SAN DIEGO — "Anybody home?" physician assistant Teagan Flint asks outside a tent on F Street in downtown San Diego.
She was hoping to find a patient she had been working with, but there was no answer at the tent. She would learn later he had been hospitalized.
Flint is part of a novel five-person street medicine team called Healthcare in Action, a nonprofit that includes physician assistants and social workers who have worked the streets of San Diego since July to provide on-the-spot and, more important, long-term health care to homeless people at no cost to the patients.
They aren't the first to provide health care to homeless people in San Diego, but Healthcare in Action is the first to be on the street five days a week and associated with a for-profit managed health care provider.
"I think what we're doing that's a little different is that we're nonprofit and trying to take a managed-care approach in terms of efficiency," said Dr. Michael Hochman, who is based in Los Angeles County and leading the teams there and in other places as the program expands. "We're thinking about an assigned panel of patients and applying that to street medicine."
Many street medicine teams are funded by charitable groups, going out a few times a week or month to tend to wounds, check vital signs and attend to ongoing or urgent health care needs of people they come across.
It's important work, Hochman said, but not sustainable for long-term care. By creating a reliable funding source through Medi-Cal, which provides health care coverage for low-income California residents, and a managed health care provider such as Molina Healthcare of California, the Healthcare in Action model can fund larger teams that work up to seven days a week, with a physician on call after hours. Once in their system, patients have the equivalent of a primary care physician who may prescribe medication, do important follow-up visits and even visit them in a hospital.
"The follow-up is really where we start to make progress and get their medical conditions under control," Hochman said. "And we really do have a goal of getting them housed, because when the mental health conditions and substance use and
... physical conditions are under better control, that's when the patient is better able to get a home."
Patients with mental health issues can talk remotely with a psychiatrist who may prescribe medication for schizophrenia and bipolar disorder, Hochman said.
"We've seen rapid results in schizophrenia," he said. "Once they start their medications, usually within a week, there's a dramatic improvement."
Hochman said a number of their patients have started medication for HIV, which affects about 20 percent of homeless people in Southern California.
"We've had dozens of patients who have started on medications to help block or address substance abuse, and we've given them counseling," Hochman said about the overall program, including patients in Los Angeles County. "Many have gotten enrolled in AA and Narcotics Anonymous. We've had close to 20 who have gone to rehab programs."
Remaking Medi-Cal
Healthcare in Action is an owned subsidiary of SCAN Group, a nonprofit created in the 1970s as Senior Care Action Network, and was created by SCAN in part as a community benefit requirement to maintain federal tax-exemption status and as a way to provide health care to the growing number of homeless people in Los Angeles County, Hochman said.
In January, Healthcare in Action partnered with Molina Healthcare of California, a managed care company that serves members through Medi-Cal, Marketplace, Medicare and Medicare-Medicaid. The first two teams were launched in Long Beach and West Hollywood.
"Molina was aware of what we were doing and said, 'We want to support it,'" Hochman said, adding that he sees an alignment with his nonprofit and Molina's focus on the safety net population, the term for vulnerable patients who are uninsured or rely on Medi-Cal or Medicaid.
Hochman said Molina saw a need for a street medicine team in San Diego and provided a grant to start the local team. The company's funding for the program came from the state's new California Advancing and Innovating Medi-Cal, or CalAIM program, a transformation of Medi-Cal that is focused on homeless people and other at-risk groups. The program has a focus on prevention and requires plans to pay for care that is more accessible, proactive, transparent and culturally competent.
Melora Simon, associate director of people-centered care for the California Health Care Foundation, noted that the state has increased its expectations for companies that manage Medi-Cal benefits. As of Jan. 1, these companies are required to provide a benefit called "enhanced care management" to disadvantaged groups such as those experiencing homelessness.
Generally, she said, the foundation has seen adoption of these new services spring up more quickly in places like San Diego where there is significant competition among Medi-Cal managed care contractors.
Efforts like Molina's in San Diego, then, are both about meeting changing requirements and proving to the state that they are capable of meeting increased demands for care that is more proactive.
"I think it's about kind of showing that they can deliver, and that's true for all of the plans," Simon said.
Healthcare in Action works with different managed care companies in other cities, but the local team is working exclusively with Molina because of the grant the company provided. The teams bill managed care companies and receive a monthly rate for the group of patients they are seeing.
"We want to be sustainable," Hochman said. "We don't want to be reliable on charitable support. We've been billing managed care companies and the goal is at some point we won't need any charity. We'll be a nonprofit, but fully self-sustaining through managed care contracts. We're not quite there yet. We're still seeking charitable support to fill in some of our gaps."
Hochman said the teams' payments are not based on each visit or service they provide, but on the number of patients they manage each month. Hochman said the state Department of Health Care Services does not make the rates public because they vary from plan to plan based on geography and other factors.
