Banning mobile care in Kensington could lead to amputations, hospitalizations, maybe even deaths
No shirt, no shoes, no wound care? A bill proposing a ban on mobile services runs counter to best health-care practices, writes street wound care nurse and researcher Eleanor Turi.
A patient was on the floor of the waiting room of our opioid use disorder clinic, his eyes closed tight from the pain pulsing from the wounds on his legs. When I asked if he’d like me to change the dressings on his legs, he said no because he couldn’t take off his pants. I suggested cutting them from the bottom up, but he said they were his only pair. We didn’t have any extras in the clinic. After much negotiation, I gave him supplies to do his own wound care, knowing they were likely to get stolen, and I might not see him again.
Through my work as a wound care nurse and as a nurse scientist studying wound care delivery, I have learned that patients like this one — for confidentiality reasons I’ll refer to him by the initial in his first name, “J” — are common, and that offering compassionate care is key to healing them.
There are thousands of our sons, daughters, brothers, and sisters like J living with severe wounds due to injection drug use on the streets of Philadelphia and other cities across the U.S. Many patients come from traumatic backgrounds, which fuels their severe chronic condition of addiction. Wounds are common among people who use drugs because the street supply often includes unsafe chemicals that are mixed with heroin and fentanyl like xylazine, an animal tranquilizer known to cause severe wounds. These people face the amputation of their limbs and even death from infections if they go untreated.
The clinic where I work in Kensington is low-barrier, which means people can easily receive care like medications for addiction, sexual health testing, and wound care despite ongoing drug use. Many low-barrier care settings are in the street or in mobile vans. My mission is to give people like J the best care while making them feel understood and cared for.
I also work as a researcher studying how to improve the quality and quantity of low-barrier wound care for patients like J. I have interviewed 30 wound care providers, administrators, and recovery specialists (people in recovery from drug use) across Philadelphia, Camden, New York, Baltimore, and Pittsburgh about what we can do to improve wound care in the community.
Many low-barrier care settings are in the street or in mobile vans.
Across the board, I learned that compassionate harm reduction care — like offering clothing, housing, and clean needles — is key to keeping people like J in care. However, it is hard to continually supply these services when funding is tight for small organizations and local policies are constantly changing.
For example, on Monday, Councilmember Quetcy Lozada introduced a bill that proposes to ban services or distributions from mobile vehicles in Kensington on residential streets or near schools/recreation centers. This is a direct action against people who use drugs and require mobile services to receive the care they need, as many are in wheelchairs, unable to walk to receive care.
Although this policy was brought forward to address the needs of local residents, the bill will not address the root problem of poverty, the criminalization of drug use, and systematic racism. In fact, without mobile care in Kensington, many people who use drugs will be unable to receive preventative wound care, leaving their wounds undressed and open for infection, leading to complications such as hospitalization, amputation, and even death.
It is imperative that Councilmember Lozada and other councilmembers recognize the downstream public health impacts of removing mobile services from Kensington. The bill is up for a vote Thursday.
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This is not the first or last policy attempting to ban or decrease low-barrier care for people who use drugs. Given ever-changing local, state, and national administrations with varied views on crime, opioid use, and homelessness, it is important to identify ways for community organizations to sustain social services and wound care.
Medicaid codes are available for billing for low-barrier wound care and could provide a steady stream of revenue to community organizations. However, administrators of low-barrier wound care sites struggle to bill Medicaid for street medicine or mobile services because they do not have the time, administrative support, or scope of practice that allows them to submit Medicaid claims.
It is important to innovate to increase the uptake of Medicaid billing. For example, city-level support could be strengthened to ensure small organizations have the administrative ability to bill for services. City-level billing guides as well as regulating the speed of Medicaid payments from managed care organizations — which are often very slow — could help reduce this burden.
Further, allowing registered nurses to directly bill Medicaid would expand use. Right now, only some providers can bill for Medicaid low-barrier services such as street medicine. Registered nurses often work alone in mobile vans or on the street delivering care, and they deserve to be paid for the care they are delivering.
I have not seen J since that day in the clinic about two months ago. However, I have hope for him and his safety because I know this community is incredibly resilient. I also have hope that one day, these patients will not need resiliency alone to survive; that they will get the clothes they need, that mobile services will go where they are, and that a new system will arise to replace the chaos we have now.
I know and believe our health system and political appointees have the power to prevent unnecessary deaths in Kensington. After all, this is America — why are we still struggling to find a pair of pants?
Eleanor Turi is a nurse and health services researcher in Philadelphia.