Mobile Dermatological Care: The community feedback period for this idea began on 2/6/2019 and ended on 4/7/2019.*STATUS UPDATE*

What is the problem that needs to be addressed? Please describe how it is related to mental health.
Homeless Dermatology. People who are homeless are disproportionately experiencing mental illness. Homelessness presents several dermatological issues including: skin cancers, crabs, scabies, etc.

 

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
Orange County has made investments in housing and healthcare for people who are or have experienced mental illness and/or homelessness. The cited goal is to return to a baseline level of functioning which may include employment or volunteering. Crabs and scabies can signficiantly disturb a person during a work or volunteer day and also be passed to others. Prior NIH officials have cited a disparity/inequity in life expectancy for people experiencing homelessness/mental illness. Skin cancer is possibly a valid cause of this reduced life expectancy.

 

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
Cost effective interventions that include: 1) Bug ovens for clothes 2) Access to permethrin (or other treatments) & showers 3) Skin exams by licensed professionals 4) Resources to segregate clothing/bedding as it goes through decontamination that may have a prolonged time table 5) Laundry facilities 6) Broad Brimmed Hats 7) Sun screen training These are not observed in the Orange County mental health care system.

 

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
Doing it for people experiencing mental illness/homelessness.

 

What is the project idea? Please describe how this project will operate.
Project A) Mobile facility to assist with scabies/crabs decontamination that includes a bug oven, licensed providers to prescribe permethrin (or other options), bags to sequester clothing/bedding. When a person moves from homelessness to housing this mobile facility would be available to ensure the move doesn’t bring extra critters. Project B) Sun Protection Outreach Training by Students (http://spots.wustl.edu/) has a precanned, evidence based curriculum to teach people about sun protection and skin cancer. It isn’t common sense. Project C) Sourcing and providing sun protection equipment and dermatological care. Sun protection equipment isn’t common sense and the best ones tend to be expensive. Budgeting for broad spectrum sun screen on an SSI budget doesn’t work too well.

 

Additional Information:
What can be learned from this project: The challenges of addressing the risk of skin cancer in a homeless demographic. The challenges of addressing crabs/scabies in a demographic without access to housing/shower/clothing sequestration resources. Understanding how skin cancer impacts the life expectancy inequity/disparity. What is project success: Protecting the mental health consumer from risks of skin cancer and treating crabs/scabies.

 

 

January 29, 2019

3 comments

Thank you for your submission. The innovation team needs additional information to explore this proposed idea. Please elaborate on your responses as best as possible so that we may work through our review process.

•The health education, physical protections (sunscreen, hats, etc. )and parasite treatments noted are common health practices known to reduce skin cancer and decrease the spread of parasites. What could be learned from this project that would be new and contribute to knowledge within the field of mental health?

•What learning objectives could be used to more closely link this idea to mental health outcomes?

A major lesson from walking through a psychiatric ward – the most common health practices may not be utilized by staff nor patients. As a previous provider I have observed functional incontinence – a consumer being so medicated that rest-rooming occurred in the bed, untreated fungal infections, inability to screen/biopsy suspicious lesions for skin cancer, discharge to non-shelter locations, etc. Thus having just a bit of curiosity about possible medical diseases in a mental health population tends to have a high yield.

Psychiatric patients may have entered the “wrong door” to get non-psychiatric help and thus must play scavenger hunt to figure out the “right door” to get help. Its not a fun game to play and is mentally draining. The Emergency Room tends to be the “right door.”

Orange County doesn’t use the Patient Centered Medical Home model of healthcare and thus likely doesn’t collect data on medical inequities and disparities that people experiencing mental illness/homelessness face. A shorter life expectancy is a documented inequity/disparity associated with mental illness. It is unclear if Orange County considers non-suicidal death as a mental health outcome or not. I take a holistic view where death is a universal outcome regardless of medical specialty.

Taking each disease process separately:

Parasites:
A survey of psychiatric wards and homeless shelters will likely reveal that people experiencing mental illness are not screened nor treated for parasites prior to entry. CDC (https://www.cdc.gov/parasites/scabies/treatment.html) states that first encounter is non-symptomatic for 4-8 weeks and so there is a lag time between exposure and symptoms. Treating parasites requires access to a shower, sometimes twice – on day 0 and day 7. A significant degree of planning and organization is required to successfully treat parasites, including segregating clothing/bedding/etc as it is laundered. As a non-fatal and non-5150able disease, parasites are low priority on the problem list. However, family members may not want to risk their homes being exposed to parasites which causes a greater barrier to support systems. New members of close quarters living may be isolated as being the known bringer of parasites. How cruel it is to provide shelter, but then be faced with the anger of others in the shelter that must cope with parasites.

Skin Cancer:
Prior research suggests a skin cancer rate of 20% in a homeless population (https://www.ncbi.nlm.nih.gov/pubmed/23374956). Regional differences in sun exposure are likely to impact skin cancer rates. Treating skin cancers can be highly disfiguring. Not treating skin cancers can be fatal. Being diagnosed with cancer is a known risk of suicide. Orange County Behavior Health is observed to consider tobacco associated cancers seriously enough to have campaigns focused on risk reduction and prevention. Quitting smoking is a “common health practice” yet lung cancer is technically a pulmonary/oncology outcome and not a mental illness outcome – if one wants to correctly classify the organ system and disease process. Addressing prevention of skin cancer is anatomically not in the central nervous system, but the downward drift to homelessness associated with mental illness suggests that the risk of skin cancer is higher than the general population. Having an educational program, like the smoking secession programs already in place, is a known intervention used outside the mental health setting. It is unclear if any such program exists specifically for people experiencing mental illness.

Thank you for your idea submission. Upon review and discussion, it was determined that the idea is tied more strongly to public health rather than mental health and it is unclear what new learning this project could contribute to the field of mental health. The Innovation team is unable to continue exploring this idea under the MHSA Innovation component as proposed.

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