 So next we have Bryce Radmall. Bryce tells me that he has caught a piranha in the Amazon River. I don't know what one uses his bait to catch a piranha, but I don't think I want to know. So he's going to talk to us about the Fourth Street clinic. The story is much less sexy than it sounds. I was on the Amazon of Peru, and I met some villagers there, and they were fishing for piranha, and they just use a hook without any bait. So they're not too hard to trick. As Dan said, I'm Bryce Radmall. I'm from the University of Utah School of Medicine and a fourth-year medical student. And excited to be here with you to talk today about the Fourth Street clinic. I know many people here have donated their time to the Fourth Street clinic, and I hope your experiences there has been as positive as my experience there. The Fourth Street clinic is a comprehensive health care clinic that's offered to Utah's homeless population. They do their best to fully encompass all health care and support services, and those that they can do actually in the clinic, they refer out to other facilities. Walter Lijinsky is a gentleman. He's a PhD who serves in Washington. He is the senior advisor for homeless health care services and lobbies for legislation for the homeless. And one of his discourses that he gave, he said, history also reminds us that one day, our actions, programs, and policies will be subject of examination and analysis. We should be committed to leaving the best possible legacy of lessons while demonstrating that our responses were the best that our knowledge and sources enabled us to deliver. And this really is the drive of my presentation today. I hope that we can be held accountable for what we're doing at the Fourth Street clinic and then also come up with ways to improve health care delivery to the homeless. So how did the Fourth Street clinic get started? It was started by a gentleman named Alan Ainsworth. In 1988, it started with just one employee or volunteer who is a part-time nurse who would basically triage the patients and then send them out to local hospitals basically to receive their care and treatment. It started because during the mid-1980s, Salt Lake City saw a large economic revitalization and boom, and many of you may have heard of the single room occupancy hotels that were in downtown Salt Lake by the Fourth Street. These housed a lot of the government projects and lower income individuals who were janitors and had other jobs in the downtown area and would walk to their jobs. This economic revitalization led to more buildings being produced and demolition of these single occupancy hotels. And roughly about 1,000 residents were cut off from their homes at that time due to those projects and which led to really Salt Lake City's first homeless population. Before this time, there wasn't much of a reported homeless population in and around Salt Lake. So the Fourth Street clinic is staffed by 50 full-time staff and then also roughly 150 volunteers who come to help with the clinic. It serves close to 4,000 homeless men, women and children yearly. And roughly a two-to-one ratio, so 66% of the patients are male. Surprisingly, 15% of the patients are less than 22 years old and only 2% are over 64 years old. So if you look at how healthcare is in the general population, that over 64 is gonna be a much greater percentage of those who receive healthcare. And we're gonna talk a little bit about why that is in the homeless population, why it's a little bit flopped here. 72% of the patients have no form of insurance that are seen there. The clinic itself documents over 22,000 primary care, behavioral health and specialty care visits, and the pharmacy dispenses close to 50,000 prescriptions a year. And this is done for minimal cost to the patient and most times is free. So going back to why there's only about 2% of the homeless population who receives their care at the Fourth Street clinic that's over the age of 64, I think this slide explains that well. This is numbers taken from the World Health Organization of 2009. You can see the life expectancy for the US population is approaching about 78 years of age. Utah we're doing a little bit better, we're just over that. And you can see how the homeless population is doing here. The average age of death for a homeless individual in the United States of America is 48 years of age and that's equal to Afghanistan and Nigeria among some of the lowest life expectancies in the world. It may go without saying but healthcare and homelessness are truly interdependent. People can't pay for their housing unless they're in good health and able to secure a job. And good health is unattainable with people who don't have any sort of safe permanent home that they can return to at night. Homelessness has been shown many times to be a substantial greater risk for infectious disease, dental problems, mental illness, chronic obstructive pulmonary disease and cardiovascular disease. And as you might imagine, infectious disease and cardiovascular disease are gonna link straight into eye care and ocular pathologies. The annual report on poverty of 2011 reported that the number one cause of death, so these people that are dying by age 48, the number one cause of death is from preventable and treatable illness in our homeless populations. So this is taken from the state of the homeless, state of Utah, 2011. And it just basically breaks down where the homeless are. Up here is the statewide homeless population. It's just over 14,000 right now. And as you can see and would well imagine that the vast majority of those are concentrated here in our own county in Salt Lake with over 9,000 there. As far as the epidemiology and what our homeless population looks like in Utah, this is taken from the same paper. I just wanna focus in on just this one little area here. All the numbers here are about a quarter that I'm gonna point out, but this is a survey that was given to the homeless population of Utah. And a quarter are sufferer from physical disability, a quarter sufferer from chronic substance abuse, a quarter from mental illness and a quarter have been the victim of domestic violence at one point in their life. So these are very complex patients who have a lot of things going on in their lives that have led to their state of homelessness. So there's a lot of papers out