‘Go to the people’: Street medicine teams bring health care to the unhoused

It’s not healthy to be homeless. California’s more than 170,000 unhoused people often lack the means and mobility to locate and visit a doctor who will accept them — so conditions fester until they need emergency treatment.

That’s inhumane and inefficient: More than half of the state’s $133 billion Medi-Cal budget is spent on the top 5% of high-needs users.

Trying to change things, the state’s Health Care Services Department is throwing its support behind street medicine teams. It’s encouraging insurers to fund and partner with organizations that bring medical care straight into encampments, and as of November, allowing those teams to get reimbursed by tapping into and managing homeless patients’ Medi-Cal benefits.

At least 25 teams now operate throughout California, strapping on backpacks filled with medical supplies and meeting homeless people where they are. Most teams stress continuity — visiting the same patients in the same places, at regular intervals. They also include community health workers, who hand out food and hygiene supplies and help people overcome hurdles to obtaining aid and housing.

This project, a collaboration between CalMatters and CatchLight, attempts to capture what street medics are doing in Los Angeles, Bakersfield, and Redding.   

LA Street Team

In the nation’s second-most populous city, the street medicine program at the University of Southern California’s Keck School of Medicine combs the neighborhoods. These teams deliver health care to people experiencing homelessness on the streets, in the riverbeds, under bridges, or wherever terrains they reside in the vast Los Angeles County. In addition to distributing medications, taking blood samples, performing ultrasounds, and treating behavioral health and substance use disorders, the four USC Street Medicine teams offer full-service primary care on the streets.

A key is to develop a relationship and understanding of the routines of unhoused people, according to physician assistant Brett Feldman, who directs the teams. This is essential in Los Angeles, a vast region where patients move or are moved, up to four times a month to avoid street cleanings, camp sweeps, or dangerous conditions.

“In almost all oppressed people, you see similar things where… There’s nowhere physically for you to put your body,” Feldman said. “So you’re constantly being told that you’re less than human. You’re eating things that humans shouldn’t eat, sleeping places where humans shouldn’t sleep, you’re not allowed in places where other humans are, you go into a restaurant, they kick you out,” Feldman continued. “And so you start to believe that about yourself, that you’re less than human. And so you do things to survive that you’re not proud of.” 

Feldman said the first step is to recognize the humanity of his patients. “And that’s done first with an act of love…after that, you bring the medical care.” One of his patients, nicknamed Uncle Frank, is in constant need of his attention but doesn’t trust doctors, Feldman said, but he does allow Feldman to check up on him on one condition: Bring him a Coke. So each day, Feldman goes to the store and picks up a bottle of soda and gives it to Uncle Frank before he begins his examination.  

“People don’t go out onto the street; they get pushed out onto the street,” said Feldman. “If we went through what they went through, we’d be worse off than them even; we would do worse things than they were doing.” 

Carla Bolen

Physician assistant Brett Feldman and Community Health Worker Michael Gallegos walk through Elysian Valley Park, up a wooded hill between a park and a viaduct above Highway 110. Just over the hill lies a set of encampments where Feldman’s patient Carla Bolen stays. The  52-year-old Bolen said she came to California from Florida in September and has been homeless for most of her life. The team first encountered Bolen in an encampment near city hall and assisted her with her leg pain. After a man attacked her there, she relocated to the camp above the highway. During February, working with Project Homekey, the street medicine team got her a room to stay in the Imperial Inn. Bolen said the team, whom she describes as a family to her, has helped her get her life back by getting her off the streets and finding her housing. “It’s a total change going from living outside to inside. You got to train yourself to where you were before you became homeless,” Bolen said. ”Like paying bills or picking up your medication. You can’t be lazy when you want your life back, and I prefer not to be lazy because I want my life back.” As of May, the team moved her into an apartment. 

Steven “Cowboy” Dombrowski

“They rescued my life,” Steven “Cowboy” Dombrowski said while counting pills into an organizer at the foot of his hotel room bed. He’s another patient of Feldman’s street medicine team, staying in the L.A. Grand Hotel thanks to Project Roomkey. Project Roomkey is an effort by the state, county, and the Los Angeles Homeless Services Authority (LAHSA) to secure hotel and motel rooms for unhoused people. Dombrowski said he met the team in 2018 while living in a dumpster behind a gas station. Feldman and his team were meeting with another patient when they saw Dombrowski crawl out of the dumpster with a bloody and infected arm. They asked to treat him on the spot. According to Feldman, Dombrowski suffered from necrotizing fasciitis, a flesh-eating disease, and had lost his pinky finger on his right arm to the disease, and his skin graft had failed. The team began checking on Dombroski three times a week for months, monitoring his arm — even though there were gaps in time when they couldn’t find him. “I was ready to give my arm up,” Drombowski said. “I just thought it was going to be amputated one day. I expected I was going to die. But with the street medicine team, it was all positive.” 

Dombrowski said the team also has helped him get dental work and new reading glasses. In February, Dombrowski moved into the L.A. Grand Hotel. As of May, he moved into another hotel designed to be a more permanent home.

Redding

Dr. Kyle Patton walks past a “no trespassing” sign in front of a snowy field on a cold February morning. The doctor carries his Red Cross medical bag and a backpack full of hand-warmers, tarps and other supplies to keep dry. He makes his way to a row of trees near a stream on the other side of the field. A row of tents can be seen just underneath the trees. Patton goes from tent to tent, talking to his patients, checking their vitals, and giving them supplies to relieve the frigid temperatures. 

