedical students from a local college. This dedicated team allocates
tasks, so that the workload is evenly distributed while also ensuring that the volunteers
are serving at the level at which they have been trained ([Table 1]). Based on conversations with our volunteers, it was ensured that volunteers work
at their highest level of ability that maximizes their satisfaction and efficiency.
At the conclusion of each clinic, the team comes together to discuss learning points
and identify areas of improvement.
Table 1
Key personnel to develop a sustainable eye clinic
|
Key personnel
|
Role
|
Examples of tasks
|
|
Leaders
|
|
|
|
Faculty champion (n = 1)
|
• Acts as liaison between the Department of Ophthalmology and the clinic
• Invested in clinic sustainability
|
• Forms the partnership between the shelter clinic and the Department of Ophthalmology's
institution
• Helps obtain funding for the clinic
• Checks in regularly with the resident champion to identify problems and find solutions
• Recruits attending volunteers
• Mentors research projects
|
|
Resident champion (n = 1)
|
• Oversees main clinic operations
• Acts as liaison between the Department of Ophthalmology and the medical students
|
• Presents for the majority of the clinic sessions
• Finds solutions to optimize clinic flow
• Teaches medical students
• Recruits attending and resident volunteers
• Applies for funding
• Performs research
|
|
Medical student coordinators (n = 2 to 3; combination of first and second year medical students)
|
• Prepare for and run each clinic session
• Represent the interests of the medical student volunteers
• Represent the School of Medicine
|
• Present for all clinics
• Communicate with service partners before and after clinic to coordinate referrals
• Recruit medical student volunteers
• Enforce clinic schedule and timeliness
• Assist in data collection
• Learn about ophthalmology as a career
|
|
Undergraduate premedical student coordinators (n = 2 to 3)
|
• Help run each clinic
• Support the medical student coordinators
|
• Equipment setup
• File patient charts
• Assist in data collection
• Learn about ophthalmology as a career
|
|
Volunteers
|
|
|
|
Attending volunteer (n = 1)
|
• Oversees the clinic
• Ultimately is responsible for the care delivered
• Teaches learners of all levels
|
• Confirms the diagnosis and management of each patient
• Signs off on each patient encounter
• Performs a wrap up teaching session
|
|
Resident or fellow volunteer (n = 1)
|
• Assists and teaches the medical student volunteers
• Mentors the medical students
|
• Coaches the medical student volunteers on the diagnosis and decision-making prior
to their presentation to the attending
• Medical student mentorship
|
|
Medical student volunteers (n = 4 or 5)
|
• See patients
• Practice presentations
• Develop ophthalmologic, decision-making and health coaching skills
|
• Collect history and perform eye exam
• Present to the attending with the help of the resident or fellow
• Perform health coaching
• Learn about ophthalmology as a career
|
|
Optometrist volunteers (n = 1 or 2)
|
• See patients
• Assist and teach learners of all levels
|
• See a larger number of patients than the medical students
• Assist with refraction
|
|
Partnerships
|
|
|
|
University of California San Francisco (UCSF) Department of Ophthalmology
|
• Endorse the clinic
• Ensure the sustainability of the clinic
|
• Support the faculty and resident champion
• Help identify funding
• Facilitate patient follow-up
|
|
UCSF School of Medicine
|
• Support the medical student volunteer experience
|
• Integrate the clinic experience into the formal extracurricular activities of the
students
|
|
Project Homeless Connect (PHC)
|
• Nonprofit organization that accepts our referrals for free spectacle correction
at their monthly “Optical Day”
|
• The medical student coordinators email PHC after each clinic with the eyeglass prescriptions
and list of patients who will present to “Optical Day” for their free eyeglasses
|
|
Zuckerberg San Francisco General Hospital
|
• Local county hospital that accepts our referrals for advanced ophthalmologic care
and longitudinal follow-up
|
• The medical student coordinators provide patients with a prespecified date and time
at the county hospital that is within 4 days of being evaluated at our clinic
|
We found that it was important to get sponsorship for our cause on an institution
level, as this gave our eye clinic credibility and allowed us to gain capable volunteers
who have a sense of ownership of the clinic. We solicited support from our UCSF Department
of Ophthalmology to formally endorse and affiliate the eye clinic with our academic
institution. This allowed us to name our clinic the “UCSF Ophthalmology Shelter Clinic”
and to include the patients that we serve in the annual department report. We also
solicited support from the UCSF School of Medicine, which formalized our relationship
with the medical student volunteers. By doing so, the medical student volunteers have
the option of gaining credit for their volunteer work through the School of Medicine.
Funding
Funding can be one of the most difficult barriers when starting an eye clinic. Most
of our funding was used to purchase essential supplies for the clinic.