there on PubMed regarding homelessness and healthcare. And the literature is far more scant regarding homelessness and eye care specifically. There are several studies that exist. There are studies done in the homeless populations of Hawaii, Los Angeles, Toronto and Germany. And all but one of those studies suggested that there's an increased rate of visual impairment and ocular pathology among the homeless. One of the severe limitations of these studies is that they seem to be limited by sample size as most of these studies are somewhere in the range of about a hundred patients. It's also been shown that homeless have a higher incidence of cataracts, glaucoma, optic neuropathies and extraocular muscle defects. And there was one very large study done trying to link socioeconomic status and visual status done at Wilmer in the early 1990s. And we'll discuss that briefly. It was called the Baltimore Eye Survey. And they enlisted 5,300 individuals from the projects of Baltimore. There were 16 different communities that they went out and gave a complete ophthalmic examination to better understand the disease and its ocular disease and its relationship to the socioeconomic and other risk factors. There are multiple follow-up studies that were done using their data. And in one of those follow-up studies produced this graph here. On the y-axis of both of these graphs is an increasing rate of the population that is described as having poor vision. And poor vision in their study was described as best corrected visual acuity worse than 2040. So as you're going up on the y-axis, vision's getting worse. And then they compared that on the x-axis here to the median household income and dollars for those 16 communities. And then also the households below the poverty level for those 16 communities. And as you can well see, as vision is getting worse and more people are suffering from visual impairment, these are people who are making much less money on a yearly income basis, roughly $5,000. As far as households below the poverty level, we see the opposite linear relationship here, showing that as again vision is getting worse in this direction up, there's an increasing percentage of the people that live below the poverty level. So this is suggesting to us that there is a direct link between socioeconomic status and poor visual function. So how did the force free get started here in Utah with regard to the ophthalmology clinic? It started with Isaac Barthelot and then Dr. Vitale. They came together in 2005 and 2006 and got the necessary equipment in place to be able to start holding clinics. And the first clinic was held on April of 2007. It's been a monthly clinic since that time when it began their averaging between five and eight patients per clinic visit. And it's been completely run and driven by volunteer technicians, medical students, residents and attending physicians who have helped staff this clinic. The eye clinic has seen significant growth since that time in 2007. We're currently seeing between 10 and 15 patients monthly. Usually the clinic runs from about six p.m. When the attending show up, the patients show up about five and we're usually there till nine or 9.30 at night. Last February saw what was our first no cost cataract surgery day where the Moran Eye Center was gracious enough to open their doors to us on a Saturday. And we were able to have 42 volunteers to come in and offer the surgeries to 11 different patients. We had 11 patients, but 12 cases one of the cases was a bilateral cataract case. And this is the theoretic cost of that day. So this is slightly underestimated in my opinion because this was calculated using Medicare rates and the patients had zero insurance coverage and the actual billable dollar amount that would have been given to an under or an uninsured patient from the Moran here would have actually been higher. But the surgeon Medicare reimbursement for the six cases that would have been classified as simple, roughly $4,000 for six cases that were classified as difficult, $5,500. And then the facility fee you would see as a huge cost here. And that gives a grand total of almost $29,000. This is the number that we were able to do the surgery day for as an out-of-pocket cost number, just over $1,200. So really in effect, we were able to save $27,000 worth of expenses in offering the surgery day. So the cost savings analysis, we were able to save this money first by soliciting surgical and pharmaceutical suppliers to offset the surgical equipment cost and that totaled about $3,500. The actual out-of-pocket cost for our project, as I had stated, was just over $1,200 and that was mitigated by seeking financial donations from private donors and businesses in the local area. The most significant cost savings that we discussed was realized when the Moran was kind enough to open their doors to us and there was 42 volunteers who fully staffed the OR for about five hours, helping to achieve the cost savings on this slide here. This is just a pie chart showing the volunteers we had about 42, so this is their job description and then the number of volunteers in each department. As you can see, the physician fee is the largest chunk of that, but these are not insignificant numbers of the number of volunteers and really as far as doing another surgery day like this, this really is our rate limiting step, is being able to open up the Moran Eye Center and be able to have this amount of volunteers there donating their time. So it turns out the cost is not at all the only barrier to eye care among the homeless. Some other barriers that we've identified is in offering this no-cost cataract surgery day is this patient comprehension. Much of the population that we deal with is illiterate. They have somewhat of a difficulty understanding their diagnosis at times and so our solution to that is we scheduled additional preoperative visits to assure solid understanding and we were able to have the patients recite back to us what their disease process was, what the procedure would be and what their expectations for the case was. This is a huge barrier among the homeless population. Very poor compliance, it's hard to get a hold of the patients and they're no show rated. Our clinic has traditionally been about 50% and we're working to improve that and I'll talk about that in just a