Street Medicine Programs Improvise to Meet Shifting Challenges
The black-and-green bus pulls into a parking lot around the corner from the Oakland Coliseum complex, where the Oakland Athletics play baseball, and the Golden State Warriors used to play basketball. This bus carries health workers, not ballplayers, and the lot is now home for dozens of individuals and families living in recreational vehicles (RVs), not parking for sports fans.
Under a light rain and gusty winds, members of the STOMP team, or Street Team Outreach Medical Program, unload items from their clinic on wheels. Out come a pop-up canopy, folding tables, COVID-19 testing kits, blue blankets, orange gloves, and boxed meals. A man with a bullhorn snakes in and out of rows of RVs, announcing “COVID testing, COVID testing,” and people emerge.
A mother and teenage daughter walk over to get free blankets and food, as does a man in a bathrobe and hoodie. Khadjia Lobo, a nurse practitioner, swabs the nose and cheeks of a man named Ruben, who has been living at the lot for 18 months. He’s been tested here before, he said, and is pleased the team has returned because some neighbors have recently been diagnosed with COVID-19. “It’s a helpful thing, and reassuring,” said Ruben, who declined to give his last name.
STOMP, a service of Roots Community Health Center, has been providing mobile care to residents of encampments, RV parks, and the streets of East Oakland since 2015, when it joined a growing movement known as street medicine that brings health care services to people who are homeless wherever they are. The focus this day is on COVID-19 testing, but if anyone at the RV park has an acute medical need, Lobo and her colleagues can invite them onto the bus, which is outfitted as a mobile clinic. In the evening, the bus would be driven to another East Oakland location for a night clinic. “We do a lot of wound care,” as well as medication refills and exams, Lobo said.
Today, street medicine teams are delivering care in cities and counties all over California. All are committed to providing humane care to vulnerable, unhoused people, but the teams take different approaches based on local needs and resources and have subtle differences in philosophy. Each has had to adapt its operations during the pandemic.
In Alameda County, Attending to Trauma and Mental Health
Street medicine efforts in Alameda County have expanded greatly since 2015, when Roots Clinic and Foothill Community Health Center, now known as Bay Area Community Health, were the first agencies to sign county contracts to bring health services to people experiencing homelessness. Today, the county’s Health Care for the Homeless program oversees a comprehensive effort that divides the county into 14 zones served by teams from five community health centers.
Most teams are led by nurses and include a social worker and community health outreach worker. The nurse treats wounds, dispenses prescription medications, and assesses the need for additional care. The outreach worker leads efforts to engage with people, learn about their social needs and, if possible, assist them with housing. A physician, nurse practitioner, or physician assistant is available to each team for about eight hours a week to visit patients with deeper needs and chronic conditions.
The STOMP model is a bit different, because its teams are led by physicians. All the county teams are linked to a brick-and-mortar health center where they try to bring people back for ongoing care.
“Our goal is really to link people to Roots and build that long-term relationship,” said Noha Aboelata, a family practice physician and the founder and executive director of Roots. Before the pandemic, “we used to have ‘Welcome Wednesday,’ which provided open access and a hot meal. The whole courtyard would have people sitting and navigators interacting with them. The clinic was open, behavioral health was open. The Empowerment Center had computers they could get on to look for housing and jobs.”
Deciding when to resume face-to-face activities in light of the pandemic has been difficult, especially for Roots clients dealing with mental health issues. “The risk of not being able to engage is high because people are more stressed and need this engagement,” Aboelata said.
She is especially concerned about one group that Roots and STOMP has served for years — people coming out of jail or prison. Their numbers have increased as efforts to reduce mass incarceration have coincided with a tight housing market. This has boosted the percentage of former inmates who are unhoused from 20% or 30% a few years ago to 70% or 80% today, she said.
“There’s a time window where if you don’t stabilize their housing situation, the newly homeless will become the chronically homeless with substance use and behavioral health conditions,” Aboelata said. “It’s only a matter of time before someone who didn’t have those issues falls into them. The time to prevent that from happening is right after someone is released.”
The street medicine zone in West and North Oakland is served directly by the county’s Health Care for the Homeless staff, who have unique expertise in mental health. Lucy Kasdin, a clinical social worker, directs the county program, overseeing both the work of the contract agencies and of the county team. That team’s focus on behavioral health developed partly because Kasdin and other senior staff members were trained in psychiatry or social work, and partly because of emerging needs.
In a 2019 survey (PDF) of 1,600 people experiencing homelessness in Alameda County, 39% said they were currently experiencing psychiatric or emotional conditions, 30% reported post-traumatic stress, 30% reported substance use, and 13% said they had suffered a traumatic brain injury. Large numbers of people experiencing homelessness also show up in clinics, emergency departments, and jails with untreated mental health conditions.
“We started that team in 2017 and switched to being less of a medical model, and more of a behavioral health model,” Kasdin said. Instead of going to many sites where unsheltered people live and doing “lighter-touch” care, the program started visiting fewer sites, with the same team going back to the same encampments at the same times every week.
For folks whose lives are so unpredictable, knowing there is space every week for them to talk to that team allows for that relationship to build over time.
