Hearts & Soles Community Foot Care Clinics Expanding Service Delivery & Educational Offerings for Wolverine Street Medicine: Re-centering the Voices of People with Lived Experience

By Molly Fessler

Introduction & Overview

The project, Hearts & Soles Community Foot Care Clinics, Expanding Service Delivery
& Educational Offerings for Wolverine Street Medicine: Re-centering the Voices of People with
Lived Experience, spanned multiple domains including education and service delivery with a
goal to be thoughtful about how to expand services as well as the educational options for future
providers of individuals experiencing homelessness. Wolverine Street Medicine is a student run
street medicine organization housed at the University of Michigan Medical School. It has a
strong educational legacy with a thorough training program for volunteers & a robust elective
course for clinical students. Our mission through this project was trifold: we sought to expand
service delivery by the development and implementation of foot care clinics, to update
educational items appropriately, and, throughout all aspects of this project, ensure that we were
using this opportunity to center the stories and experiences of people with a lived experience of
homelessness.

This project had three components which, though distinct, offered considerable overlap
between them. These included a “listening” phase in which we learned from our partners,
patients, students and residents; an “education” phase, in which we developed tools designed to
meet the learning needs of our students and trainees; and an “implementation,” phase in which
we designed and delivered new services in a community clinic model to our patients.
In the first phase, we conducted a community partner and community health needs
assessment, going directly to our partners and patients to hear their perspective on the needs of
the community and the ways in which we could serve them best. We updated the street medicine
clinical elective material to reflect these recommendations. In the second, education phase, based
on feedback from student leaders and our own observations about the need for a more
comprehensive set of educational offerings, we began the process of designing new modules for
the medical student clinical elective as well as spearheaded the development of the Wolverine
Street Medicine Clinical Playbook, the first resource of its kind to offer illustrated,
on-the-ground, practical field based instruction for students and trainees.

In the third phase of this work, we developed our foot care clinics. Similarly, our work to
develop the Hearts & Soles Community Foot Care Clinics had roots in the need for foot care we
were hearing about from our patients, our partners, and the importance of training medical
students and residents to provide that care well. People experiencing homelessness struggle with
access to traditional systems of healthcare (Davis & Wood, 2018). Persons experiencing
homelessness are often forgotten and left behind by traditional medical systems; so too are their
feet. Not only do studies articulate a higher burden of foot conditions among people experiencing
homelessness (Nikoo, 2014), but many unhoused individuals struggle with care navigation and
self-advocacy when it comes to getting their foot concerns addressed (D’Souza et al, 2022).

The Hearts & Soles Foot Care clinics provides community connection and healing
through foot care, by seeking to address several unmet needs within the community experiencing
homelessness. We currently provide thrice monthly clinics for people experiencing homelessness
where they may access this care in a community setting familiar and comfortable to them,
serving our patients at Delonis Shelter, Mercy House, and at the rotating warming center in Ann
Arbor and Ypsilanti. Hearts & Soles clinics include students, community partners, and clinicians
in providing this care. We have served over 50 patients at over 20 discrete clinics, with
participation from over 30 students and residents. This work also enabled us to provide over 100
foot care kits to patients on the streets and develop unique trainings and protocols which we have
made available to the community writ large.

As part of the development of the clinics, we engaged in research about foot care and
instituted protocols, exams, and workflows for our foot care clinics. Members of our team
participated in a month-long rotation learning podiatry skills and wound care from professionals,
in order to institute these best practices in street and field settings. Our team developed a
comprehensive template for foot care exams, a training module to teach students about tools and
appropriate use, and have provided numerous training sessions for interested students.

Phase 1: Listening

We began our inquiry into feasibility and importance of this project through a community
health needs assessment. The aims were as follows:

1. Understand the experience of persons experiencing homelessness when it comes to
   accessing healthcare and foot care resources in Washtenaw county.
2. Appreciate the barriers to accessing foot care among population experiencing
   homelessness.
3. Learn the conditions that lead to homelessness and chronic disease associated foot
   problems, as articulated by community members themselves.
4. Listen to the perceived solutions expressed by individuals with lived experiences of
   homelessness for increased access to foot care services.

