As a nurse at St. Vincent de Paul Village, a transitional shelter for homeless persons in San Diego, I am stuck each day by the challenge to deliver care with such limited resources. The Village clinic delivers incredible care, and continues to be the only clinic in San Diego that offers free care and medications to the homeless. However, the combination of the lack of resources of the patients and limited funding in the clinic itself makes creativity in delivering healthcare a necessity.
Healthcare for vulnerable populations proves to be unsuccessful if it is only one-sided. A patient cannot demand what he wants and I cannot tell a patient what to do. If we want to work toward better health and wellness then we must work together to figure out a realistic plan of care. This is especially pertinent when resources, spanning from knowledge to lifestyle to actual finances, are brought into the scenario. It would be simple to tell a diabetic patient struggling with blood glucose levels to pair protein with carbohydrates at meals to help minimize spikes in blood sugar, but a patient whose education was secondary to supporting himself and his family may not know what a source of protein or carbohydrate is. He may not be able to access a meal each day. It would be simple to instruct a patient with a wound to wash it with warm water twice a day and keep it clean, but a patient whose bed is compiled of tattered blankets to soften the sidewalk may not be able to attain cleanliness. He may not be able to access warm water. Simple resources quickly transform from basic to lavish, and working through that toward feasible solutions requires a collaborative approach.
There are clients who have successfully moved from the Village into low-income housing, and although they no longer suffer the limitations of the homeless, they are still confined by their minimal incomes. Two clients in particular wish to improve their nutrition and alter their body weights, but their funds limit their efforts. One client hopes to gain weight but suffers from psychosomatic reactions to food. Her anxiety is subdued by organic items, which she views as her solution, but it is one she cannot afford. The second client longs to lose weight, but fresh produce and lean protein are much more expensive than the packs of doughnuts he can buy using “I O Us” at the liquor store. It is challenging to set attainable goals when merely developing basic grocery lists is too idealistic. Without finances we must instead access other resources in the community, such as food banks, soup kitchens, and other opportunities to obtain healthy food at an affordable cost. We must work together within these limitations to problem solve and advocate for health.
The Village clinic relies on federal grants and private donations to pay for supplies, medications, the staff, etc. Unfortunately, donations are not sustainable, and with the economic challenges facing the general population, let alone the underserved, the little old ladies with their check books who support the movement for social justice, are no longer as able to sign off on the dotted line. We are minimally staffed and all wear an assortment of hats to accommodate the patient load that moves through the clinic each day. Unlike bustling hospitals, if a patient needs a breathing treatment, we cannot call the respiratory therapist, but we ourselves can go grab some tubing and assemble the nebulizer. If a patient needs a dressing change, we cannot call the wound team, but we can go gather packing supplies. We may not have a sling, or pillow, or eye patch to give a patient in need, but we know what we can use to make one. We exercise flexibility and innovation to confront this challenge each day and with this acquired resourcefulness and focus on collaboration with patients, we truly make it work. At the end of the day, the delivery of care always outweighs whatever obstacle we faced along the way.
San Diego, CA 2010-2011