Pain on the Street: Implementation of a Field-Based Pain Response for People Experiencing Homelessness

Background: Homeless individuals are disproportionately affected by limited access to primary care and pain management services. While community-based organizations frequently conduct outreach, few have ethical, standardized, or replicable methods for assessing pain and distributing referrals in field settings. Existing models range from passive, meals-only outreach, to costly mobile clinics with limited reach. This leaves a critical gap that a low-resource, agile framework is designed to address. Objective: The aim of this quality-improvement initiative was to implement and iteratively refine a standardized, field-based pain assessment and response pathway for adults experiencing homelessness and to evaluate its feasibility, fidelity, safety, and operational barriers during routine outreach. Methods: A cross-sectional quality improvement needs assessment was conducted during homeless outreach activities in San Francisco and Sacramento using convenience sampling. The intervention framework incorporated volunteer training, cognitive capacity screening, verbal informed consent, vital sign collection, and predefined criteria for emergency escalation. Participants were unsheltered adults with adequate decisional capacity to provide voluntary informed consent. Results: The dataset included 193 encounters, with valid pain scores for 175 participants. Mean pain was 3.79 plus or minus 2.78, with a median of 3. Cold packs were used for acute discomfort and foot or ankle pain, while hot packs were used for joint pain. Some participants declined comfort measures. No supply shortages, referral confusion, or emergency-escalation delays were documented. Telephone access remained a barrier to referral completion. Conclusion: This framework demonstrates a replicable and ethically grounded model for field-based pain assessment and referral during homeless outreach. The pathway was feasible and safe to implement, expanded care options beyond default emergency-department referral by directing stable nonemergent pain toward primary care, and identified limited telephone access as a major barrier to completing follow-up.