How Street Medicine Teams Are Tackling the Unhoused Health Care Crisis - KQED

Kristen Hwang

Dec 8

Physician adjunct Brett Feldman does a checkup connected Gary Dela Cruz connected the broadside of the roadworthy adjacent his encampment successful downtown Los Angeles connected Nov. 18, 2022. Feldman is the manager and co-founder of Street Medicine astatine the Keck School of Medicine astatine the University of Southern California. (Larry Valenzuela/CalMatters)

Burdened by disproportionate rates of substance usage disorders, intelligence wellness disorders and chronic disease, radical experiencing homelessness are immoderate of the state’s neediest patients, but fewer person thing much than exigency services. Barriers similar deficiency of proscription and cumbersome security rules support astir from getting regular wellness care. Instead, they drift done the exigency country during a crisis, racking up precocious costs to the strategy (PDF) and deteriorating physically successful the interim.

Delivering wellness attraction this mode is costly and not peculiarly effectual for the diligent oregon the system. More than fractional of the state’s $133 cardinal Medi-Cal fund is spent connected the apical 5% of high-needs users (PDF), according to the California Department of Health Care Services.

“Where we person been falling short, particularly with this population, is their world is truthful antithetic from ours that we haven’t been gathering reality-based systems for them,” Feldman said. “They person Medi-Cal. They’re eligible for each these benefits, but they can’t entree these benefits.”

The state’s efforts to span the spread betwixt eligibility and entree is supported successful portion done CalAIM, a multiyear program to revamp the state’s low-income wellness security program. Grants to prosecute unit oregon put successful billing oregon information postulation bundle connection immoderate stableness to teams that person historically been volunteer- oregon charity-operated. The section besides issued a regularisation alteration successful November allowing thoroughfare medicine teams to pat into and negociate unhoused patients’ Medi-Cal benefits (PDF), meaning providers tin beryllium reimbursed for their work.

“One of our halfway principles of CalAIM is breaking down the walls of wellness attraction and gathering radical wherever they are,” said Jacey Cooper, manager of the state’s Medi-Cal program. “We truly consciousness similar thoroughfare medicine helps america bash that.”

What is thoroughfare medicine?

Several months ago, Feldman’s Skid Row diligent suffered a encephalon wounded from deficiency of oxygen during an asthma attack. She’s present confined to a wheelchair and reliant connected a person for basal needs similar uncovering nutrient and utilizing the toilet.

Newer asthma medications mightiness beryllium capable to assistance extremity her hospitalization cycle, but until precocious lone her assigned superior attraction doctor, whom she has ne'er seen, was allowed to notation her to a specializer for appraisal nether Byzantine Medi-Cal rules. Feldman had been trying to get her a superior attraction assignment for much than a year, to nary avail.

Under the caller rules, however, Feldman could person referred the asthmatic diligent straight to the lung specializer she needed oregon gotten anterior authorization for the medicine since it was recommended during a infirmary stay. Instead, without capable aesculapian attraction to code her condition, her beingness has been irrevocably altered.

Statistically, she’ll beryllium fortunate to unrecorded longer than a fewer much years.

“She utilized to beryllium a staple down here. She knew everybody,” Feldman said. “Now, she can’t walk, is confined to her tent. She’s lonely due to the fact that she’s utilized to being portion of the Skid Row community. She had a precise afloat beingness contempt being unhoused.”

Feldman, co-founder and manager of the thoroughfare medicine programme astatine the University of Southern California’s Keck School of Medicine, said the extremity of thoroughfare medicine is to springiness immoderate autonomy backmost to radical who usually person precise small powerfulness near successful their lives.

Physician adjunct Brett Feldman checks Carla Bolen’s humor unit portion she sits successful her encampment astatine the Figueroa St. Viaduct supra Highway 110 successful Elysian Valley Park connected Nov. 18, 2022. (Larry Valenzuela/CalMatters)

Each time helium and a squad of providers scour the region streets diagnosing chronic and acute conditions, treating intelligence unwellness and substance use, delivering medicine, drafting humor for tests and pursuing up with patients who petition a visit. Community wellness workers manus retired nutrient and hygiene supplies and assistance them navigate hurdles arsenic they effort to get lodging and societal services.

“We cognize that radical who are experiencing homelessness person higher mortality, person higher ER utilization, person higher magnitude of enactment erstwhile they get admitted,” Cooper said. “We truly spot this arsenic portion of a broad attack to ensuring that we person a existent continuum of attraction for radical experiencing homelessness.”

The accepted wellness attraction strategy thrives disconnected efficiency: The much patients determination done an office, the much the supplier gets paid, resulting successful little appointments and small sympathy for circumstances that marque patients late. But that setup doesn’t enactment for unsheltered radical who tally the hazard of getting their belongings stolen if they permission their campy — oregon who would alternatively find thing to devour than instrumentality attraction of what whitethorn look similar a insignificant malady.

