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The Point of Return
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Dr. Tanya Page has worked to establish Outside In as a primary medical home that helps marginalized people experiencing homelessness in Portland, Oregon. It helps people work towards self-sufficiency and improved health. Outside In’s medical clinic serves roughly 6,000 adults and youth each year, offering traditional and alternative medical supports, mental health care, community referrals, and mobile outreach.
The point of Return


Outside In receives a Services in Supportive Housing (SSH) grant from SAMHSA’s Center for Substance Abuse Treatment, under the Grants for the Benefit of Homeless Individuals program.

When Dr. Tanya Page thinks of Outside In, she thinks about home. “The people we work with are homeless,” Tanya says, “so our goal is to provide them with a home in the medical sense.”

As the Assistant Medical Director at Outside In’s medical clinic, Tanya has worked to establish the agency as just that. Its program is based on a primary care medical home model that helps marginalized people experiencing homelessness work towards self-sufficiency and improved health.

One client who found this type of medical home there is Cyndi*, who was an active drinker with acute hepatitis when she first showed up at Outside In. “But now, she’s in recovery from alcoholism and hepatitis. Her other health issues are resolved, she’s housed, she’s taking care of her children, and she’s in school to be a nurse,” Tanya says. “I think about where she was, and how far she’s come in the last few years, and it’s amazing.”

Outside In has integrated its services in a way that is entirely patient centered and is modeled on other primary care medical home initiatives around the country. “We try to keep in mind – for every single decision we make – what is good for the patient,” Tanya explains. “And this means that if you’re a patient in our clinic, you have access to talk to somebody, to be seen, or to ask a question about your health at any time.”

This is no more apparent than in Outside In’s approach to patient appointments. Clinicians take a team approach, with a nurse, medical assistants, primary care and naturopathic physicians, a behaviorist, and a referrals coordinator working on each patient’s case. Every morning, this multidisciplinary team discusses the holistic needs of every patient scheduled for an appointment that day, a process they call “scrubbing the chart.”

“So,” says Tanya, “by the time patients get in the room with us, we’ve already thought about what needs they might have beyond what they’re coming in to see us for. We try to make it as easy as possible for patients by addressing as much as we can while they are actually in our offices.” This can be anything from helping navigate the bus system to providing and explaining medications at the on-site pharmacy - no small task for an organization serving roughly 6,000 individuals on a yearly basis.

The more mainstream medical supports, however – such as primary care, mental health care, and referrals – are only a relatively recent addition to Outside In’s spectrum of services. Tanya says that the organization is committed to offering a wide range of services, including alternative medicine. Acupuncture, naturopathy, massage, energy healing, and chiropractic medicine are all available at the clinic.

“Patients seem to be really happy that it’s available, and they are willing to participate in it, even the ones who don’t know much about it when they come to the clinic,” she says.

People come to Outside In’s clinic through a variety of pathways; some are referred from Outside In’s own youth drop-in day program upstairs, while others come via emergency rooms or other community health clinics.

And when patients cannot travel to the clinic, the clinic comes to them. Outside In staff use a mobile medical van to find and serve some of the most marginalized individuals experiencing homelessness in the community.

Tanya reports that mobile outreach has aided many powerful transformations. She says that it has brought much-needed health care to some of the most marginalized individuals on the streets, and it has added new complexity to the concept of the primary medical home.

Tanya says that finding the right community partners is the biggest lesson learned from mobile outreach. “If we work with community partners where people are already gathering anyway, we’ve found outreach to be very effective,” she says. “But when we go in without a community partner, it’s often less successful.”

Outside In’s program is designed to create not only sustainable change for its patients, but also a more sustainable flow of doctors working with underserved populations. Doctors who leave medical school without any exposure to underserved communities are far less likely to pursue careers working with these populations.

“One of the things we do is make sure that residents and students [of both traditional and alternative medical care] have the opportunity to work with us here,” Tanya says. By engaging local students in this way, they hope to foster understanding of, and interest in, careers in community medicine.

Tanya has a deep appreciation for the clinic’s approach to understanding patient health. “At Outside In, we understand that getting a patient into stable housing is just as important as treating their diabetes – and in fact, you cannot separate the two. You cannot treat the diabetes without treating the social issues,” she says. This approach can feel overwhelming because of the resources, time, and money it often takes to get patients to a healthy place.

But for Tanya, Outside In’s tagline, a point of return, can only be achieved if providers are willing to help address patients’ real issues. “No matter what client or patient you’re working with, the key thing is to really understand what is truly happening to cause their problems,” she says. “Just getting at that truth – and suspending judgment once you’ve found it – is the most important thing.”

*Not her real name. Her name has been changed to protect her privacy.

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