Redefining the Medical Clinic
Posted by Carson WalkerComment

Carrie Kowalski taking pulseCarrie Kowalski, PA-C
Venice Family Clinic, Venice, Calif.

Carrie Kowalski, PA-C, practices in Venice and Santa Monica, Calif. Through her employment at the Venice Family Clinic she is able to practice in an unconventional setting—a van. Along with her supervising physician, Coley King, DO, Kowalski participates in an emerging model of care known as street medicine.

Kowalski began working at the Venice Family Clinic shortly after graduating from the University of Southern California’s PA program in 2012. She spends her mornings with the street medicine team and her afternoons in the clinic, which serves more than 24,000 low-income individuals annually—most of whom are from western Los Angeles County. Since moving to Los Angeles, Carrie has lived on the Westside, where the clinic is known as “a much-needed resource in the area.”

Kowalski says that she knew she wanted to work at the clinic while she was in PA school. After her graduation she kept sending her resume and cover letter over and over again.

“Finally they called me back and said they have a position to work with a highly vulnerable group of clients,” she says, “They asked would I be interested and I said ‘Yes!’ ”

Kowalski is the first PA to work at the clinic. She says Dr. King played a huge role in convincing the clinic that a PA would be an incredibly valuable addition to both the clinic and the street medicine team. When Kowalski was hired, the clinic was looking specifically for a PA to be part of its Street Medicine Project, which offers integrated mobile service to a subset of highly vulnerable homeless clients.

“We practice medicine on the street, and anywhere that our clients are located,” she says. “So that might be on the street, the beach, or in the shelters. And we also offer care in our clinics.”

Before working with Dr. King, Kowalski says she had no idea there was a street medicine movement. Dr. King gave her names of innovators in this area of medicine, as well as information on other street medicine agencies throughout the country.

“One of the major goals of street medicine is to decrease [emergency room] utilization,” she says, “by outreach to clients and being able to serve some of their immediate healthcare and triage needs.”

Since starting, Kowalski has learned a lot about these immediate needs.

“There’s the obvious need to find shelter and food on a day-to-day basis, but I’ve also learned that many of [our patients] have triage-type health needs,” she says. “A lot of these clients’ diseases are multifactorial, so their problems are not only chronic medical conditions, but they are also faced with disabling mental conditions, and a lot have serious substance abuse. So I’ve definitely learned that it really needs to be a multidisciplinary approach to begin to offer care to these clients.”

The large spectrum of issues facing her patient population is what makes Kowalski thankful the street medicine team is multidisciplinary, with several different healthcare providers involved in coordinating patient care. She sees a variety of illnesses/conditions in her patients on a daily basis, including cellulitis, scabies and head lice, complications from peripheral vascular disease such as skin ulcerations and dermatitis, dental infections, asthma, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and pneumonia, as well as chronic diseases such as obesity and osteoarthritis. Kowalski also attends to various trauma, as patients are often struck by vehicles, fall off bikes or get into physical confrontations.

The healthcare team meets each morning to discuss their patients’ urgent needs and prioritize the patients that need to be seen that day, and which member of the team should see that patient. “For example, if I’ve seen a patient the day prior that was increasingly anxious, depressed, or psychotic,” Kowalski says, “I’ll ask the psychiatrist or a therapist to make a point to see that patient that day on street outreach.”

Kowalski and Dr. King’s practice includes the management of mental and behavioral health conditions such as depression, anxiety and schizophrenia. Kowalski regularly touches base with the psychiatrist and Dr. King about patients’ medications. “This is to make sure [the team has] a comprehensive list and can look out for any drug interactions,” she says. “Often there are specific labs that the psychiatrist will ask us to monitor, for example some of the psychiatric medications can impact liver function tests, hemoglobin A1C, and lipids.  [The team] works together to rule out medical conditions that could manifest as a mental health problem.”

However, she says, “It’s a very challenging position because we are limited in what we can offer medically on the street. Also, resources are often quite limited for the clients. A lot of them don’t have insurance because they don’t even have an ID or record of their birth.”

Kowalski tries to see her street outreach patients at least monthly. “[The patients] have a difficult time storing medications, so we typically offer a one-month supply,” she says. “This allows us to keep a closer watch on our high-risk patients.”

She believes that the medical care provided by the street medicine team has been the first step in many homeless patients accepting more comprehensive services such as case management, therapy and eventually housing. She says that a recent patient of hers is an excellent example of this.

“While on street outreach, [the team] saw a homeless patient with a history of glaucoma complaining of a ‘red eye’ and poor vision. She had already completely lost vision in one eye, as she had gone untreated for a long time. She was living on the streets, and suffering from untreated glaucoma, hypertension and alcohol dependence.

“[The patient] began working with our integrated team and became enrolled in intensive case management services. We were able to have her seen by an ophthalmologist, who prescribed medication to prevent loss of vision in her other eye. During our time working with her, she also sustained a distal radial fracture in her forearm while living on the street. In collaborating with mental health providers, we were able to help her achieve sobriety in order to undergo orthopedic surgery for her fracture.

“Currently, she is drinking much less, has a housing voucher, and will be moving into her apartment during the next month. She is receiving treatments for hypertension and glaucoma, and is working with mental health providers to gain the skills needed to remain successfully indoors. Although her success can be attributed to a great deal of motivation on her part, our multidisciplinary approach to patient care has undoubtedly helped facilitate her wellness.”

Kowalski believes it’s an exciting time to be a PA. “As long as PAs continue to be flexible, active politically and in healthcare policy, then our opportunities are immense.”

She is really enjoying and appreciating her unique opportunity. Her greatest reward is “to really be able to help people who are typically stigmatized and often feel very ignored. The appreciation is really there from a lot of people.”

Carson Walker, JD, is a policy analyst at AAPA for Constituent Organization Outreach and Advocacy.


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