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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.

Jim Withers, MD S Medicine, an emerging field of medicine in the United States, is the provision of health care directly to those living on the streets of our communities. As such, it represents a trend in both health care delivery and medical education in which the reality of those we serve is central. While initiatives such as patient centered care, the medical home and motivational interviewing strive to build health care around the individual, Street Medicine is a more radical attempt to create a care relationship on the terms of those who have been largely excluded from our system of organized health care. The unsheltered homeless living under our bridges, in our alleys, and along our rivers have arguably the worst medical care in the U.S. in terms of continuity and effectiveness. Many receive care in Emergency Departments or not at all. The life expectancy of a homeless person is approximately 47 years.1 For those who do not generally use shelters, it is even shorter. In addition, there is growing evidence that the chronic street homeless population incurs a disproportionate amount of cost due to frequent and prolonged hospitalizations and emergency room visits.2 If ever there was a case of a system not fitting a population, the chronic street homeless are that case. The American health care delivery system has become a victim of its’ own success. While the system’s scope and efficiency are impressive, this has come at the cost of flexibility. Patients are forced to come to the structure of health care delivery and mold themselves to the needs of that system. Indeed, many people never make it into our health care institutions at all, despite having very real needs. Barriers of culture, economics, and other circumstances create gaps between a growing number of citizens and the health care industry. The result is a divorce between established medicine and reality. Our rigid structure prevents us from reaching people. The antithesis would be the traditional house call, in which the physician literally came to the patient in their own world, on their terms. Dismissed as a quaint historical legacy, the house call deserves a serious second look. By going directly to the patient, the nurse or physician immediately establishes the centrality of that person’s reality. This creates trust, and an acknowledgement that any health care plan will be grounded in a shared recognition of real circumstances. The person is honored for who they are. Even if this occurs only one time, the patient will forever value the respect they were given and are more likely to work in partnership with us. Equally important is the insight we gain about the actual determinants of the patient’s health. We see the forces at work in their lives and health. Without such information we are working with incomplete data. This is illogical if our goal is truly