Street Medicine: A Critical Pathway for Behavioral Health in California

The Behavioral Health Crisis on the Streets

California is facing a behavioral health crisis that touches communities across the state, straining emergency services, jails, and social services while leaving too many people without the care they need. The crisis is most acute among people living unsheltered. They face high rates of serious mental illness (SMI) and substance use disorders (SUDs) yet encounter the most significant barriers to care. In 2023, over 181,000 Californians were living unsheltered, and the disparity between their health needs and their access to treatment is stark:¹

• Prevalence of need. 82% of people experiencing homelessness report facing SMI at some point in their lives.² Additionally, 60% experience alcohol use disorder, and 37% report regular drug use in the past six months.³

• The treatment gap. While 66% of unhoused people experience symptoms of depression, anxiety, or psychosis, only 24% receive mental health counseling or medications.⁴

Despite expanded state investments, traditional health and social service systems are failing to reach this population. The severity of mental illness often compounds the logistical challenges of homelessness, creating a paradox where those with the greatest needs are the least likely to successfully access care.

Flipping the Model: How Street Medicine Delivers Care

Traditional behavioral health systems rely on patients seeking care in offices or virtual visits, an unrealistic expectation for unsheltered people navigating the daily trauma of survival without housing. Street medicine reverses this dynamic by bringing care directly to people in their own environments. This model builds trust by addressing immediate physical needs, such as wound care, which opens the door to behavioral health engagement.

How Street Medicine Delivers Behavioral Health Care

Street medicine is not just a change of setting; it is a fundamentally different method of practice. It supports behavioral health through several core clinical and operational mechanisms:

• Integrated and “full-spectrum” primary care. Teams address behavioral health, substance use, and physical health simultaneously. This “whole person” approach allows clinicians to differentiate between primary behavioral health conditions and substance-induced symptoms through direct, ongoing observation. Providers assess for and manage a wide array of mood disorders, such as depression and anxiety. Additionally, because street medicine occurs within the community, a full-spectrum approach can reduce stigma associated with a behavioral health–only team.
• Bridge to specialty care. Street medicine providers conduct in-field diagnostic and functional assessments, including cognitive function. These assessments often provide the critical clinical insights and documentation required for referrals to medical specialists, specialty behavioral health, and appropriate housing settings — effectively extending the reach of the safety net. Teams can also arrange for transportation to appointments and may even accompany patients to appointments.
• Direct delivery of specialty care:
  • Field-based medication-assisted treatment for addiction. Teams can prescribe and manage medication-assisted treatment for opioid, stimulant, and alcohol use disorders directly in the field. This harm-reduction approach reaches those excluded from traditional systems and significantly reduces overdose risks.
  • Treatment for SMI. Trained street medicine providers can diagnose and treat SMI in unsheltered people. Providers can also support treatment plans created by psychiatrists in traditional settings. By administering long-acting injectable antipsychotics and other psychiatric medications on the street (with patient consent), teams overcome barriers like medication loss during encampment sweeps or difficulty with daily adherence.

Why Street Medicine Works: Core Strengths of the Model

Street medicine offers distinct advantages over clinic-based care for this population:

• Barrier-free engagement. Street medicine teams meet people where they are. Care is provided without appointments, ID requirements, or transportation hurdles. This approach overcomes the need for unhoused people to choose between care and the pressing demands to find food, shelter, and safety.
• Continuity of care. Teams follow patients across outdoor settings, shelters, and housing, preventing the disruptions in treatment that typically occur during transitions.
• Relationship centered, equity driven, and trauma-informed. By meeting people where they are, teams enable care at the pace of trust. In using noncoercive harm-reduction strategies, street medicine teams effectively reach marginalized communities who may have been harmed by and mistrust traditional medical systems, a disproportionate number of whom are people of color.
• The power of lived experience. Street medicine teams reduce stigma and increase engagement by integrating community health workers and peers who reflect the communities they serve, using shared experiences to build essential trust.
• Real-world functional assessments. Behavioral health assessments include determining the degree of functional impairment resulting from mental illness. This is better done in the person’s lived environment, observed over time, than in a clinical or hospital setting.

