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Providence Community Clinic Operations Manager and Behavioral Health Provider
Chair of Spokane Homeless Coalition and Co-Chair of Spokane Regional Continuum of Care Board

"Thank you, " the woman said as she entered the clinic. Those two words were the simple prologue to a heartfelt story. She proceeded to tell me that earlier in the year she had come to the clinic as a patient when she was experiencing homelessness and addiction to get a free two-hour bus pass. During her visit, we asked if she would like to use the clinic shower. She still remembered how that water washed off more than a little grime — it empowered her to manifest a new belief in herself. She then used her bus pass to get to a local rehab facility. "Today, " she said, "I am proud that I have been clean for three months and am no longer homeless. "

We passionately believe that our job at the Providence Community Clinic in downtown Spokane, Washington, is to welcome people and meet them where they are in their lives, regardless of their circumstances. From there we look to God. This woman's story illustrates a powerful expression of God's healing love, which is central to Providence's service as a Catholic health care organization.

OPENING DOORS TO CARE
Providence Community Clinic was the first free medical clinic in Washington state when it opened in 1976.¹ Our patients include people who are uninsured or underinsured, most of whom are experiencing chronic homelessness. Providence's investments in community benefit covers the cost of care for people who cannot afford it.² This opens the door for many people who put off care or have gone without it. Our philosophy is to gain trust and develop lasting relationships with those we serve, recognizing that the only common denominator in all homelessness is lost relationships.

Homeless individuals have few people to rely on, often leading them to be very distrustful. The continuity of the program's staff helps to build trust. Being greeted at the clinic by familiar individuals who understand the patient's situation helps us to better support them.

We have a few different ways to build this trust. For example, we take photos of each of our patients to include in their private files. That way, we can greet them by name when they walk through our doors. For those who have experienced generational trauma resulting in mistrust in people and systems, we've created a safe space in the clinic for patients to leave their pets while they see our care teams. This is not an option at most health care facilities, but we felt it was important to offer this option because, for many patients, these animals are their best friends and most trusted supporters.

We recognize that homeless individuals struggle with access to medical care due to lack of insurance, transportation and necessary funds to cover health care costs. Because their needs often do not fit the constructs of the health care system, we make Providence Community Clinic more accessible with walk-in care and extended appointment times so that we can assess complex issues with a person's medical and mental health. We offer everything from basic medical exams to consultations with specialists, immunizations, screenings and mental health evaluations. For more urgent concerns, we may triage to local medical facilities, arranging for transportation and care coordination.

For example, a woman named Carol came to our clinic with severe arthritis and carpal tunnel syndrome in her wrist. Not only did we treat her medical issues, but our team helped sign her up for medical coverage and connected her with affordable housing resources.

Within a few visits, Carol had the medication and brace she needed for her chronic pain. I'm excited to share that through our referral to other community resources, she found the housing support she needed, too. She now has her own place to call home.

"Providence Community Clinic went over and beyond, " Carol said. "They 're truly here to help us." Carol's full name and the names of some other patients in this article are not being disclosed to protect their privacy.

Providence Community Clinic also has an outreach program that makes visits to homeless shelters and encampments to ensure these individuals receive care even if they don't have the means to visit the clinic. This outreach program is made possible by volunteers who are active or retired medical health care providers who treat minor illness, provide wound care and serve as conduits to community resources.

This outreach creates an additional touch point to reach people in need. During one of our visits to a day center for homeless people earlier this year, we met a man whose prescription medicine had been stolen. By the end of his visit, we were able to provide him with a short-term prescription and create a new bond that we believe will bring him into our clinic for additional care.

"The time was taken to make sure I was comfortable and cared for," he told us.

THE NATIONAL SCOPE OF HOMELESSNESS AND HEALTH
Homelessness takes many forms, and can encompass people living on the streets, in encampments or shelters, in transitional housing programs or doubled up with family and friends. The federal government found that more than 580,000 people were experiencing homelessness on a single night in January 2022.³ Estimates show homelessness has increased every year since 2017.⁴ There also continues to be an overrepresentation of Black people and Indigenous people (including Native Americans and Pacific Islanders) among the homeless population, when compared to their proportion of the total U.S. population, according to the U.S. Department of Housing and Urban Development.⁵ For example, Black people are estimated at 39% of all individuals experiencing homelessness in the country and 53% of those experiencing homelessness in families with children, however are only 12% of the total U.S. population.⁶

Health risks associated with homelessness can lead to a broad range of adverse health outcomes. Those experiencing homelessness have much higher rates of diabetes, hypertension, tuberculosis, asthma, HIV/AIDS and mental health disorders.⁷ The barriers that unhoused people face lead to greater use of emergency services and higher rates of medical hospitalizations for serious conditions. In addition, homeless individuals are often discharged with minimal resources into settings inappropriate for recovery, leading to higher rates of readmittance and adverse health outcomes.

According to the National Health Care for the Homeless Council, homeless people, on average, experience shorter life expectancies by 12 years compared to the general U.S. population.⁸ Living on the streets and in homeless shelters pose unique health risks to homeless individuals, including exposure to communicable diseases, harmful weather conditions, violence, drug use and malnutrition. These issues are then intensified by the emotional and mental stressors inherent to the state of homelessness. Stable housing provides privacy and safety, and it is also a place to rest and recuperate from surgery, illness and other ailments without worry about where to sleep and find a meal, or how to balance those needs with obtaining health care and social services.

