Homelessness and Public Health: A Focus on Strategies and Solutions

Material hardship, forced displacement, and negative health outcomes among unhoused people who use drugs in Los Angeles, California and Denver, Colorado: a latent class analysis

BACKGROUND

Homelessness is a growing concern in the United States, especially among people who use drugs (PWUD). The degree of material hardship among this population may be linked to worse health outcomes. PWUD experiencing homelessness in urban areas are increasingly subjected to policies and social treatment, such as forced displacement, which may worsen material hardship. It is critical to describe hardship among PWUD and examine if it is linked to health outcomes.

METHODS

Data were collected as part of a prospective cohort study of PWUD in Los Angeles, California and Denver, Colorado (n = 476). Analysis sample size was smaller (N = 395) after selecting for people experiencing homelessness and for whom data were complete. Five indicators assessing hardship (difficulty finding food, clothing, restrooms, places to wash/shower, and shelter) in the past three months were obtained from participants at baseline and were used in latent class analysis (LCA). We chose a base latent class model after examination of global fit statistics. We then built three auxiliary models using the three-step Bolck-Croon-Hagenaars (BCH) method to test the relationship of latent class membership to several hypothesized social and health variables in this same three month time period.

RESULTS

Fit statistics, minimum classification probabilities, and ease of interpretation indicated a three-class solution for level of material difficulty. We termed these classes "High Difficulty" (n = 82), "Mixed Difficulty" (n = 215), and "Low Difficulty" (n = 98). Average classification probabilities indicated good class separability. "High Difficulty" participants had high probabilities of usually having difficulty accessing all five resources. "Mixed Difficulty" participants indicated a range of difficulty accessing all resources, with restrooms and bathing facilities being the most difficult. "Low Difficulty" participants were defined by high probabilities of never having access difficulty. In auxiliary analyses, there were significant (p < 0.05) differences in experiences of displacement, opioid withdrawal symptoms, nonfatal overdose, and violent victimization between classes.

CONCLUSIONS

This LCA indicates that among PWUD experiencing homelessness there exist distinct differences in resource access and material hardship, and that these differences are linked with political, social, substance use, and other health outcomes. We add to the literature on the relationship between poverty and health among PWUD. Policies which increase difficulty accessing necessary material resources may negatively impact health in this population.

Material Hardship, Forced Displacement, and Negative Health Outcomes Among Unhoused People Who Use Drugs in Los Angeles, California and Denver, Colorado: A Latent Class Analysis

Background

Homelessness is a growing concern in the United States, especially among people who use drugs (PWUD). The degree of material hardship among this population may be linked to worse health outcomes. PWUD experiencing homelessness in urban areas are increasingly subjected to policies and social treatment, such as forced displacement, which may worsen material hardship. It is critical to describe hardship among PWUD and examine if it is linked to health outcomes.

Methods

Data were collected as part of a prospective cohort study of PWUD in Los Angeles, California and Denver, Colorado (n = 476). Analysis sample size was smaller (N = 395) after selecting for people experiencing homelessness and for whom data were complete. Five indicators assessing hardship (difficulty finding food, clothing, restrooms, places to wash/shower, and shelter) in the past three months were obtained from participants at baseline and were used in latent class analysis (LCA). We chose a base latent class model after examination of global fit statistics. We then built three auxiliary models using the three-step Bolck-Croon-Hagenaars (BCH) method to test the relationship of latent class membership to several hypothesized social and health variables in this same three month time period.

Results

Fit statistics, minimum classification probabilities, and ease of interpretation indicated a three-class solution for level of material difficulty. We termed these classes "High Difficulty" (n = 82), "Mixed Difficulty" (n = 215), and "Low Difficulty" (n = 98). Average classification probabilities indicated good class separability. "High Difficulty" participants had high probabilities of usually having difficulty accessing all five resources. "Mixed Difficulty" participants indicated a range of difficulty accessing all resources, with restrooms and bathing facilities being the most difficult. "Low Difficulty" participants were defined by high probabilities of never having access difficulty. In auxiliary analyses, there were significant (p < 0.05) differences in experiences of displacement, opioid withdrawal symptoms, nonfatal overdose, and violent victimization between classes.

Conclusions

This LCA indicates that among PWUD experiencing homelessness there exist distinct differences in resource access and material hardship, and that these differences are linked with political, social, substance use, and other health outcomes. We add to the literature on the relationship between poverty and health among PWUD. Policies which increase difficulty accessing necessary material resources may negatively impact health in this population.