Policy and Financing Pathways: Sustaining Behavioral Health Care Delivery on the Street

Background

California’s behavioral health system is bifurcated between Medi-Cal managed care plans (MCPs), responsible for covering non-specialty (previous called mild-to-moderate) mental health and physical care, and county behavioral health departments, responsible for SMI, SUD, and crisis response. In this report, “county behavioral health departments” refers to these entities, while “mental health plans” (MHPs) refers specifically to the Medicaid specialty mental health delivery system operated by counties.

Of note, within the county behavioral health system (including MHPs), SMI does not refer to a specific diagnosis such as schizophrenia or bipolar disorder, but rather to the combination of a diagnosis and a high level of functional impairment requiring more intensive services. For example, a person with a schizophrenia diagnosis who is well controlled on medications from their primary care street medicine provider would not meet criteria for SMI.

People living unsheltered often fall into the gap between these two systems. Disconnected from conventional care settings, they may not ever be appropriately assessed or diagnosed, let alone engaged in appropriate treatment. In addition, functional impairment can be difficult to assess for somebody living unsheltered. For example, if a person cannot obtain food, it may be unclear whether this reflects functional impairment or simply a lack of available resources. Street medicine offers a practical strategy to bridge this divide.

As part of CalAIM (California Advancing and Innovating Medi-Cal), in 2022 the California Department of Health Care Services (DHCS) released the No Wrong Door policy.⁵ Its goals are twofold:

• Members can access mental health services when they need them, no matter what Medi-Cal service delivery system they first go to (MCP or MHP).
• Members can maintain treatment relationships with trusted providers without interruption.

The MCP and MHP must coordinate or cross-contract so that the experience of care is seamless for the client. DHCS developed a screening tool to help both the MCP and MHP determine which system members should start in when members directly contact the plans, rather than a provider, seeking mental health services.⁶ Two of the ten questions involve screening for unstable housing, making it highly likely that many unsheltered people with serious mental health symptoms will score high enough to necessitate services provided by the MHP.

Table 1. Impact of the No Wrong Door Policy on Mental Health Access

Prior to No Wrong Door	Since No Wrong Door
Barriers to initial treatment Counties had to ensure that a client met specialty mental health access criteria, and providers had to complete an assessment and treatment plan before any treatment could begin.	Immediate access County behavioral health can provide treatment before a final diagnosis is determined and before it is clear whether an MCP or MHP should provide services.
Siloed co-occurring care Specialty mental health providers were prohibited from directly treating an SUD when working with a person who had co-occurring mental health needs and SUD.	Integrated care Providers can discuss, document, and bill for treating a co-occurring SUD, provided the session primarily addresses the person’s mental health need.
Binary coverage A person had to receive all mental health services through the MCP or the MHP.	Concurrent coverage A person can receive non-specialty mental health services through the MCP and specialty mental health services through the MHP at the same time.

Source: Authors’ analysis of Michelle Baass (director), to California Alliance of Child and Family Services et al., “No Wrong Door for Mental Health Services Policy” (PDF), Behavioral Health Information Notice, March 31, 2022; and No Wrong Door for Mental Health Services, webinar, California Department of Health Care Services (DHCS), April 28, 2022. Notes: MCP is managed care plan; MHP is mental health plan; SUD is substance use disorder.

Street Medicine Contracting Options

Taken together, CalAIM reforms and the No Wrong Door policy create multiple, complementary pathways to sustain behavioral health care delivery on the street. Because unsheltered people may, over time, have changing circumstances that affect the severity of symptoms and where they are eligible to receive services, or may need to receive services from both systems concurrently, both Medi-Cal MCPs and county behavioral health departments play critical roles in financing and coordinating street-based care.

1. Managed Care Plan Pathways

Medi-Cal reforms, including CalAIM, have created sustainable pathways for MCPs to contract with street medicine programs. Street Medicine All Plan Letter 24-001 established a billing pathway for primary care outside traditional settings. Additionally, DHCS released guidance on acceptable place of service codes that may be billed when rendering medical services outside.⁷

The value of street medicine for MCPs. For Medi-Cal MCPs, contracting with street medicine programs supports core access, coordination, and quality obligations under CalAIM and No Wrong Door, particularly for members with complex behavioral health and housing-related needs.