little bit, but it would be really hard to have had another cataract surgery day or even have it be a possibility if we had 12 patients on our schedule and one or two of them showed up and we had 42 volunteers there ready to help. So in order to prevent that from happening we required several really buy in visits where they had to come in multiple times. We brought them up to the Moran Eye Center here to meet with them and if they missed any of those appointments they were removed from the surgery list. This made it so that of the 12 scheduled patients that we had on our schedule 11 of them arrived for surgery. Another large barrier is communication as I mentioned it's hard to get a hold of them. Many of them do not have any sort of cell phone, home phone and oftentimes it's only you can try to call a shelter to get a hold of them. So we identified liaisons at the homeless clinic that was able to relay information to the local shelters. As well post-operative housing proved to be a little bit of a difficulty. We didn't want to operate on patients and then send them to the streets. We wanted to make sure they were safe for that first 24 hours before we saw them post-operatively the next day. And so what we did is we collaborated with the local homeless shelter, the road home and secured beds for the patients if they needed those and all patients had a safe place to stay following surgery. And then long-term follow-up. This is a very transient population. They come and they go. They have a hard time coming up and paying for travel to get up to the Moran Eye Center. So we've been able to do all follow-up clinic that first 24 hour post-op all follow-up appointments and care has been done at the four street clinic where many of them live on a day to day basis. Thank you. So a new model for the eye care clinic. Before we talk about the new model we have to understand how the old model worked. So the old model just began with identification of patients. Patients were self-identified or their primary care providers of the four street clinic requested that they be seen in the ophthalmology clinic. They immediately went to step three here at the ophthalmology clinic and we were serving as the primary eye care team, the consulting team, the surgical team. So what we're hoping to do and what we wanna see done is that we have patients identified through self-identification, primary care referral, diabetic screening and visual acuity screening. First step is to identify if the problem is emergent or not. If it's not emergent, this is gonna be a new clinic that we hope to be up and running by the end of September. We're just waiting on approval. It's in place and ready to go. We're just waiting on approval from the four street. This is going to be managed by Tina Mamelis, who's a first year medical student this year at the University of Utah and Dr. Mamelis and Dr. Oliphson has been kind enough to offer to staff that clinic and then Moran optometry is also going to be involved and this really is going to be our primary eye care clinic. They're gonna perform the initial eye exam and if it's an emergent case, they just get sent to the resident clinic at the Moran Eye Center. So once they've been seen at this primary clinic, they've shown an ability to show up for an appointment and I hope that's gonna decrease no show rates. So does it require off the helmet consultation? Does it need more than the primary clinic? If it's yes, then we go to this Tuesday, what has traditionally been the Tuesday night ophthalmology clinic and if not, they can get a refraction for refractive air through the primary care clinic. Here at the ophthalmology clinic, we hope to be the consultation team, the surgical and medical management team. And then most of the followup is able to be done at the four street. There are a few things that we don't have at the four street that needs referral up to the Moran Eye Center at the resident clinic and we can do that. And then if they need surgery, we can schedule surgery for our surgery day. So what's on the horizon for the four street? We're currently generating an IRB for prospective and retrospective studies. The retrospective studies, we have a list of roughly 400 to 500 charts that's been maintained since 2007. We wanna look at the prevalence of the various pathologies that these patients are suffering from and then correlate that to visual outcomes at given intervals and track that over time as they return for the return visits. Our prospective arm of the study we're hoping to enlist 100 patients and really evaluate the effectiveness of our eye care screening that's done by the primary care physicians and then also get some quality of life measures through validated surveys to these patients. We also hope to do a cost analysis of the treatment for the various diseases of the four street population versus a similar patient with the same disease that would be covered by insurance. Also, if you volunteer to the four street clinic, you know a lot of the equipment is not in the best working condition. You may have seen plumes of smoke emit from this slit lamp here. It's no longer functional. This slit lamp can cause dyplopia as you look through the lenses there and it's somewhat difficult. Wayne and Bresica has been instrumental in trying to secure some equipment and place it on loan down to the four street clinic and we're just waiting for a memorandum of understanding that's currently being drafted and just needs approval to get that clinic, the new equipment that equipment's in place and ready to go. All these efforts, again, are in hope to leave the best possible legacy of lessons while demonstrating that our responses were the best that our knowledge and resources enabled us to deliver. A huge thank you to Dr. Vitale who helped start the clinic. He also helped me in the preparation of this talk. Dr. Petty as well and then Brian Stagg introduced me to the four street clinic and I owe him a lot as far as my experience is there and as you heard, Dr. Petty talked about his instrumental care of the patients and getting them to the surgery day. So a special thanks to all the attendings, residents, technicians, medical students and anybody who's otherwise contributed to the four street clinic over the years. This is my bibliography and I'm happy to take any questions. Thank you.