Scurvy presenting in a homeless 32-year-old male: a case report

Vitamin C deficiency, otherwise known as scurvy, is one the oldest known diseases. Although its prevalence has substantially diminished, certain populations such as smokers, alcoholics, elderly, and those with malabsorptive syndromes remain at risk. Deficiency presents with perifollicular hemorrhage, corkscrew hairs, and petechiae that can evolve into ecchymoses and purpura. Diagnosis starts with clinical suspicion and is confirmed with plasma and leukocyte ascorbic acid levels. Early suspicion is key. Treatment with vitamin C offers an excellent prognosis and avoids unnecessary workup for differential diagnoses. In our case, a 45-year-old male alcoholic with progressively worsening symptoms was found to have scurvy. Treatment was initiated with vitamin C supplementation, and he had remarkable improvement in his symptoms within weeks. This case demonstrates that scurvy is not a disease of history and must be considered in modern medicine, especially as homelessness with concomitant poor nutrition continues to increase.

Exploring the inflammatory profile of homelessness population: a comprehensive analysis of individuals in two temporary shelters in Lisbon

Background

Homeless people are continuously facing adverse living conditions as poor access to basic nutrition, hygiene conditions and healthcare services, being at increased risk of severe infectious diseases as HIV and hepatitis as well as cardiovascular diseases and mental disorders. The characterization of homeless people's health is fundamental to identify their health care needs. Considering that the aforementioned diseases are associated with chronic inflammatory processes, the main goal of this study was to characterize the inflammatory profile of a homeless population through quantification in saliva of a panel of inflammatory cytokines.

Methods

The inflammatory profile was assessed in 114 individuals residing in two temporary shelters located in Lisbon and that accepted to participated in the study. Inflammatory proteins were quantified using a Multiplex Immunoassay approach. Data analysis was performed using the GraphPad Prism software and statistical significance among the groups was assessed using the nonparametric Mann-Whitney test.

Results

Even though some protein levels might be masked by drug treatment, data analysis showed high levels of INF-ϒ, IL-10 and TNF-α in the infectious disease group, critical cytokines for the immune response against viruses and bacteria. Also, cytokines like IL-1β and IL-6 were detected at statistically significant levels in the cardiovascular disease group and all cytokines included in this study were quantified in the mental disorders group.

Conclusion

These findings may help the healthcare services in the evaluation of treatment efficacy and disease monitoring, and in the development of effective public healthcare strategies and policy interventions to improve quality of life of the homeless population.

Access to hygiene facilities and experiences of hygiene-related disease: A pilot study of unsheltered individuals in Tucson, Arizona

Unsheltered individuals have limited access to restroom facilities. With this, many unsheltered individuals are forced to urinate, defecate, and engage in other hygiene practices outdoors. They may also lack access to necessary hygiene toiletries or wait to urinate or defecate until they are able to gain access to a facility. These challenges can lead to health issues, like urinary tract infections (UTIs), diarrhea, rashes, etc. The study objective was to understand the relationship between lack of access to basic hygiene facilities and health effects among unsheltered individuals. A verbal survey (English and Spanish) was used to explore the relationship between hygiene and unsheltered status. In Fall 2022, a researcher accompanied the homeless outreach team from El Rio Health, a Federally Qualified Health Center in Tucson, Arizona to verbally consent and recruit participants. Thirty consenting unsheltered adults ranging in ages from 29 to 68 years old participated in the study. Access to water was the greatest reported hygiene barrier, followed by access to soap, concerns for privacy, and concerns for safety. Eleven of thirty participants experienced a UTI at least once since becoming unsheltered and nine of thirty experienced a yeast infection at least once, with female participants having a statistically significant (p < 0.05) higher rate of occurrence than male participants. In addition, 19/30 of participants experienced a rash at least once and 17/30 of participants experienced diarrhea at least once. However, 20/30 of participants did not seek medical care for their health-related issues. Low healthcare utilization when there is a high need for care highlights the importance of community outreach and care for those experiencing homelessness. Next steps include replicating the project on a larger scale to determine generalizability.

Growing Concern About Unsheltered Homelessness Among Veterans: Clinical Characteristics and Engagement in Health Care Services

OBJECTIVES

Veteran homelessness has declined in the past decade, but the proportion of unsheltered homeless veterans has increased. We identified characteristics of unsheltered homelessness in a large contemporary veteran cohort and examined outpatient and inpatient encounters before and after intake to US Department of Veterans Affairs (VA) homeless programs.