Less than 30% of unhoused radical with Medi-Cal person ever seen their superior attraction provider, according to a authorities legislative investigation of a thoroughfare medicine measure vetoed by Gov. Gavin Newsom successful 2021. The measurement passed the legislature with wide enactment but was opposed by the authorities Health Care Services Department for imaginable duplication of services. In the veto (PDF), Newsom directed the section to enactment with thoroughfare medicine teams to capable immoderate gaps near by CalAIM — 1 specified spread was adjusting billing codes that prevented thoroughfare medicine reimbursement.

“When you’re focused connected those precise basal needs, similar food, safety, shelter, however are you past capable to absorption on, you know, managing your diabetes oregon your humor unit oregon immoderate of these hazard factors that tin pb to much superior downstream effects?” said Dr. Kyle Patton, aesculapian manager of the thoroughfare medicine programme astatine Shasta Community Health Center successful Redding.

On a Monday successful September, Patton and Anna Cummings, a lawsuit worker, trekked done a wooded country connected the northbound borderline of municipality to conscionable Amber Schmitt, 47, a diligent with an infected leg. The crushed is muddy from a tempest the nighttime before. Schmitt is paying a person $700 a period to enactment successful his apartment, but hidden among the trees and rolling hills is her abandoned encampment, on with dozens of others. Schmitt gets $1,000 a period from Social Security, but it’s not capable to spend a information deposit oregon rent successful the area, she said.

Dr. Kyle Patton prescribes Amber Schmitt with medicine to dainty the coiled connected her limb successful the backmost of his motortruck connected Sept. 19, 2022. (Larry Valenzuela/CalMatters/CatchLight Local)

The gash connected Schmitt’s close shin is mottled and inflamed. She said she scraped it connected a fallen branch. Patton cleaned and dressed it for her previously, but she had nary prime but to reuse bandages aft moving out. Now she tin hardly locomotion from the pain.

“This is simply a silver-based dressing, which volition termination bacteria successful wounds,” Patton tells Schmitt aft rinsing the country with a saline wash. “We’ll get you immoderate much dressing too. And past you’ve got immoderate tegument breakdown and maceration betwixt your toes. I don’t similar the look of that.”

He gives her a fungal pick and a vessel of antibiotics. Schmitt is simply a leukemia subsister and has had a hep replacement connected the aforesaid injured leg. Her aesculapian past makes her prone to infections and mediocre circulation successful her extremities, Patton said.

“There’s radical that would possibly marque the statement that … they person wellness security present successful California, they should conscionable utilize the strategy arsenic is. The world is due to the fact that of definite factors wrong the discourse of their homelessness, they’re not capable to bash that,” Patton said.

Although they suffice for broad wellness sum nether Medi-Cal, the programme wasn’t needfully designed with unhoused radical successful mind. For example, Medi-Cal volition wage for proscription to and from a doctor’s appointment, but it requires the diligent to supply a fixed code and springiness respective week’s announcement to the driver, thing astir radical experiencing homelessness aren’t capable to arrange.

Link betwixt homelessness and health

Health information connected unhoused radical are sparse, with nary authorities bureau and lone a fistful of counties tracking the information, but it’s wide that astir of their deaths are preventable.

In Alameda (PDF) and Marin (PDF) counties, fractional effect from acute oregon chronic wellness conditions similar cardiovascular disease, crab oregon respiratory failure. In Orange County, these marque up a 4th of deaths among the unhoused. In Los Angeles County, bosom illness is the second-leading origin of decease among radical experiencing homelessness, 2nd lone to overdoses.

Even overdose deaths are considered preventable — yet successful San Francisco, overdoses origin 82% of deaths among the unsheltered.

“We commonly spot conditions that you would spot successful a emblematic population, but they’re conscionable not addressed; truthful out-of-control precocious humor pressure, uncontrolled diabetes … besides substance usage successful presumption of opioids, we spot a full batch much than successful the wide population,” said Dr. Absalon Galat, aesculapian manager for LA County’s Department of Health Services’ Housing for Health division.

Galat’s squad started its foray into thoroughfare medicine successful an effort to dole retired COVID-19 vaccines, but squad members rapidly recovered they needed to bash more. The region utilized COVID-19 alleviation funds to acquisition mobile clinics, and CalAIM backing has helped them prosecute 60 unit members.

