Meet Joshua, a nurse practitioner and founder of ICT Street Team
Joshua Reed founded ICT Street Team after becoming frustrated with a healthcare system that he saw exclude unhoused individuals from accessing quality care. While working as a nurse in emergency departments in Kansas, he routinely saw individuals experiencing homelessness admitted to the hospital with diseases that were extremely advanced and that would often worsen with no follow-up care. He joined a public health clinic, thinking that he could have more of an impact there; however, despite their free primary care and pharmacy service, very few individuals without housing visited the clinic.
Wanting to do more, he spent his free time researching models for delivering care to unhoused individuals. He also started providing basic medical care out of his own pocket in Wichita. For the first two years, with just a backpack, he went out on the streets, talking to individuals, gathering data, and performing basic first aid, but not delivering a wide array of care.
During the beginning of his grassroots efforts, Joshua met a patient at the public health clinic who drastically changed the trajectory of his career. The patient came to get his blood pressure medicine refilled, but it became clear very quickly that more was wrong. He was running a fever, his heart rate was high, and he looked very ill. Joshua found that he had a large ulceration on his foot that the patient had been trying to manage himself out on the streets, and it was obvious that the infection was very severe. Joshua sent the patient to the hospital, where he was admitted and ended up having to get progressive amputations, despite which he became septic and eventually died. Because this person didn’t have necessary access to healthcare, a small cut that could have been easy to manage, if seen earlier, became something that ended up taking his life.
Joshua witnessed too many situations where unhoused adults suffered severe consequences for minor health issues that should never have progressed. This inspired him to become more devoted to his work on the streets. In 2019, he decided to organize his efforts by creating a 501(c)3 nonprofit organization, assembling a board of directors, and recruiting other volunteers. The resulting project, which he named “ICT Street Team,” has since grown to become a comprehensive primary care structure for people experiencing homelessness in Wichita (ICT is the airport code for Wichita). Last year, the nonprofit provided just under one million dollars of charitable care, served thousands of patients, amassed hundreds of volunteers, and created their own affiliate pharmacy to provide prescriptions free of charge.
How to provide culturally competent care for individuals experiencing homelessness
ICT Street Team’s model is deeply rooted in transcultural care theory, meaning that they work to deliver care services in a way that is culturally sensitive to their population’s needs. Though homelessness is not considered a “culture” per se, being unhoused influences how these individuals interact with the world on a day-to-day basis. To treat an unhoused individual in the same way that one would a housed person, and to push them into traditional primary care, doesn’t work.
There’s a common misconception that if you’re unhoused, then you have nothing going on and nowhere to be, which is absolutely not the case. In fact, people living on the streets have very rigid schedules that need to be followed in order to survive. Since meals and other critical services are only available at certain times of day and in certain locations, these folks need to coordinate their schedules in order to take advantage of such programs. For ICT Street Team, this means that location and hours of service are critical; setting the clinic up at an inconvenient time or place would be a disservice to potential patients.
Joshua knew that ICT Street Team couldn’t have a strong impact unless they complemented other critical services, such as access to food, and eliminated geographic and transportation barriers, as well. The team has developed partnerships to offer their clinical help at the same time and in the same location as other necessary services. By doing so, they’ve expanded their reach and met their patients where they are.
The way care is delivered also needs to be tailored to the specific needs of the unhoused population. “In medicine, there are guidelines that exist for approaching specific treatments, and the considerations of those who are experiencing homelessness are not often taken into account in those frameworks,” says Joshua.
One example of this bias, Joshua says, can be found in the standard approach to treating patients with diabetes: “The conventional wisdom for treating diabetic patients today would say that there are medications like Humalog insulin that provide better blood sugar control than older medications. The problem with prescribing this ‘standard’ medication to unhoused individuals, however, is that it’s short-acting insulin, meaning that if the patient doesn’t start eating soon after taking the medication, their blood sugar will drop. So, prescribing that medication to a person who doesn’t have consistent access to food is dangerous.” Treating those experiencing homelessness typically requires unlearning what is medically “conventional” and taking a step back to find a treatment that is appropriate for the patient’s unique situation.
Lack of trust
Geographic and medical barriers to care are important to address, but Joshua says the biggest barrier “is that people who are living on the streets have a very high threshold for trusting individuals who appear to be in some position of authority. They’re constantly being told where to sleep, they’re being run off by police, they’re being harassed by business owners. When they go to the hospital for something they are usually treated poorly in comparison to others because it’s obvious they are unhoused. Therefore, it’s not easy to come in as a medical authority and immediately start treating. But the longer we’re out there and the more they get to know us, the more willing they are to allow us to help them and get them back on the medication they need.” Joshua has found that, when that trust is established, the adherence level for following treatment plans goes way up.
