Harm reduction services for veterans in supportive housing: A pharmacist-led, interdisciplinary, street medicine approach.

Abstract

Background: United States Veterans are disproportionately impacted by homelessness. Substance use, mental health conditions, and trauma increase the risk for homelessness and contribute to challenges in maintaining housing. Street Medicine utilizes a trauma-informed approach to provide low-barrier health and social services for those at risk for and experiencing homelessness. Limited evidence exists describing pharmacist roles on Street Medicine teams, including provision of harm reduction services. Objective: To implement a pharmacist-led Harm Reduction Program Street Medicine intervention at a supportive housing building in San Francisco, California, evaluating overall Veteran acceptance of harm reduction resources and the total number of Veterans who accepted 1) referral for infection screening, immunizations, and follow-up care, 2) referral for mental health and substance use disorder (SUD) care, and 3) pharmacist-provided harm reduction resources. Methods: During phase 1 (August-September 2022), Harm Reduction Program informational materials were mailed to Veteran residents. During phase 2 (October-December 2022), pharmacists called Veteran residents to offer harm reduction resources. During phase 3 (December 2022-June 2023), an interdisciplinary team (pharmacists, physicians, nurses, and a social worker) completed 6 HUD-VASH housing building visits to offer harm reduction resources. Data were prospectively collected, and descriptive statistics were used to evaluate results. Results: During Phase 2, most Veterans (49/72, 68.1%) were unable to be reached by telephone. Of those remaining, 16 (22.2%) declined and 7 (9.7%) accepted ≥1 resource. During Phase 3, team members met with 29/73 (39.7%) Veterans a range of 1-6 times. Twenty-three (31.5%) accepted ≥1 resource, and 6 (8.2%) declined. Through combined telephone and on-site outreach, a total of 26/73 (35.6%) Veterans accepted ≥1 resource, including referral for infection screening, immunizations, and follow-up care (n=6, 8.2%); referral for mental health and SUD care (n=6, 8.2%); and pharmacist-provided harm reduction resources (n=24, 32.9%). The harm reduction supplies most frequently accepted included naloxone (n=20, 27.4%), antibiotic ointment (n=11, 15%), alcohol pads (n=10, 13.7%), and bandages (n=10, 13.7%). Conclusions: Telephone-based outreach to Veterans in supportive housing was challenging, as many did not have a working phone. In-person visits increased Veteran acceptance of harm reduction services from 10% to 36%, demonstrating the value of a Street Medicine approach. Many Veterans reported mistrust of the healthcare system and were not engaged in care. Ultimately, the focus of outreach visits shifted from offering resources to building rapport, tailoring discussions to individual needs, and linking individuals to services, including a new on-site primary care/infectious disease provider. Future research should evaluate impacts on health and patient-reported outcomes and cost-effectiveness.