UC Davis Nurse Practitioner Ventures into the Field to Treat Sacramento-Area Homeless
By Stephanie Jordan
CANP Correspondent
When the California State Legislature approved the passage of Senate Bill 1152, a measure aimed at reforming the discharge process for homeless patients in hospitals late last year, Dr. Holly Kirkland-Kyhn, who has worked as a nurse practitioner for over 20 years in the Sacramento community, cheered.
Under SB 1152, hospitals are required to include a written homeless patient discharge planning policy and process, and discharge them to a safe and appropriate location. Hospitals are further required to develop a written plan for coordinating services and referrals for homeless patients with the county behavioral health agency, health care and social services agencies in the region, health care providers, and nonprofit social services providers to assist with ensuring the appropriate homeless patient discharge.
Governor Jerry Brown signed Senate Bill (SB) 1152 into law on September 30, 2018. Specifically, SB 1152 modifies Section 1262.5 of the Health & Safety Code that currently requires hospitals to have a written discharge planning policy and procedure that provides for appropriate post-hospital care for patients after discharge. Existing law focuses on those patients who are likely to suffer adverse health consequences after being discharged from the hospital, if there is no adequate discharge planning. The new law goes further by focusing specifically on homeless patients. The law went into effective January 1.
Although trained in the U.S. as an RN, Kirkland-Kyhn spent her early career working as a nurse and midwife in England and Ireland. She has travelled to Africa, Haiti, and Belize to work in disaster relief and in promoting safe maternal-child care in rural areas. She now works at UC Davis Medical Center as the Director of Wound Care. Kirkland-Kyhn is actively involved in research in the comparison of hospital acquired pressure ulcers and community acquired pressure ulcers and has led interdisciplinary team initiatives throughout the hospital to improve the safety and quality of care for patients. She doesn’t, however, limit her care to inside the hospital walls. She dedicates countless hours to educating the community on wound care, in particular as it relates to the indigent and homeless.
“Myself and a graduate student developed relationships with the homeless population along the American River encampment known as “The Island” – it is very large, maybe up to 50 people or more,” says Kirkland-Kyhn. “We would bring sandwiches, sanitary supplies, socks, and the like.”
Kirkland-Kyhn goes on to say that in these large homeless communities, there are designated leaders, rules to follow, and roles assigned. “There is always a medic,” she explains. “On my visits I teach about wound care and I ask what else they want to know. One time I was asked to teach the medic and others how to do CPR because that was something the encampment needed. So we arranged for that.”
She often participates in conferences to train and build awareness about wound care for the homeless because of their particular challenges. Wound care is especially important within the homeless community because living in unsanitary places without easy access to bathrooms, clean water, and trash disposal can mean fairly common infections can become lethal.
“Teaching patients and the community about how to care for an abscess, for example, is important,” explains Kirkland-Kyhn about her work with the homeless. “I meet with them where they are. I am not trying to rehabilitate anyone.”
Many people experiencing homelessness often suffer from mental and/or physical illnesses exacerbated by drug use and inhospitable living conditions. According to the California State Auditor’s report, based on 2017 information from the U.S. Department of Housing and Urban Development (HUD), California leads the nation with both the highest number of people experiencing homelessness – about 134,000, or 24 percent of the nation’s total – and the highest proportion of unsheltered homeless persons (68 percent) of any state. In contrast, New York City and Boston shelter all but 5 percent and 3 percent, respectively, of their homeless populations.
“The beauty of wound care is that you are actually touching people,” says Kirkland-Kyhn. “I see it as very humbling, to be allowed to care for them and for them to trust me. But you have to go where they are. For them, hospitals are not places they want to go. But if they do arrive in the emergency department, I do my best to greet them there, and do a warm handoff to one of the street nurses in the community.”
An example of this outreach effort, which partners a number of caregivers and advocates at a single location, is a mobile event at a recycling center or in a local park “We offer cell phone charging stations, so that while the phone is charging, we can help with supplies, teach basic wound care, and have access to animal vet care,” explains Kirkland-Kyhn.
“I’m always amazed at what they want to learn from us as medical providers. There are so many things that they were never taught when they were young or may not know how to adapt to while experiencing homelessness.”
Giving her time to the indigent and homeless is not part of her job description (although she works in a safety-net hospital), but she is deeply committed to helping those experiencing homelessness.
“I just do it,” says Kirkland-Kyhn. “I have bags of bottled water, protein drinks, dressings, supplies, and dog treats (there are always lots of dogs!). The goal is to get them through a few days and to develop a trusting relationship. But if we can get a week of good care, then the people don’t have to worry about it. You do have to be thoughtful about any food you might provide, it has to be on the soft side, as many have missing teeth.”
Kirkland-Kyhn acknowledges that behavior issues can scare caregivers off. “It is important to remember people who are experiencing homelessness are in survival mode. The use of drugs and alcohol are an escape or a way of coping with their situation. Most often we find they have experienced significant trauma, which has led them to be homeless and that homelessness leads to drugs and or alcohol use. The truth is there aren’t a lot of options once one becomes homeless. We can only give them tools that they can choose from and then allow them the autonomy to do what they need to do.”
Kirkland-Kyhn will be inducted as a Fellow in the American Association of Nurse Practitioners in June for her dedication to educating both medical providers and the community on wound care.
Holly Kirkland-Kyhn’s Top Tips
Holly Kirkland-Kyhn has learned a lot along the way in her outreach efforts with the homeless and she is eager to share that experience with her fellow CANP members and anyone else she can connect with.
- Many homeless have a dual-diagnosis, with mental illness being one. Kirkland-Kyhn recommends that homeless helpers not ask a lot of questions, or if a question is asked, make it very specific. For example, if working on a knife wound, rather than say: “What happened to you?” (in which you may get a very long and convoluted story) instead ask: “When did this happen?”
- Most homeless persons have phones with cameras. Ask to take, or ask the patient to take, a photo of the wound. Tell the patient to be sure to show the photo to their next caregiver, so they can see the wound at baseline and the care provided. “Let them own their own wound,” Kirkland-Kyhn advises. She has even had patients videotape the wound care in order to educate themselves and future providers.
- Go to where the homeless are and where they feel most comfortable. Kirkland-Kyhn has had great success setting up mobile units in recycling centers, where homeless often come most regularly, or community-based needle exchange facilities that offer harm reduction services that work towards disease prevention and health promotion.
- Get to know the advocate groups and services in the community. Help to train these groups in basic wound care (or your specialty) utilizing products from discount stores. Kirkland-Kyhn will get calls from her local HRS (harm reduction service) to come over when someone is there and in need of wound care. She does her best to head straight over, knowing that there is a chance the person will be gone before she can arrive.
- Most homeless people do not have access to supplies. Kirkland-Kyhn makes up cards or posters and hands them out to colleagues and homeless advocates with tips on what to tell homeless patients about wounds and aftercare, focusing on what they can pick up at a dollar store rather than a pharmacy. Resources for the homeless are severely limited and the lack of budget for medical supplies can lead to poor aftercare.