• Closing the access gap. Street medicine allows MCPs to fulfill contractual obligations to provide medically necessary physical and behavioral health services to all members quickly, especially those who cannot be effectively engaged through traditional outreach and care models, no matter where they seek care.
• CalAIM housing supports integration. Street medicine teams are well positioned to be effective Enhanced Care Management providers for unhoused members with complex needs. They are also well suited to connect unhoused members to Community Supports such as Housing Transition Navigation and Recuperative Care. They will likely have a critical role in identifying eligibility for and referring to Transitional Rent, a new Community Supports service launched in January 2026 for unhoused people with behavioral health conditions and then expanding to other populations of focus.
• Enhanced coordination for people with complex behavioral health needs. Under the No Wrong Door policy, members can receive care from both their MCP and MHP at the same time, if the services are coordinated and not duplicative. For example, a patient might be prescribed medication from one system and receive therapy from the other. Street medicine teams are poised to provide care that is contracted by the two systems. If the MCP has a contract with street medicine, then the MHP should too. This helps avoid discontinuity once a diagnosis and functional review have come through.
• Quality and equity goals. Partnerships with street medicine teams help MCPs meet Healthcare Effectiveness Data and Information Set measures for follow-up after psychiatric hospitalization and substance-use-related emergency department visits and capture social determinants of health data.

Momentum is building. As of late 2025, 57% of street medicine teams in California have clinical contracts (executed or in process) with MCPs, and 64% have Enhanced Care Management contracts (executed or in process).⁸ Expanding these contracts is essential for reimbursing behavioral health services that are already being provided as part of street medicine in outreach settings, and to ensure ongoing, appropriate care regardless of the patients’ diagnostic complexity or housing status.

2. County Behavioral Health Pathways

Many county behavioral health departments, but not all, have deep expertise in serving people experiencing homelessness. The Behavioral Health Services Act (BHSA) aims to ensure that more funding is directed toward services for people with the most serious mental health and SUDs, including those experiencing homelessness. For example, beginning in 2026 under the BHSA, counties must spend one-third of their funding allocation on housing interventions for precariously housed or unhoused Californians with the most significant behavioral health needs.

The value of street medicine for county behavioral health departments. Under reforms like the BHSA, counties must demonstrate how they will reach unsheltered people.⁹ Street medicine partnerships offer a mechanism to meet these mandates through the following:

• Creating a continuum of behavioral health and primary care. Primary care street medicine teams can support people with non-specialty mental illness and refer to county mental health when someone is identified as having SMI and needing specialty services. Street medicine continues to provide physical health care to maintain continuity and remains available for a “reverse referral” when county behavioral health services are no longer required.

• Participating in design and implementation of mandated County Integrated Plans.¹⁰ Street medicine teams can help counties meet requirements to strengthen continuity of care and reach unhoused people who are disconnected from clinics, enabling counties to deliver and document high-quality, culturally responsive, and timely care for clients experiencing homelessness.
• Facilitating No Wrong Door. Partnering with street medicine teams expands entry points to county services, enabling rapid triage for unhoused people with complex mental health and substance use needs. Trained street medicine providers can handle triage and referrals, or county-licensed clinicians can embed with street teams to streamline assessments and specialty care. If county outreach determines that a person does not meet SMI criteria but still requires behavioral health support, staff can refer directly to street medicine rather than risk the person going without care.
• Expanding access through a “whatever it takes” approach. Through contracts with street medicine teams trained to provide field-based Full-Service Partnerships (FSPs), counties can expand their capacity to provide intensive treatment and case management to unhoused people with serious behavioral health conditions.¹¹ Under the BHSA, counties must bring FSPs into adherence with evidence-based models by 2029. Partnering with street medicine teams helps meet these requirements by supporting community-based engagement, rapid initiation of services (including field-based SUD treatment), and continuity of care for people living outdoors.¹²

Recommendations: Scaling Behavioral Health Care Through Street Medicine

To effectively address the behavioral health crisis among people experiencing unsheltered homelessness, California must invest in scaling and sustaining street medicine as a core component of the state’s behavioral health delivery system. We recommend the following actions.

1. Expand Clinical Contracts Between MCPs and Street Medicine Providers

MCPs have a contractual obligation to ensure access to medically necessary services for all members, including those living unsheltered. Because street medicine is often the only feasible model for engaging these members, MCPs should establish formal clinical contracts (in addition to existing Enhanced Care Management contracts) with street medicine teams. This creates sustainable reimbursement pathways, integrates field-based services into the broader delivery system, and ultimately paves the way for better outcomes for unhoused members.