Patient Isaac Pierce gets a check-up successful the Los Angeles County Department of Health Services' mobile session parked successful Whittier Narrows Park connected Nov. 17, 2022. (Larry Valenzuela/CalMatters)

In September, the county’s fleet of mobile clinics, implicit with afloat outfitted exam rooms, began visiting areas wherever services are sparse. Smaller teams of clinicians and lawsuit workers roam encampments to follow-up with patients, dainty insignificant issues and bring patients to the mobile clinic. There’s immoderate disagreement among thoroughfare medicine providers astir whether mobile clinics region capable barriers due to the fact that they inactive necessitate patients to question to a acceptable location, but Galat said his extremity is to amended access, whether it’s by instrumentality oregon foot.

“People are dying each day,” Galat said. “So we person to effort with what we cognize champion successful the aesculapian tract close present to bounds radical who are dying.”

The Los Angeles County Department of Health Services' mobile session parked successful Whittier Narrows Park to spot unhoused patients connected Nov. 17, 2022. (Larry Valenzuela/CalMatters)

The transportation betwixt homelessness and wellness is inextricable, said Dr. Michelle Schneidermann, manager of the People-Centered Care squad astatine the California Health Care Foundation, a statewide wellness argumentation deliberation tank.

“Either 1 tin pb to the other. A catastrophic wellness incidental oregon a bid of conditions tin pb to idiosyncratic not being capable to work, starring to poverty,” Schneidermann said. “We spot this each the time, wellness conditions precipitating homelessness, and the different mode around.”

Take Danny Doran, 56, who visited LA County’s mobile session astatine Whittier Narrows Park connected a caller Thursday to prime up insulin. He spent his vocation arsenic a plumber and owned a location successful Bishop. Three years agone helium fell into a diabetic coma and was hospitalized for months. A person Doran trusted to wage his bills portion helium was hospitalized emptied his slope relationship and disappeared — Doran has been unhoused ever since. Several weeks agone helium was beaten and robbed by different unhoused man, who near him with a fracture successful his skull and a tremor successful his hands.

“I conjecture I’m a small spot naive,” Doran said. “We’re each humans and we’re prone to mistakes, you know? So I hatred for anyone to person their wealth stolen similar excavation was and extremity up similar maine connected the streets.”

At the mobile clinic, Doran said the doc connected unit agreed to beryllium his superior attraction physician. His erstwhile superior attraction doc stopped accepting Medi-Cal insurance, and Doran hasn’t had regular entree to insulin ever since.

“The doc here, she genuinely has compassion for her patients. I’m gladsome our paths crossed,” Doran said.

Unhoused diligent Danny Doran sits successful the waiting country for the mobile session parked successful Whittier Narrows Park connected Nov. 17, 2022. Doran is being checked  aft being assaulted adjacent his encampment conscionable a fewer days before. ( Larry Valenzuela/CalMatters)

Schneidermann, who is overseeing a survey connected thoroughfare medicine programs crossed California, said CalAIM, which besides pays for lodging services, is an accidental for the authorities to code its astir pernicious problem.

“Until we tin extremity our situation of homelessness…we person to find a mode to present attraction for radical connected the streets,” Schneidermann said.

New programs popping up

Prior to CalAIM and the Health Care Services Department’s regularisation changes, thoroughfare medicine programs operated extracurricular of accepted wellness care, funded by philanthropies oregon the uncommon wellness enactment consenting to suffer money. Now, the department’s changes connection immoderate anticipation for stability, Feldman said.

Noting that these programs were birthed retired of the pandemic, Feldman said they “might not beryllium successful a fewer years if they’re not supported, but they person each these patients that trust connected them.”

A twelvemonth agone lone 25 programs existed crossed the state, chiefly concentrated successful municipality areas, Feldman said. But ever since CalAIM launched astatine the opening of 2022, he’s tally into much organizations looking to statesman services. CalAIM requires Medi-Cal insurers to coordinate patients’ physical, behavioral, dental and developmental attraction arsenic good arsenic societal services — thing galore thoroughfare medicine teams already do. The extremity is to marque the “system hustle down the scenes alternatively than making the diligent hustle,” California Health Care Foundations’ Schneidermann said.

One specified programme is tally by Anthony Menacho successful Sacramento. Unlike USC, Shasta Community Health oregon LA County’s teams that are staffed afloat time, Menacho’s thoroughfare medicine set is composed wholly of volunteers. They sojourn six camps each different weekend.

The enactment was funded initially by a $100,000 assistance from Health Net, the largest Medi-Cal supplier successful the state, but Menacho, who trained arsenic a doc adjunct with Feldman astatine USC, wants to beryllium capable to bash the enactment afloat clip and prosecute much clinicians. He’s moving to unafraid wealth done CalAIM and the Department of Health Care Services.

“We don’t person the world resources oregon radical down america to beryllium capable to enactment successful a section oregon infrastructure connected the driblet of the dime,” Menacho said. “We tally connected grants, but that’s not existent sustainability. We can’t bash it ourselves. It has to beryllium a coordinated effort and I deliberation that’s what CalAIM is trying to do.”