– 12 individuals were interviewed as well as 3 community partners.

– Themes from the needs assessment included: need for greater access to foot care services, need
for greater understanding of available services, and need for greater access to supplies that would
enable individuals to better care for their feet. Communication and perceived care of providers for
patients were other crucial ideas that emerged from this assessment. Patients also wanted
providers, especially students, to demonstrate greater prowess in delivering foot care.

Phase 2: Education

– Development of training tools, website, and resources, available at the following link:
https://www.wolverinestreetmedicine.org/hearts–soles.html#/
– Development of the Clinical Playbook, which includes key protocols, exam guidance,
and clinical knowledge related to foot care as well as many common conditions seen in
street based care (sample pages in appendix V).
– Workshops & Trainings:

• Foot Care trainings were provided at multiple junctures as part of the Wolverine
  Street Medicine Trainings starting in October 2023 and continuing monthly
  through the present.
• Special education events, including:
  • Podiatry event: Podiatrists taught medical students how to provide
    specialized care. April 2023. (Images in appendix II).
  • Wound/foot care journal club on management of foot/wound conditions in
    field settings. April 2023.

Phase 3: Development

• – Foot care clinics were instituted at multiple community clinics (images in
  appendix) with input from community partners.
• – Events also focused on engaging the community by creating foot care kits for
  clinic patients (kit images in appendix).
• – Evaluation:

• • – Process/Outcome Measures:
  • – Over 20 clinics completed at 8 community locations with 3
    community partners from April 2022-April 2023
  • – Over 50 patients served
  • – Over 30 student & resident participants
• – Patient Satisfaction: Patient satisfaction was measured during randomly
  assigned clinic days using a modified Likert scale (appendix VII).
• – Overall, patients expressed 56% improvement in average satisfaction
  with their feet after the foot care clinic.

Average Satisfaction with Feet, Pre-Foot Care
Clinic
(1 being the lowest or least satisfied, 5 being
the highest, or most-satisfied) 2.38

Average Satisfaction with Feet, Post-Foot
Care Clinic
(1 being the lowest or least satisfied, 5 being
the highest, or most-satisfied) 4.23

• – Advocacy and consideration of the importance of sharing the story of foot care.
  • – Work shared at the University of Michigan Student Impact Symposium by
    first year student, Kaitlin Malley in October 2022 (appendix VI).
  • – Work due to be shared at Physicians for Human Rights Conference by first
    year student, Sarah Hatfield, April 2023.
  • – Featured in the University of Michigan Alumni Newsletter for Spring
    2023 (see appendix VI)
  • – Authority Health Blog Post available at the following link:
    https://authorityhealth.org/community_health/hearts-soles-community-foo
    t-care-clinics/

Conclusions

Moving forward, we continue to train our new leaders in foot care and education to
sustain and continue these efforts. We have identified 2 senior medical students and 2 junior
medical students to continue this work. Our work over the past year has demonstrated to us that
this work is much needed and valued within the community. We’ve seen sustained growth in the
number of events we are able to hold and staff with medical student and resident volunteers. Our
presence has become known in the community and patients seek us out for care and guidance
when it comes to addressing their foot care concerns. Community partners routinely reach out to
Hearts & Soles as a partner in the Ypsilanti and Ann Arbor communities.

This project sought to include the aim of sustainability as a central tenet from its very
inception. At every point, we have sought to ensure that we were thoughtful about creating
systems that would last the test of time and enable future leaders to carry on our work. We feel
confident we have achieved this; a strong train the trainer model, with stakeholders invested at
multiple levels has resulted in a core leadership group with active volunteer involvement. We
routinely have waitlists for medical student participation in our foot care clinics and active
resident involvement in providing care. Student leadership has transitioned from the exclusive
purview of the Schweitzer fellow, to a cohort of experienced, highly-competent leaders with a
vested interest in service to the community and improvement in access of these services for the
underserved. With a strong foundation and reputation in the community, we’re hopeful we can
continue to offer these services for many years to come.

Molly Fossler is a Schweitzer Fellow for Life and a Student at the University of Michigan School of Medicine