2. Strengthen County Capacity for Street-Based Behavioral Health

Counties should leverage street medicine partnerships to expand access to behavioral health services for people with SMI and/or SUD who are living unsheltered. Counties are well positioned to:

• Create reimbursement pathways for field-based specialty behavioral health care, including FSPs. Counties can establish mechanisms to reimburse street medicine teams for the specialty behavioral health care they provide in the field. For example, county behavioral health departments could contract directly with street medicine providers to deliver field-based behavioral health care on the county’s behalf, creating field-based FSP or Assertive Community Treatment teams to overlay the primary care team. These models meet BHSA requirements for intensive, community-based care while extending the reach of county services to people living outdoors who are unlikely to access clinic-based settings.
• Establish county–street medicine case conferencing to improve coordinated care. Counties and street medicine teams can hold recurring cross-team huddles to review shared patients, align treatment plans, and troubleshoot real barriers such as diagnostic clarification, medication authorization, or eligibility questions.
• Integrate street medicine into shared workflows to improve SMI assessment and follow-up care. Counties and street medicine teams can establish joint protocols for identifying and assessing SMI in the field, coordinating crisis responses, and supporting people during the high-risk period after hospital discharge. Street medicine teams can provide real-time updates from encampments, monitor symptom changes, support medication continuity, and maintain steady contact during posthospital stabilization. These shared workflows reduce missed follow-ups, strengthen continuity across levels of care, and help prevent repeated crises for people living outdoors.
• Use street-medicine-generated documentation to streamline assessments and eligibility. Street medicine teams can provide in-field assessments, symptom observations, and functional updates that counties can accept as required documentation for FSP, outpatient mental health services, SUD treatment, and housing programs. Leveraging this information prevents duplicated assessments, speeds eligibility determinations, and accelerates access to services for people living unsheltered.
• Improve access to real-time psychiatric consultation for street medicine through county systems. Counties, in coordination with Medi-Cal MCPs, should establish clear pathways for street medicine teams to access timely psychiatric consultation under the No Wrong Door policy. Street medicine teams routinely encounter SMI in the field; this recommendation seeks to ensure that they are backed by timely psychiatric consultation to enhance clinical decisionmaking, medication management, and crisis response. Because counties hold primary responsibility for specialty mental health services under Medi-Cal and oversee BHSA implementation, counties should establish and oversee mechanisms that guarantee consistent psychiatric support in street-based settings.

3. Invest in Workforce Training and Support

Street medicine primary care providers are often the first, and sometimes only, touchpoint for people with severe behavioral health needs. Sustaining this frontline workforce calls for coordinated investment from the state, counties, Medi-Cal MCPs, and health systems.

To support this frontline, the Department of Health Care Access and Information (HCAI) could expand training pathways that equip both new and current clinicians for field-based behavioral health care, including intensive case management and crisis response. Under the BHSA (SB 326), HCAI is already directed to implement a comprehensive behavioral health workforce initiative in consultation with DHCS, counties, behavioral health professionals, education and training programs, and consumer advocates — creating a clear opportunity to explicitly incorporate street-based models of care into these pathways.¹³

California’s BH-CONNECT workforce initiative, administered by HCAI, is well positioned to accelerate these pipelines by funding training, supervision, and skills development tailored to work with people living unsheltered.¹⁴ BH-CONNECT could more intentionally partner with street medicine programs to ensure that funded training pathways reflect the realities of field-based care, including engagement in nonclinical settings, crisis response outside of brick-and-mortar facilities, and longitudinal care for people with high acuity needs who are disconnected from traditional systems. In particular, community health worker and peer pathways could be strengthened through street-medicine-specific curricula, field placements, and supervision models that value lived expertise alongside clinical training. Formal partnerships between BH-CONNECT grantees and street medicine providers would help translate workforce investments into practical, scalable pathways for delivering behavioral health care to people experiencing homelessness.