So, what is the state of homelessness in Spokane? A recent 2022 Point in Time Census of Spokane County's homeless populations, conducted under the umbrella of the U.S. Housing and Urban Development Department, indicated an approximate 13% rise in homelessness over the last complete tally conducted two years prior.⁹ The growth of "outdoor encampments" more than doubled in the two years between 2020 and 2022.¹⁰

COVID'S IMPACT ON HOMELESSNESS
COVID changed everything almost overnight. In Spokane, shelters slashed their occupancy by half to accommodate social distancing,¹¹ community partners shut their doors, and other providers to homeless people decreased access at an alarming level. Case workers felt like they were "sailing in the nighttime" with everyone simply frozen, unsure how to chart a course through choppy seas.

Providence Community Clinic was one of the few organizations that did not shut its doors. I am proud to say that our clinic did not close for one day throughout the entire pandemic. We quickly established protocols and precautions for testing and provided separate spaces for symptomatic and nonsymptomatic patients. We provided clinic lunches because many of the homeless outreach food sources were closed.

We distributed hygiene kits as well. While that was a difficult time, it also highlighted the persistent needs of our community, which revealed an opportunity for growth in outreach or field medicine. With the support of volunteer providers, we expanded our services into some of our local shelter systems, allowing us to help even more people.

PLANNING AHEAD
Providence has cared for our community in numerous ways and for many people since the Sisters of Providence arrived in Spokane more than 135 years ago. Providence Community Clinic continues that tradition of improving the health and well-being of our community, thanks to support from Providence Inland Northwest Foundation donors. Past gifts helped us update our clinic space, supplied new medical equipment and provided supportive services, such as bus passes and warm clothing.

The staff at Providence Community Clinic also engages in applying for grants and identifying new collaborations with regional partners and resources. Our hope is to increase our outreach capacity to help the vulnerable with expanded services. That includes recruiting and training volunteers who have a commitment to consistency. Because we know that trust is built through consistent interactions between patients and staff, we look for specialty providers who are regularly available, whether weekly or monthly. Through these volunteer relationships, we also have psychiatry residency support and dermatology and podiatry care for our patients in Spokane.

It takes the right type of personality and a deep commitment to join a team of providers caring for people experiencing homelessness. The marginalization of homeless individuals as being "less" is a barrier for many people. I spent seven years working with hospice before joining Providence Community Clinic and found a unique similarity between the two. There is a vulnerability associated with working in situations where you can't control the outcomes for the patients. That is why caregivers who work within these specialized health care fields must lead from their heart, not just their head.

I see this with my team every day. We have a patient who regularly visits, and when he does, we let him use our phone. He uses it to call his mom.

Another patient, named Matthew, is working hard to find a steady job. While our clinicians helped him with concerns he has about pain in his feet, I looked over his resumé, and, before a big interview this year, I helped him prepare by leading him through a mock interview.

As a behavioralist, I believe that exposures in childhood mold the future and create neural pathways that help you think in certain ways. My childhood was influenced by a single mother who opened her house to family and friends who were facing difficult situations — an uncle in hospice, a friend who was facing loss and many others. My own room was often given up to someone who needed shelter. My mother passed away after a brief time in the workforce after completing her formal education in social work, but her legacy as a community advocate was embedded in me to speak up for those who are viewed as "less."

Today, I am dedicated to enhancing the value of relationships among the people we serve and helping them heal in whatever way possible. The Providence Community Clinic has a long history in our community. Sister Peter Claver, MSBT, the leader and builder of Providence Sacred Heart Medical Center and Catholic Charities Eastern Washington, shared a desire to provide people experiencing homelessness in our community access to health care. In 1976, this dream became a reality with the House of Charity Medical Clinic. It has served thousands of patients for more than 40 years with volunteer doctors and nurses. The success of the clinic grew through the decades, and it now stands as Providence Community Clinic, embodying the heart of the Providence mission: As expressions of God's healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

ROBERT LIPPMAN is chair of the Spokane Homeless Coalition and co-chair of Spokane Regional Continuum of Care Board. He is clinic operations manager and behavioral health provider for Providence Community Clinic in Spokane, Washington.

NOTES

1. "Providence Community Clinic," Providence, https://www.providence.org/our-services/wa/providence-community-clinic.
2. "Annual Report to Our Communities," Providence, https://www.providence.org/about/annual-report.
3. "HUD Releases 2022 Annual Homeless Assessment Report," U.S. Department of Housing and Urban Development, December 19, 2022, https://www.hud.gov/press/press_releases_media_advisories/HUD_No_22_253.
4. Tanya de Sousa et al., "The 2022 Annual Homelessness Assessment Report (AHAR) to Congress," The U.S. Department of Housing and Urban Development, December 2022, https://www.huduser.gov/portal/sites/default/files/pdf/2022-AHAR-Part-1.pdf.
5. Tanya de Sousa et al., "The 2022 Annual Homelessness Assessment Report."
6. Tanya de Sousa et al., "The 2022 Annual Homelessness Assessment Report."
7. "Homelessness & Health: What's the Connection?," National Health Care for the Homeless Council, February 2019, https://nhchc.org/wp-content/uploads/2019/08/homelessness-and-health.pdf.
8. "Homelessness & Health," National Health Care for the Homeless Council.
9. "Point-in-Time Count 2022: Homelessness and Housing in Spokane, WA," ArcGIS StoryMaps, May 19, 2022, https://storymaps.arcgis.com/stories/cfa1af9e03d14501b95f2fce6e8c1197.
10. "Point-in-Time Count 2022," ArcGIS StoryMaps.
11. Adam Shanks, "Coronavirus Measures to Cut Shelter Capacity in Half; Officials Looking for Alternative Sites," Coeur d'Alene Press, March 16, 2020, https://cdapress.com/news/2020/mar/16/coronavirus-measures-to-cut-shelter-capacity-5/.