social issues Taking health services to the streets

Come January, medical teams in Southern California will step up treatment of older people who struggle with homelessness, hoping the expansion of such street medicine will result in more health care, at lower cost, for them.

Called Healthcare in Action, and backed by Long Beach-based health insurer SCAN Group, the initiative will operate much like existing Medicare Advantage Plans offered by private insurance companies, basically, as HMOs that replace traditional fee-for-service Medicare coverage.

But the doctors and nurses in Healthcare in Action will treat people - Medicare-eligible adults - in all kinds of nontraditional settings: on sidewalks and in parks, behind dumpsters or in alleys, wherever their needs can be met. The goal is to overcome hurdles that make it hard for homeless people to get medical help until a crisis sends them to more costly hospital emergency rooms.

And as SCAN Group ramps up its expansion into street medicine, California lawmakers are close

to creating new rules that could boost health care for older homeless people.

Assembly Bill 369, or the Street Medicine Act: Bringing Care to the Street, has passed both houses in Sacramento and is on the desk of Gov. Gavin Newsom. The legislation is intended to make it easier for health treatment and reimbursement under Medi-Cal, the state's public health insurance program for the poor.

Many of California's more than 150,000 homeless people qualify for Medi-Cal but are not signed up. And among those who are signed up, nearly 3 in 4 do not regularly see a primary care doctor, according to background information in the bill.

Also, health providers face a hurdle if they try to bill Medi-Cal for their treatment of homeless people. Under current law, the agency requires a billing address for where care is delivered - typically a hospital clinic or doctor's office - before it will process claims.

Though the Healthcare in Action project and the state legislation are unrelated, they're taking independent tracks toward the same issue: finding ways to get more health care for people who live outdoors.

Dr. Michael Hochman, a Los Angeles-based primary care doctor who will serve as chief executive officer of Healthcare in Action, said the driving question for SCAN Group was how to improve the health and overall outcomes for aging homeless people - a fast-growing segment of the street population - while also reducing costs.

A recent count of homeless people in Los Angeles County found that from 2019 to 2020, the 62-or-older cohort jumped 20%. Hochman, who for 10 years has been an attending physician at Los Angeles County-USC Medical Center, estimated that roughly 1 in 4 people who get treatment there are homeless.

"They are some of the most costly patients," he said.

"Could we take better care of them?"

Lower-cost care

SCAN is attempting to create a lower-cost business model for street medicine.

In recent years, studies conducted in parts of California, including Los Angeles and Orange counties, have illuminated costs associated with healing the homeless. An analysis by UC Irvine researchers, for example, estimated that in Orange County the price tag for treating the chronically homeless at local hospitals and emergency rooms ran to $77 million over a 12-month period that ended in 2015.

Most of the street medicine currently provided in Southern California comes from groups dependent on charity and money from city and county governments. Healthcare in Action payments will be managed through SCAN Health Plan, a not-for-profit Medicare Advantage subsidiary of SCAN Group.

Also, SCAN intends to provide more than medical care.

In addition to doctors, physician assistants and nurse practitioners, its street teams will include social workers, substance use counselors and others who can connect homeless people with services that might improve their lives. That help is expected to include guiding the homeless patients served by the SCAN teams toward housing.

For now, funding provided by SCAN will cover two teams in Los Angeles County, one based in Long Beach and the other in the midtown section of Los Angeles, said Hochman, who will supervise the SCAN teams. Orange County is also being explored.

"There are other really good street medicine providers out there," Hochman said. "What is different is they rely on charitable funding. We're trying to put a backbone on street medicine."

Legislative action

While the backers of SCAN hope to improve the financial side of health care for homeless people, the bureaucratic side of the puzzle could be tweaked by the Street Medicine Act.

Among other things, AB 369 would require Medi-Cal to recognize the street as a legitimate venue for providing health care. It also would make it easier to enroll homeless people in Medi-Cal. And it could make it possible for somebody being treated on the streets to eventually be referred to a specialist.

Key to the legislation is something called "presumptive eligibility," which would let people living on the street get medical treatment even if they're applying on the spot for Medi-Cal insurance.

The street medicine legislation was introduced in February by now-Sen. Sydney Kamlager, D-Los Angeles. On Sept. 10, the bill was sent to Newsom.

Even for homeless people already enrolled in Medi-Cal, actual medical care is nearly nonexistent. The state has enrolled a majority of people experiencing homelessness in the Medi-Cal program, yet some 73% of people who are enrolled "have never seen their health care provider," according to the bill's author.

If you're homeless, the barriers to getting medical care can seem endless. If you lack any of the following - transportation, identification card or a mailing address - that can be a hurdle to getting treatment. Other issues, such as mental illness, addiction and a general lack of trust, also serve as reasons why health care for homeless people is, at best, spotty.

The results are devastating and lethal. Homeless people are far more likely than others to suffer from chronic conditions such as diabetes and hypertension. It's also a reason why homeless people die younger than the general population - by about 30 years.

Advocates of the legislation include Keck School of Medicine of USC and its director of street medicine, Brett Feldman, a physician's assistant who started working in street medicine in 2007.

Over the years, Feldman has watched the movement grow. When he started, Feldman said, the key provider in Los Angeles County was the Venice Family Clinic, which had a pioneering program. Today, there are 28 street programs statewide, including several in the Los Angeles area.

In Orange County, the volunteer-driven Wound Walk OC delivers basic first aid to the unhoused.

"There is tremendous interest," Feldman said. "Which is why the legislation needs to catch up."

Street experience

Three years ago, CalOptima, the Medi-Cal administrator in Orange County, began working with county workers and community health clinics to provide health care in shelters and other places where homeless people congregate.

Preliminary results from data collected between April 2018 and March 2021 found that when health services were provided, the number of homeless people who visited emergency rooms or were checked into hospitals declined by nearly 25%. Separate data on a smaller group of homeless people found a 60% increase in visits to specialists, while visits to primary care doctors grew by a more modest 10%.

Similar outcomes could come to the areas served by the Healthcare in Action project. Feldman, who is working as a consultant on the project, describes the leader, Hochman, as someone who is "mission driven" and knowledgeable about the uniquely vulnerable population.

The project also will include peer navigators - people who understand homeless living and can serve as street guides for the SCAN medical teams. And the person leading the peer navigators is someone who once was homeless and, since then, has spent years working with the skid row population in Los Angeles.

Feldman said that kind of firsthand experience could be critical to the project's overall success, and in helping individual medical providers as they work in non-traditional settings.

"Sometimes you're not in the best neighborhoods, or you're not seen as part of that neighborhood. When you're on your knees, doing wound care, you don't want to worry about what's going on around you."

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