4. Integrate Street Medicine into Regional Planning

Street medicine must be explicitly included in existing planning structures to ensure that resources align with the needs of the unsheltered population. Street medicine providers and people with lived experience of homelessness should be included in county MHP meetings, local health jurisdiction Community Health Assessment and Community Health Improvement Plan convenings, and BHSA Integrated Plan processes. Inclusion in these forums will help surface regulatory barriers, align funding, and ensure that the No Wrong Door policy becomes a reality for all Californians, regardless of housing status.

5. Protect Medi-Cal Coverage to Sustain Behavioral Health Care for People Living Unsheltered

H.R. 1 (119th Cong. 2025-2026) has introduced new work requirements and accelerated Medi-Cal redetermination timelines, substantially increasing the likelihood that people who are unhoused will cycle on and off coverage for administrative reasons rather than ineligibility. These changes heighten the need for street medicine teams to be actively involved in ongoing Medi-Cal enrollment maintenance, including medical certification of exemptions, repeated redeterminations, and rapid response to coverage disruptions — particularly for people with SMI and SUDs.

State agencies, counties, and Medi-Cal MCPs should partner with street medicine teams to support continuous enrollment for people living unsheltered. Counties and plans should establish clear processes that enable street medicine clinicians to certify behavioral health–related exemptions, submit and update required medical documentation, and serve as durable clinical points of contact during repeated redetermination cycles. Street medicine teams can monitor coverage status over time, identify terminations or pending closures in real time, and facilitate rapid reinstatement to prevent gaps in behavioral health treatment, medication access, and crisis services.

Conclusion

California’s behavioral health reforms cannot succeed without a delivery model capable of reaching people living unsheltered. Street medicine is not an adjunct or pilot intervention — it is a proven, equity-driven pathway that operationalizes the state’s commitments under CalAIM, No Wrong Door, and the BHSA. By expanding contracting pathways, strengthening county partnerships, investing in workforce capacity, and embedding street medicine into regional planning, California can close long-standing access gaps and ensure that people with the most severe behavioral health needs are no longer left outside the system. Scaling and sustaining street medicine is essential to achieving a behavioral health system that is accessible, coordinated, and responsive to those living at the margins.

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Endnotes

1. Tanya de Sousa et al., 2023 Annual Homelessness Assessment Report (AHAR) to Congress: Part 1 – Point-in-Time Estimates of Homelessness (PDF), U.S. Department of Housing and Urban Development, 2023. ↩︎
2. California Statewide Study of People Experiencing Homelessness (CASPEH) (PDF), University of California San Francisco: Benioff Homelessness and Housing Initiative, June 2023. ↩︎
3. Olubunmi O. Asana et al., “Associations of Alcohol Use Disorder, Alcohol Use, Housing, and Service Use in a Homeless Sample of 255 Individuals Followed over Two Years,” Substance Abuse 39, no. 4 (2018): 497–504. ↩︎
4. California Statewide Study of People Experiencing Homelessness (CASPEH) ↩︎
5. No Wrong Door for Mental Health Services, webinar, California Department of Health Care Services (DHCS), April 28, 2022. ↩︎
6. Adult Screening Tool for Medi-Cal Mental Health Services (Form DHCS-8765-A) (PDF), California Department of Health Care Services (DHCS), January 2023. ↩︎
7. “Clarification on Billing Guidelines for Medi-Cal Providers for Street Medicine,” California Department of Health Care Services (DHCS), March 7, 2025. ↩︎
8. Kaitlin Schwan, Financing Street Medicine in 2025: Insights from Medi-Cal Managed Care Contracting, California Street Medicine Collaborative and USC Street Medicine, University of Southern California, 2026. ↩︎
9. “3. County Integrated Plan,” in Behavioral Health Services Act County Policy Manual, version 1.0.0, California Department of Health Care Services (DHCS), 2025. ↩︎
10. “3. County Integrated Plan.” ↩︎
11. “Essentials: Full Service Partnerships,” Steinberg Institute, September 9, 2025.  ↩︎
12. BHSA and BH-CONNECT Evidence-Based Practices Overlap: Frequently Asked Questions (FAQ) (PDF), California Department of Health Care Services (DHCS), August 2025. ↩︎
13. “Behavioral Health Transformation—Proposition 1,” California Department of Health Care Services (DHCS), August 2025. ↩︎
14. BHSA and BH-CONNECT Evidence-Based Practices Overlap FAQ. ↩︎