—Lucy Kasdin, Alameda County
Health Care for the Homeless
Residents got to know team members and to expect them at scheduled times. “It became less about the immediate delivery of services and more about building trust,” Kasdin said. “For folks whose lives are so unpredictable, knowing there is space every week for them to talk to that team allows for that relationship to build over time.”
The program is funded by a grant from the US Health Resources and Services Administration rather than an insurance program like Medicaid, so team members don’t have to focus on providing services that are deemed medically necessary in order to gain reimbursement.
“That’s the beauty of street health,” Kasdin said. “If you’re the social worker on the team, and somebody needs you to work with them closely for three hours a day, three times a week, for three months, that’s what you do.”
In contrast to some efforts targeting high-cost “super utilizers” of health services, “our program is really about those underserved folks who are struggling with mental health and tucked in their tents, people who nobody’s aware of.”
Lawmakers in Sacramento are considering a bill that would authorize Medi-Cal-enrolled providers to bill the program for services rendered outside of traditional medical facilities to a person experiencing homelessness. These covered services would include street medicine, shelter-based care, or care within transitional housing settings.
USC Street Medicine: Caring for the Sickest in “Authentic Solidarity”
In 2015, Brett Feldman, a certified physician’s assistant who had been running a street medicine program in Allentown, Pennsylvania, came to Los Angeles to conduct an assessment on behalf of the international Street Medicine Institute: Could street medicine programs have a real impact in such a sprawling place, where a huge number of people experiencing homelessness were living, unsheltered, across a vast geographic area? He wasn’t sure then, but three years later he started one for USC’s Keck School of Medicine.
In Allentown, to provide care “across the continuum” of where people who are homeless spent their time, Feldman set up clinics at soup kitchens and shelters, as well as visited people under bridges. In Los Angeles, he quickly realized that approach wouldn’t work; there were simply too many people experiencing homelessness — an estimated 59,000 in all, including 48,000 unsheltered. After spending time talking to people about what they needed, Feldman and his colleagues decided to focus on the sickest among them. “We want to find the people who are most in need of street medicine,” he said.
The need was critical. Many chronically unhoused people don’t live past 50. And many feel so disrespected by the health care system that they avoid seeking medical attention until they are desperate. Feldman and his team went to the county’s general hospital, LAC+USC Medical Center, and began tracking people without housing who had been admitted. “We used inpatient admission as a proxy for medical necessity,” Feldman said. “If they were admitted for something, they would need follow-up for something.”
This information helped Feldman design his program, which now consists of two teams, each composed of a physician, physician’s assistant or nurse practitioner, a nurse, and a community health worker who may have experienced homelessness and can act as a guide. The team follows people after hospital discharge, visiting them at encampments or shelters to be sure they have needed medication, support, and follow-up care. Like most street medicine programs, they try to connect people to other services, including housing. They also try to provide a broad range of services, knowing that many of their patients won’t go to brick-and-mortar clinics.
The hardest part is that we love to hug our patients. I’ve learned to try and be as expressive with my eyes as I can, but the mask makes the intimate connection that we’re looking for much harder.
—Brett Feldman, certified physician’s assistant
“We try to provide the same quality of care on the street as in the clinic,” Feldman said. “We dispense medications, draw labs, do ultrasound and EKGs on the street.” Feldman works with some of the most medically fragile people on the street. Through effective housing navigation and advocacy, his team makes the case for partner agencies to prioritize them for housing. In 2019, before the pandemic, 42% of the team’s patients ended up getting housed. After COVID-19 hit, many patients got temporary rooms through the state-funded Project Roomkey. Still, Feldman worries that not all of them will be permanently housed and that social workers may lose track of their clients. He’s trying to learn when any patient returns to the street so the team can maintain their care.
While the team has done some COVID-19 testing, it tries to avoid devoting too much time to it so it can focus on other priorities. In 2020, according to data obtained by the news site Capital & Main from the county coroner, 1,371 people died while experiencing homelessness in Los Angeles County. Through January 25, 2021, Capital & Main said, 123 people experiencing homelessness had died of COVID-19 — fewer than 10% of all who died on the streets. “Our approach has been that people are really, really sick, they’re dying of other things, and we’re not going to stop what we’re doing and do COVID all the time,” Feldman said.
The pandemic has created other hardships. The stay-at-home orders and closures of restaurants and other businesses limited the presence of the housed and employed people who provide money and food. It also made it hard to find bathrooms.
“A few months ago, I gave one patient a whole pack of socks, and later that week, he asked me for more,” said Feldman. “I could see the shame on his face. He said he used them for toilet paper, because he didn’t have anything else.”
Another big change forced by COVID-19 is the imperative that Feldman and his colleagues must maintain physical distancing.
“The hardest part is that we love to hug our patients,” Feldman says. “I take every opportunity I can to touch them in some way. Even when I’m listening to their heart and lungs, I have a hand on their shoulder. I like to smile at them. And you can’t really see a smile with just my eyes showing. I’ve learned to try and be as expressive with my eyes as I can, but the mask makes the intimate connection that we’re looking for much harder.”