METHODS

National data from the Homeless Operations Management Evaluation System (HOMES) database and the Corporate Data Warehouse were analyzed on 191 204 veterans experiencing housing instability from January 2018 through December 2021. We used hierarchical multivariate logistic regressions to model associations between sheltered status and veteran correlates. Repeated-measures analysis of variance assessed changes in care utilization after intake in homeless programs.

RESULTS

Age <50 years (odds ratio [OR] = 1.3; 95% CI, 1.2-1.4), Hispanic ethnicity (OR = 1.2; 95% CI, 1.1-1.3), some college education (OR = 1.1; 95% CI, 1.0-1.1), and a bachelor's degree (OR = 1.2; 95% CI, 1.1-1.2) were associated with veteran unsheltered homelessness. Unsheltered veterans were more likely to have a VA service-connected disability (OR = 1.4; 95% CI, 1.4-1.5), military sexual trauma (OR = 1.1; 95% CI, 1.0-1.1), and/or combat exposure (OR = 1.1; 95% CI, 1.0-1.1). Unsheltered and sheltered homeless veterans had an increase in outpatient encounters and a decrease in inpatient care after intake to the VA homeless program.

CONCLUSIONS

Contemporary unsheltered homeless veterans are younger and Hispanic with some college education. Innovative public health approaches that better engage and reduce barriers to entry need to be tested for a diverse unsheltered homeless population.

A stakeholder co-design approach to designing a dental service for adults experiencing homelessness

Introduction

The homeless population faces a "cliff edge of inequality" when trying to access essential dental services. There are several additional barriers to accessing dental care in comparison to the general population and the heterogeneous nature of patients presents a significant challenge when designing dental services to meet their needs. Following the Smile4Life report in 2009, there is limited up-to-date and population-specific evidence available for the optimal model of service delivery.

Aim

This study aimed to co-design principles for a prospective dental service for adults experiencing homelessness.

Methods

A qualitative methodology was used to incorporate experts-by-experience into elements of co-designing a dental service for adults experiencing homelessness. The study combined elements of an experienced-based co-design framework for healthcare innovation with community-based participatory research. Focus groups with people experiencing homelessness and healthcare practitioners were conducted to identify principles for any prospective dental service, as well as several barriers and enablers to establishing a homeless dental service. The findings were transcribed and analysed using thematic analysis on Nvivo software.

Results

From the qualitative analysis five key themes emerged: (1) Impact and expectations of oral health while experiencing homelessness, (2) Barriers to accessing dental care; (3) Practitioner's views about homelessness and access to care; (4) Barriers to designing a homeless service and (5) Enablers for co-designing a new model of dental care delivery for the homeless population.Five key principles for a new model of homeless dental service were identified: (i) Services designed to address the needs of patients; (ii) Services delivered in a safe and welcoming environment (iii) Training and consistency of staff; (iv) Focus on dental education (v) Developing peer mentoring and peer support.

Conclusion

While the barriers to accessing dental care while homeless are well established and understood by healthcare practitioners, more work is required to gain consensus on the most effective way to deliver an innovative a sustainable dental service for patients experiencing homelessness. Previous negative experiences, lack of readily available information on services and barriers to access in the current system could be addressed by developing peer mentors within the homeless community, empowering individuals to share their knowledge and skills to support others in improving their oral health.

Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review

BACKGROUND

Homelessness creates a significant social and economic burden in the society. Homelessness and mental illness are two interconnected social issues that poses challenges to individuals and communities across the globe. This systematic review aims to synthesize the existing literature on interventions for the homeless persons with mental illness.

OBJECTIVES

To systematically review the existing literature on psychosocial interventions for homeless persons with mental illness.

SEARCH METHODS

Five databases including PubMed, ProQuest, Cochrane Library, OVID, and Google Scholar were searched using homelessness, psychosocial interventions, mental ill, residential mental health facility, and case management for experimental studies published from January 2000 to December 2022.

STUDY SELECTION

Abstract review was conducted for the screened studies, and full-text review was done for studies which met inclusion exclusion criteria.

DATA EXTRACTION AND ANALYSIS

Among the 6,387 studies screened 20 studies were selected which fulfilled inclusion criteria. The full text review yielded data of 12,174 homeless persons with mental illness who undergone intervention.

