Delivering health care on the streets: challenges and opportunities for quality management

Street Medicine focuses on the health needs of unsheltered homeless through mobile teams that provide care in the locations where individuals are found. Innovative strategies are needed to manage the quality of care provided within the atypical clinical settings encountered. In our study, contextual elements and practices for managing quality of care were explored through qualitative analysis of program components presented at the 2007 and 2008 International Street Medicine Symposia. Our analysis identified several common contextual elements, including unconventional living situations and lack of financial resources of patients, inconsistency in contact with transient patient populations, and informal clinical settings. Several practices were developed to address these elements and improve the quality of care delivered. Best practices included the use of mobile clinic vans, electronic medical records, collaboration with community clinics and hospitals, and provision of comprehensive social support. An example of quality auditing was also found in the reviewed programs. Additional work is needed to further quality management in Street Medicine and support achievement of replicable practices and measurable outcomes. We propose that 2 short-term outcome measures be used that acknowledge the contextual challenges faced in Street Medicine. These are patient engagement and patients' subjective assessment of their well-being.