About three-quarters of people on the street already are on Medi-Cal, and the San Diego team has almost 100 patients signed up with a goal of 400, Hochman said. Under state law, the only people not eligible for Medi-Cal are undocumented individuals ages 27 to 49.
The team is not reimbursed for uninsured patients they treat on the street, but they encourage those individuals to sign up to receive longer-term benefits.
Tracking patients is a challenge
Back on the street, one team member took the blood pressure of a man with a long gray beard sitting on a chair along Eighth Avenue while lead peer navigator Laine Goettsch approached Betty McDaniel, 59, who was sitting on the sidewalk at the intersection.
A few yards away, a sign tied to a fence served as a reminder of the dangers of life on the street. It read, "RIP. Ms. Burnadette will be truly missed." McDaniel said she had been struck by a vehicle a week earlier.
While Goettsch began the process of enlisting McDaniel as a patient, another team member bandaged a leg wound on another person who had just walked up. Across the street, several people from encampments approached the white Healthcare in Action van with questions, and soon the vehicle was a sort of mobile MASH unit.
Inside the van, a physician assistant bandaged the open wounds on Matthew Lombardo's calves. Stepping out of the van with his lab-pitbull mix Rosco, the 44-year-old San Diego native said he'd had the wounds for two years.
Lombardo suspected the wounds might be related to his use of fentanyl over the past two years, the latest narcotic in a lifetime of drug use he said began at 6 when he first tried heroin.
Lombardo thanked the team for dressing his wounds, but he seemed unlikely to seek a follow-up visit.
"I'm not really good at staying in touch or speaking with people, you know what I mean?" he mumbled.
Hochman said staying in touch with patients and locating them for checkups has been a challenge, and for a while teams in Los Angeles provided mobile phones to clients.
"We lost a lot of cellphones that way," Hochman said.
As an alternative, he said teams have begun offering GPS tracking devices to their patients on the street, and almost everybody agreed to take them once trust was established.
Hochman said street medicine teams that work out of the University of Southern California have about a 50 percent success rate of connecting with their patients after they are discharged from a hospital, and Healthcare in Action hopes to do better with the tracking devices. The teams also are making connections at hospitals so they can be alerted when a patient they are treating is hospitalized or discharged.
Hochman said the San Diego team is following about 80 patients with a target of 200 active members at a time and 400 overall throughout a year.
The San Diego team consists of Flint, Goettsch, physician assistant Natalie Pohl, case manager Lydia Holcott and peer navigator Gavin Goff.
While the physician assistants provide health care, other team members help clients with other needs, connecting them with services that one day could lead to permanent housing.
Hochman said many of the team's clients have heart disease, about half have a serious mental illness and half have active substance abuse. Patients with mental issues are connected with a psychiatrist who speaks with them remotely, which Hochman said has proven to be the most effective method.
About 20 percent of patients in major urban areas are HIV positive, about a third have hepatitis C, and many have cuts and infections, Hochman said.
The team also visits formerly homeless people who recently received housing, including Frazier Johnson, 52, who moved into a downtown apartment eight months ago.
Relaxing in his apartment with devices to help him breathe at the foot of his bed, Johnson said he has sarcoidosis, a rare condition that can affect the lungs and causes small patches of swollen tissues on skin and organs.
"If I need medicine or if I need a ride to an appointment, they book that stuff for me," said Johnson, who was homeless seven years. "Just the other day, Lydia (Holcott) brought me water, which is a number one struggle for me, picking up heavy things and carrying them around. Whatever they can do to make it easier for me."
Holcott also brought him a new bed to replace a leaking air mattress he had to refill every four hours.
"For me, Lydia is the next step in evolution of what health care should be," he said.
Johnson said he never knows when his condition is going to flare up, and one recent night when he was not feeling well he called Holcott, who passed along Flint's number to call. He didn't think he should go to a hospital, but after Flint arrived at 10 p.m. and saw his condition, he agreed that she could call him a ride to a hospital. He ended up staying two nights.
Goff, one of the team's peer navigators, is a San Diego native who has been with the team just a month. After spending two and a half years homeless in Los Angeles' skid row, the 27-year-old has overcome his addictions and is helping others find their own path to recovery.
He knows from experience that some won't make it, but said he is motivated to help the ones who can.
"There's always a piece in my mind where I think anybody can make it," he said. "If I can make it, anybody can make it. But I have accepted the harsh reality of dealing with addicts. Some are not going to make it. Some people are going to die."
Even if the odds are one in 100, Goff said he is determined to do what he can.
"How I deal with the job is, I'm going to try my best to help that one person, because I was that one person. Somebody helped me. If I can help that one person, it's worth it."
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(Staff writer Paul Sisson contributed to this report.)
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