RESULTS

The major psychosocial interventions found including critical time intervention, case management, housing support intervention, assertive community treatment, and life skills training. These interventions were helpful in sustaining housing stability, preventing relapse, reducing hospitalizations, and improving quality of life of the homeless persons with mental illness.

CONCLUSION

Targeted and integrated interventions addressing homelessness and mental illness are required to tackle the social problems of homelessness and mental illness. Further research is required to explore the most effective strategies that address homelessness and mental illness.

Discharge process for patients experiencing homelessness in the emergency department: A thematic qualitative study

People experiencing homelessness are more likely to utilize emergency departments than their non-homeless counterparts. However, obtaining a bed in a homeless shelter for patients can be complex. To better understand the challenges of finding a safe discharge plan for homeless patients in the emergency department, our team conducted interviews with emergency department social workers and homeless shelter case managers in the Boston area. We identified and mapped the stages in the processes performed by both parties, identifying challenges with successful placement into a shelter. Furthermore, we assembled a data dictionary of key factors considered when assessing a patient's fit for a homeless shelter. By identifying bottlenecks and areas of opportunity, this study serves as a first step in enabling homeless individuals to receive the post-discharge assistance they require.

Prevalence of dementia among people experiencing homelessness in Ontario, Canada: a population-based comparative analysis

BACKGROUND

Cognitive decline in people experiencing homelessness is an increasingly recognised issue. We compared the prevalence of dementia among people experiencing homelessness to housed individuals in the general population and those living in low-income neighbourhoods.

METHODS

We conducted a population-based, cross-sectional, comparative analysis using linked health-care administrative data from Ontario, Canada. We included individuals aged 45 years or older on Jan 1, 2019, who visited hospital-based ambulatory care (eg, emergency department), were hospitalised, or visited a community health centre in 2019; and identified people experiencing homelessness if they had one or more health-care records with an indication of homelessness or unstable housing. Prevalence of dementia was ascertained as of Dec 31, 2019, using a validated case definition for Alzheimer's disease and related dementia that was modified to include diagnoses made at a community health centre. Poisson models were used to generate estimates of prevalence. Estimates were compared with Ontarians that accessed any of the same health-care services over the same time, overall (general population group), and among those who were in the lowest quintile of area-based neighbourhood income (low-income group).

FINDINGS

12 863 people experiencing homelessness, 475 544 people in the low-income comparator group, and 2 273 068 people in the general population comparator group were included in the study. Dementia prevalence was 68·7 per 1000 population among people experiencing homelessness, 62·6 per 1000 population in the low-income group, and 51·0 per 1000 population in the general population group. Descriptively, prevalence ratios between people experiencing homelessness and the comparator groups were highest within the ages of 55-64 years and 65-74 years in both sexes, ranging from 2·98 to 5·00. After adjusting for age, sex, geographical location of residence (urban vs rural), and health conditions associated with dementia, the prevalence ratio of dementia among people experiencing homelessness was 1·71 (95% CI 1·60-1·82) compared with the low-income group and 1·90 (1·79-2·03) compared with the general population group.

INTERPRETATION

People experiencing homelessness experience a high burden of dementia compared with housed populations in Ontario. Findings suggest that people experiencing homelessness might experience dementia at younger ages and could benefit from the development of proactive screening and housing interventions.

FUNDING

The Public Health Agency of Canada.

"Death Is a Possibility for Those without Shelter": A Thematic Analysis of News Coverage on Homelessness and the 2021 Heat Dome in Canada

Among the most vulnerable to the health-harming effects of heat are people experiencing homelessness. However, during the 2021 Heat Dome, the deadliest extreme heat event (EHE) recorded in Canada to date, people experiencing homelessness represented the smallest proportion of decedents (n = 3, 0.5%)-despite the impacted region (British Columbia) having some of the highest rates of homelessness in the country. Thus, we sought to explore the 2021 Heat Dome as a media-based case study to identify potential actions or targeted strategies that were initiated by community support agencies, individuals and groups, and communicated in the news during this EHE that may have aided in the protection of this group or helped minimize the mortality impacts. Using media articles collated for a more extensive investigation into the effects of the 2021 Heat Dome (n = 2909), we identified a subset which included content on people experiencing homelessness in Canada (n = 274, 9%). These articles were thematically analysed using NVivo. Three main themes were identified: (i) public warnings issued during the 2021 Heat Dome directly addressed people experiencing homelessness, (ii) community support services explicitly targeting this population were activated during the heat event, and (iii) challenges and barriers faced by people experiencing homelessness during extreme heat were communicated. These findings suggest that mass-media messaging and dedicated on-the-ground initiatives led by various organizations explicitly initiated to support individuals experiencing homelessness during the 2021 Heat Dome may have assisted in limiting the harmful impacts of the heat on this community.