When Joshua looks back at his patients’ records from hospitals, he’s fascinated by how many patients are labeled as “noncompliant” when ICT Street Team’s compliance and return rates are so high. He attributes these stellar rates to the trust that their team has developed by being present and being consistent. “The problem here is not that somebody doesn’t want to take care of themselves; the problem is that we don’t address the extreme barriers they face,” he says. Additionally, ICT Street Team has found that a key component to their success has been identifying patients who are trusted in the communities as liaisons. By having those individuals present at the clinics, the level of trust increases exponentially.
A typical day at the clinic
ICT Street Team has established fixed clinic times and locations so that their patients always know where to find them. On any given clinic day, they load all their equipment and medications onto their mobile medical unit and then drive to that day’s location, where their team of nurses, PAs, paramedics, and physicians will see patients. Because the organization has built relationships with local hospitals, they have referrals coming in 24/7, so much of the day is also spent meeting with patients in hospitals and coordinating care from there.
As Joshua explains, “It’s not only routine colds and coughs. We deal with a lot of really terrible things that happen to people. Out on the streets, I have been astounded and shocked by the kind of things I’ve seen in our society. I’ve seen so many women in the sex work industry who have been assaulted but won’t file a police report because they have a criminal record or they’re afraid of being arrested because their assault happened during illegal activity. I’ve seen folks with mental illness who come to the clinic with strange rashes only to find out they’ve been shot and that rash is being caused by a bullet buried under the skin. Because these are people forgotten about by society or who may have criminal records, they don’t have access to the same justice system we do, and it’s awful to see.” The ICT Street Team works to make sure that each patient is treated with dignity and compassion.
Spruce helps ICT Street Team to deliver care
ICT Street Team primarily uses Spruce for communicating within their team. “Our coordination of care on the backend is 100% driven by Spruce. There is no other platform that we looked at that would have been able to do the things that Spruce does, especially with us being so mobile and with our hours being so unique,” says Joshua. By using secure team messages, they are able to seamlessly and securely coordinate care across time and space. Spruce’s mobile-friendly platform is also critical because so much of their work is done away from an office setting.
Some ICT Street Team patients have cell phones, so the team also uses Spruce as a means of patient follow-up by phone or text message. Spruce’s phone system allows ICT Street Team staff to communicate with their patients without having to use personal cell phone numbers, and because of Spruce’s shared inbox, no matter who is on call, the team will always get the incoming messages.
Above all, Joshua has found that “the most fantastic thing is actually the ability to send and receive faxes. Here’s why: I have been under a bridge before with a patient, and I have found out that they were recently seen at a hospital, but they don’t know what they were given or what they were there for. I can send a fax right then, the hospital can send their information right back to me, and I can view their records right from my phone. So if there was one feature out of all of them that has been the most impressive in allowing us to expedite the delivery of care, it is, out of all things, your fax service.”
What’s next for ICT?
Affordable housing in Wichita is a problem, as it is in many parts of the country, so ICT is expecting the number of unhoused people to increase. Planning for this, they are expanding their capabilities so that they will be able to meet this projected need.
Additionally, Joshua has his sights set on expanding the reach of the program to help not only unhoused individuals, but also those who have recently found housing but still lack insurance or funds to access medical care. “Homelessness is very fluid,” Joshua adds, “so having a system in place where we can manage that full continuum of homelessness is really important.” This larger approach to considering and meeting the needs of unhoused individuals is increasingly considered to be a subfield of healthcare, called “street medicine” by some organizations, and it includes “health and social services developed specifically to address the unique needs and circumstances of the unsheltered homeless delivered directly to them in their own environment.”
Street medicine is gaining popularity in certain regions of the country. Some hospital systems have actually increased their revenue by focusing more on the population of those experiencing homelessness, such as by assisting unhoused individuals to sign up for Medicare or Medicaid so that their hospitals can be reimbursed for services provided. However, as Joshua explains, ”The savings are only seen 12, 24, sometimes 36 months after implementation. You kind of have to backdoor the process by getting everything started first and then justifying why it works later. You have to prove you can do it before you can get many people interested.”
How you can help
If you want to help ICT Street Team fulfill their mission, you can do so via the following options: