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Pioneering a New Specialty for Homeless Healthcare

Dr. Catherine Castillo
Dr. Catherine Castillo

Homeless Healthcare Fellow

Dr. Josh Rodriguez
Dr. Josh Rodriguez

Homeless Healthcare Fellow

In the summer of 2020, the Helmsley-funded Collaborative for Homeless Healthcare partnered with Montefiore Medical Center to launch the New York City Homeless Healthcare Fellowship, a first-of-its-kind program designed to improve access to quality healthcare for New Yorkers without homes and to encourage more physicians to focus on homeless healthcare. Helmsley’s Laura Fahey recently sat down with Dr. Catherine Castillo and Dr. Josh Rodriguez – two members of the 2022 fellowship class – to learn about their experiences thus far, the skills and knowledge they are developing, and the critical need for programs like this to provide comprehensive healthcare services for homeless populations. The interview has been edited for clarity and length.

What led you to pursue a career in medicine?

Catherine: “I became interested in medicine, and family medicine in particular, because it merges my interests in preventing illness, caring for chronic health conditions, and addressing health inequalities. While I was in residency and doing a 2-week rotation in Homeless Healthcare, I was introduced to this different field of practice and during my rotation, I learned about how many of my assumptions of homelessness were incorrect. For example, I learned that two-thirds of people experiencing homelessness in New York City were experiencing homelessness as part of a family unit – and as a family doctor who often cares for generations of patients, this really resonated with me.”

Josh: “I was attracted to the idea of helping vulnerable populations and figuring out how I could deliver care to these patients most efficiently and effectively. This led me to a career in emergency medicine and acute care because the emergency room basically serves as the social safety net for society, as you treat the uninsured, underinsured, as well as people who are experiencing homelessness or are undocumented.”

Why is this area of practice important to you as a healthcare provider?

Catherine: “There are roughly 60,000 people experiencing homelessness, and there are so many different reasons why. My experience over the past several months has really highlighted how homelessness itself can be traumatic and that there are so many forces at play that make it hard to exit homelessness.

I also learned early in this new position that some patients I meet come in for a required health screening, while others come in because they are interested in primary care. I want to meet patients where they are, whether that is to obtain a Tuberculosis screening, manage their chronic health conditions, or continue gender-affirming hormone therapy. I view my role as supporting patients in being successful in meeting their goals, whatever makes sense for them at that time.”

A lot of the people you work with have experienced really significant trauma and betrayals, not just by medicine but by other services as well. If you can be the exception to that rule, that builds trust in the greater system.”

Josh: “Caring for people experiencing homelessness should be viewed as its own specialty and, coming from a big public hospital, I really thought I had some expertise in treating this population. However, that was truly not the case. If I had started practicing street medicine without doing the New York City Homeless Healthcare Fellowship, I would be much less prepared and less knowledgeable about how to best treat this population. A lot of the people you work with have experienced really significant trauma and betrayals, not just by medicine but by other services as well. If you can be the exception to that rule, that builds trust in the greater system, outside of just the medical aspect.”

What skills and knowledge are you developing as a New York City Homeless Healthcare Fellow?

Catherine: “In recent months, our lectures focused on topics like HIV medicine and a history of racism and homelessness, and we completed modules on wound care and asylum medicine, now a new interest of mine. We discussed and practiced providing trauma-informed care. Through the fellowship, I met organizations providing care to people experiencing homelessness through a harm-reduction lens. As I get to know the systems people find themselves navigating, as a medical provider, I am learning how to adapt to better assist these patients.

Josh: “The kind of medicine I am practicing now is called ‘street medicine’. A big portion of what I’m learning is how to keep patients on the street healthy and prevent them from having to go to the emergency room. Sometimes we provide care in a shelter but generally, I am on the street either with a backpack or in a mobile van. The idea is to bring the best standard of care, similar to what somebody would get in a clinic, to a person’s location on the street. Aside from the clinical aspect of learning a new field of medicine and how to treat diseases that disproportionately affect the homeless patient population, this fellowship is also teaching us important skills, like trauma-informed care and motivational interviewing.”

What advice would you give physicians entering this field?

Catherine: “Provide care to the person in front of you. Which of your skills and resources would the patient benefit from? Acknowledge the patient’s priorities and their autonomy. Follow-up care may be challenging, since patients may not have a cell phone or may have moved to another shelter in another borough, so be creative in reaching out to the patient. And have other providers you can problem-solve and share resources with; do not practice in a void.”

Josh: “I’ve heard from multiple patients about their frustration with navigating systems because the systems by nature are difficult – there’s a lot of bureaucracy and paperwork involved. Imagine this in addition to a literacy issue, language barrier, or mental illness, it can be even more difficult to navigate. In street medicine, I have the ability to let the patient drive the encounter. It’s a very different style of practicing medicine than in a hospital setting. The best piece of advice that I would give to someone interested in this field is to be consistent and build relationships with your patients.”