A Community Initiative to Help Children Who Are Homeless

Children experiencing homelessness (CEH) have several health-related needs. It is necessary to address barriers posed by homelessness to improve health outcomes. Our objectives were to (1) conduct a health-related needs assessment and (2) determine acceptability/feasibility of the community-based initiative designed to identify and address health-related needs for CEH. The initiative involved a mobile care center, a health-focused education series for CEH, and resource provision, which included establishing connections with a stable source of health care. The needs assessment included standardized screening questions assessing health-related needs. We surveyed guardians of CEH who attended Summer360 between June and July 2022. Guardians were invited to evaluate our intervention via survey. We used descriptive statistics to characterize health-related needs. A needs assessment was completed on 36 of 100 children (42% white persons, 64% male), with 94% reporting at least 1 health-related need, and 61% with ≥3 needs. The most common needs identified were dental health and food insecurity. Twenty-four (24%) campers participated in a mobile health clinic that included hearing and vision screening, fluoride application, and vaccinations. The education series included dental hygiene, nutrition, and mental health. All families who desired assistance (73%) were connected to resources, and 91% of guardians agreed that the initiative helped meet their children's health-related needs and provided helpful resources. Implementation required planning with contributors including dental partners, mobile clinic operators, and school leadership. A community-based health initiative may serve as a unique opportunity to identify and address health-related needs for CEH.

Sheltered from the heat? How tents and shade covers may unintentionally increase air temperature exposures to unsheltered communities

Objective

Heat vulnerability and homelessness are central public health concerns in cities globally, and public health implementation should address these two challenges in tandem to minimize preventable heat-related morbidity and mortality. Populations facing unsheltered homelessness use tents (or similar shelters) with shading features to minimize sun and heat exposure. This study evaluates the efficacy of different tent cover (shading) materials and how they moderate the in-tent air temperature (Tair) exposures of tent users during extreme summer conditions.

Study design

Within-tent Tair monitoring using Kestrel Drop devices occurred across three full typical summer days in Phoenix, Arizona in July 2022.

Methods

In-tent Tair were statistically compared between six small side-by-side identical tents with different cover materials (control (no cover), mylar, white bedsheet, tarp, sunbrella fabric, aluminum foil), as well as with ambient Tair.

Results

Using any tent resulted in higher daytime in-tent Tair than ambient Tair. Further, compared to a control tent, the Tair within tents shaded with sunbrella, tarp, and white bedsheet had significantly higher Tair at all times (2.36 °C, 2.46 °C, and 1.11 °C higher Tair, respectively), controlling for Tair and day/night.

Conclusion

Adding cover materials over tents may increase heat risk to an already vulnerable population at certain times of the day. Higher in-tent Tair is attributable to the reduced ability for heat and vapor to escape, largely due to reduced ventilation (mixing). Local authorities and welfare associations should reconsider using unventilated tents for shading and promote more widespread, ventilated tents and shade to ensure that prevention efforts do not further marginalize the most vulnerable. Future work should incorporate more comprehensive measurements of solar radiation to quantify overall heat stress for exposure reduction techniques.

Bridge Healing: A Pilot Project of a New Model to Prevent Repeat "Social Admit" Visits to the Emergency Department and Help Break the Cycle of Homelessness in Canada

Homelessness continues to be a pervasive public health problem throughout Canada. Hospital Emergency Departments (EDs) and inpatient wards have become a source of temporary care and shelter for homeless patients. Upon leaving the hospital, homeless patients are not more equipped than before to find permanent housing. The Bridge Healing program in Edmonton, Alberta, has emerged as a novel approach to addressing homelessness by providing transitional housing for those relying on repeated visits to the ED. This paper describes the three essential components to the Bridge Healing model: partnership between the ED and a Housing First community organization; facility design based on The Eden Alternative™ principles; and grassroots community funding. This paper, in conjunction with the current pilot project of the Bridge Healing facilities, serves as a proof of concept for the model and can inform transitional housing approaches in other communities.