When searching for funding, it is helpful to use many avenues to identify funding
and to prioritize the essential equipment that is needed to get started. The majority
of our funding came from The California Endowment, a nonprofit whose goals were aligned
with supporting a clinic like ours. We purchased the majority of our equipment through
this gift. We suggest identifying a local or state-specific nonprofit organization
as a starting point; this does not necessarily need to be an ophthalmology-specific
nonprofit organization. We also reached out to pharmaceutical companies and obtained
the majority of our eye medications from their generous donations. By distributing
our search for funding to both nonprofit organizations and private companies, we obtained
the basic equipment and supplies necessary to start our clinic. We recommend identifying
more than one source of funding ideally from a variety of industries (i.e., nonprofit
organizations, private companies, and academic institutions).
Logistics
The above steps took approximately 4 months to complete. At this point, we had a physical
space for our clinic with potential patients, passionate volunteers, and the basic
equipment and supplies necessary to get started. The last step was to determine operational
logistics of the clinic. One of our goals was to make follow-up for our patients as
seamless as possible. Given that our partner nonprofit's “Optical Day” was the second
Monday of each month, we decided to hold our eye clinic on either the first Monday
or Wednesday of each month so that referral to “Optical Day” was within a close follow-up
time. As mentioned above, the accepting county hospital agreed to see our patients
within 4 days of referral. Accordingly, we identified preapproved appointment times
to give to our referred patients, so that they knew the time and location of their
follow-up appointment at the time of referral.
Our first clinic was a pilot clinic to further characterize the logistics of our clinic,
work out any potential obstacles with the physical space and equipment, and orient
the volunteer leadership team. This pilot clinic was attended only by the volunteer
leadership team (i.e., premedical and medical student coordinators, resident champion,
and faculty champion) with the goal of seeing a small number of patients. This pilot
clinic was organized by the resident and faculty champion and the vision was then
explained to the volunteer leadership team. Each clinic then expanded from there as
an iteration from the previous clinic, with particular attention to optimizing the
logistics.
Limitations and Obstacles
While performing complete ophthalmologic examinations in the eye clinic are sufficient
for many patients, it is also important to understand the limitations of the clinic
to fully meet patient needs and provide appropriate care. We identified several such
limitations in our clinic. The first significant limitation involved finding a way
to obtain spectacles for our patients who did not have the ability to purchase them.
We identified a local nonprofit organization called Project Homeless Connect that
had the resources to provide free spectacles. Given our similar goals and mission,
we formed a partnership with this organization that agreed to accept our referrals
to their monthly “Optical Day.” We provide patients with spectacle prescriptions and
the patients then present to “Optical Day” to obtain free spectacles ([Table 1]).
Another limitation of our eye clinic was an inability to provide more advanced ophthalmologic
care if necessary (i.e., intravitreal injections, laser, and surgery). A partnership
was formed with the Chief of Ophthalmology at the local county hospital (Zuckerberg
San Francisco General Hospital) to accept referrals from the eye clinic if advanced
ophthalmologic care was indicated ([Table 1]). In fact, the county hospital evaluates our referred patients within 4 days of
our eye clinic, which maximizes the potential for follow-up in this vulnerable population.
When referring patients to the country hospital, the medical students perform health
coaching centered on the patients' values and the reason for referral to hopefully
address patients' potential concerns and/or existing distrust in the healthcare system.
Lastly, the high turnover rate in the leadership of the clinic, which is run primarily
by medical students in their preclinical years, is a limitation in our clinic. We
addressed this challenge by confirming a year-long commitment with the volunteer leaders
of the clinic and training the new volunteer leaders 3 to 4 months in advance.
Important Points
Sustainability is Critical
Our eye clinic has been in operation for over 2 years, which is a testament to our
emphasis on sustainability. We focused on sustainability during each step of development
and started small to ensure each patient received comprehensive care. Our goal remains
to continue growing sustainably.
Measure Outcomes and Impact Prospectively
We have served a total of 131 patients to date in our clinic. Of these 131 patients,
we have referred 78 patients for spectacle correction and 33 patients to the local
county hospital for more advanced ophthalmologic care. Of those patients referred
to the county hospital, 16 patients had glaucoma or were glaucoma suspects, 9 patients
had visually significant cataracts, and 16 patients had diabetic retinopathy (12 patients
with nonproliferative diabetic retinopathy and 4 patients with proliferative diabetic
retinopathy). Of the patients who were referred for free spectacle correction and
to the county hospital, 35 and 42% presented to their appointments, respectively.
We are actively measuring outcomes to guide our decisions about the clinic prospectively
to quantify our impact and improve follow-up rates. We also use this data when advocating
for additional funding and support.
Education
Education is at the center of an academic institution. To date, over 65 medical students,
approximately 10 premedical students, and 10 optometrists have volunteered at our
clinic. The clinic provides an additional forum to train future physicians and eye
professionals.
Recruitment
An institution's support of a free eye clinic for underserved populations enhances
its reputation and provides a foundation upon which to recruit like-minded faculty.
It also serves as an appealing differentiator for resident recruitment. Thus far,
over 35% of our ophthalmology faculty and 70% of our ophthalmology residents have
volunteered at the clinic.