The Prevalence and Perceived Utility of Mobile Health Technology Among Recently Incarcerated Homeless Adults

Mobile technologies can deliver physical and mental health services for recently incarcerated homeless adults (RIHAs). The purpose of this study was to examine the prevalence and perceived utility of mobile technology to support health behavior change among RIHAs. Participants (n = 324) from an ongoing clinical trial at a homeless shelter in Texas were included in the current descriptive cross-sectional analyses. Over one fourth (28.4%) of participants had an active cell phone. Nearly 90 percent (88.6%) of participants reported at least weekly use of the internet, 77 percent used email (77.2%), and more than half used Facebook (55.2%). Although most participants (82.8%) believed that smartphone applications (apps) could help change their behavior, only a quarter (25.1%) had used an app for this purpose. These findings highlight the potential for smartphone-based intervention technologies, and future studies should examine whether smartphone apps that address mental health and health behaviors are feasible among RIHAs.

Challenges and Prescriptions for Homeless Drug Users’ Social Reintegration; An Experience of Partnerships Between Iran and Europe NGOs

The research addressed challenges and prescriptions for reintegration of homeless people who use drugs. Data were collected through conducting semi-structured interviews. Twenty-nine participants were recruited. The primary codes were extracted and divided into two main categories of challenges and prescriptions; the former included becoming homeless after a long term recovery, workplace stigma, service users’ different cultural backgrounds, dismissing the 12-Step Program, message fatigue, negative effect of relapse on groups and cyberspace overuse; and the latter included connection by hook or by crook, abstinence-harm reduction orientation, organizational service collection, pushing boundaries of interventions, and expanding services umbrella.

Assisting Homeless Women in a City in Brazil during the COVID-19 Pandemic in the Context of a Street Outreach Office: The Perceptions of Health Professionals

This study aimed to understand the perception of Street Outreach Office professionals regarding the health care offered to homeless women during the COVID-19 pandemic. This is a qualitative and descriptive study developed with nine health professionals of a Street Outreach Office team from a large city in the countryside of São Paulo State (Brazil) from December 2020 to April 2021. Data were obtained through interviews using a semi-structured script with questions about care practices directed to homeless women. The data were analyzed according to content analysis in the thematic modality. Two thematic categories were identified: (i) the reorganization of the Street Outreach Office to meet the demands of the population and (ii) the challenges in caring for homeless women during the pandemic. The activities were intensified with the team's expansion and distribution of supplies such as masks and alcohol-based hand sanitizers. Our findings showed that the primary problem faced was pregnancy during the pandemic. The lack of material and structural resources and social apparatus to care for homeless women was also evidenced. It was possible to conclude that even with all the adversities, the professionals employed creative strategies, contributing, within their limitations, to the care of homeless women.

Melanoma Identification and Management in an Unsheltered Male Using Teledermatology: Street Medicine Perspective

Skin cancers are concerning for unsheltered people experiencing homelessness because of their high levels of sun exposure. Currently, there is little data on the prevalence of skin cancers in people experiencing homelessness. Skin diseases are often untreated in people experiencing homelessness due to a lack of access to specialized care. Miami Street Medicine (MSM) is an organization that provides people experiencing homelessness in the Miami Health District with medical care in a nonclinical street setting, near overpasses, sidewalks, and encampments. We present a case of an unsheltered 59-year-old male with a pigmented, 2 cm × 2 cm facial lesion that developed over several years. Through a teledermatology consultation, his lesion was highly suspicious of melanoma and further evaluation was recommended. Due to a lack of insurance, he could not be treated at any dermatology clinic. Coincidentally, 2 weeks later, he developed cellulitis of his lower extremity and was admitted to the local safety-net hospital through the emergency department. By coordinating with his primary inpatient team, MSM was able to include a biopsy of the lesion as part of his hospital stay. The results demonstrated melanoma in situ. The vital course of action was to ensure treatment before metastasis. After registration for insurance and follow-up with a surgical oncology team, he is weeks away from excision and reconstruction surgery. His unsheltered status made follow-up difficult, but MSM bridged the gap from the street to the clinical setting by incorporating teledermatology into patient evaluations and leveraging connections with community shareholders such as charitable clinics and volunteer physicians. This case also represents the barriers to care for cancer-based dermatologic outreach among people experiencing homelessness.