Patton is the medical director of the HOPE street medicine team at Shasta Community Health Center. Patton stops at one tent and drops off hand warmers and a tarp to a patient named Stephanie. Stephanie says that seeking medical treatment isn’t something she thinks about when trying to survive while unhoused. To protect her privacy, CalMatters is identifying Stephanie by first name only.

“I didn’t seek medical treatment, and in a way, I still don’t,” Stephanie said. Patton, she said, “seeks us, and that’s helpful because when it comes down to it, some of us don’t take care of ourselves as we should.” Patton noted, “It’s hard for my patients to focus on their health when they are focused on the basics of food, safety, and shelter.”.

Patton says his patients have dealt with institutional trauma in medicine, and often distrust health professionals. “We play the long game, and we focus on that relationship. When they go to the hospital, it’s like, we’re (hospital doctors) just going to get things done. We’re going to diagnose. We’ll treat you, and then we’ll get you out. But, with (the street medicine team), we are out on the streets. And a big part of our job is not just the medical care, but it’s building the patient’s trust. I tell the residents that work with me like 30 percent of my job is taking care of people in the field. The rest is just shooting the breeze and convincing my patients that I’m a guy worth talking to.” 

Timothy Knight

“If I had a million dollars, I’d give it to Shasta Community (Health Care) in a heartbeat,” Tim Knight says while getting his heartbeat checked by Patton in his room at the Red Lion Inn. Knight is a 62-year-old Army veteran and patient of Patton whom the street medicine team helped to place at the inn. He said he met Patton two years ago in an encampment under Redding’s Cypress Avenue Bridge, where the doctor gave him a first aid kit. Eventually, he began to go to him for all his ailments. Knight said he always had a bad experience with hospitals and felt that he was being rushed out the door. “I’ve been to, you know, other emergency rooms and stuff like that. And it just seems like, ‘oh, just another person,’ like cattle being rushed through there,” Knight said. But at Shasta Community Health Care, “it’s more of a personal thing with them,” he said.  “Everybody that goes through there, you know, they’re tired. They’re, they’re sick, you know? And they treat them good.”

The street team is currently trying to help Knight get a set of new hearing aids after his old pair was stolen. “It’s more expensive to live on the streets than it is even to live, you know, rent a place and stuff because you had to buy food that you got to eat on the run itself, you know, you don’t always have the place to cook food, stand warm. People steal stuff all the time. I’ve had my backpack key, my passport was stolen,” Knight said. In May, the Shasta Community team reported it was able to help Knight move into an apartment. 

Gregory Sovick

In his apartment, Gregory Sovick sits at his desk — its surface covered with paint supplies, brushes, unfinished canvasses, and a photo of him with Dr. Kyle Patton. Sovick once had a deep fear of doctors. When Patton first approached him a few years ago at an encampment, he wanted to check a mass he could see growing on Sovick’s nose. A biopsy confirmed it was malignant. The team arranged for surgical removal of the mass in an adjoining county, but on the day of the appointment, Sovick’s medical transport never showed. Afterward, when the team tried to meet with him, his encampment had been cleared out. The team lost track of Sovick for more than seven months. By the time it found him again, the mass had grown significantly, invading his nasal cavity and sinus, putting one of his eyes, and even his life, at risk. Patton said that a nurse on the team helped Sovick deal with his delusions and got him an anti-psychotic injection, while a case manager helped Sovick secure a motel room and search for longer-term housing during his recovery as he underwent seven weeks of radiation therapy. Patton’s team provided continual help and check-ups and connected Sovick with the federal Department of Veterans Affairs to find an apartment.

Bakersfield

Before the sun rises in Bakersfield, Dr. Mathew Beare and his street medicine team with Clinica Sierra Vista begin loading their trucks and vans with the food, water, warm clothes and medical supplies they need for patients. Every Thursday, the team does its rounds caravanning along the Kern River and searching for patients who camp nearby. The team eventually parks in one area of a nearby park, and like clockwork, patients begin to show up. The team even gives out dog treats to patients’ pets.

It’s the driving philosophy of any street medicine team: Go to the people.

“This is an incredibly underserved, but deserving, population that has limited access to health care,” Beare said.  “And on top of that, most of them have prior encounters with health care that left very negative impressions. And so they’re not actively seeking health care because they know they are often ostracized or treated ‘less than’ when they get treatment. And so we just want to bring the high-quality clinical care that we provide in the four walls of a typical clinic out to these patients on the street.” Beare’s team includes case managers and outreach workers to help patients get vital documents and secure housing. 

“If you’re thinking about ‘What is one intervention I can do for this chronically unsheltered individual that will markedly improve their morbidity and mortality?’ housing is number one,” Beare said. “I can treat wounds all day, I can treat chronic disease, Hep C, HIV all day long. But the thing that’s going to have this person alive 10 years from now is if I get them into a house.” 

The Process

“I don’t come out in a white coat, and, you know, a tie or anything like that, we want just to look very approachable. And then, when we do approach, we try to do so in just a very friendly, non-threatening manner. Just like, ‘Hey, man, how are you? My name’s Dr. Beare, can we provide the services out here —  just if there’s anything we can do, we want to help.’ A large component to how we make that initial contact with someone is, you know, we don’t, we don’t want to be too aggressive. We don’t want to be there. I don’t have too many people on that first contact. I like it if it’s going to be us introducing ourselves to a new patient, I like it to be like one or two of us going out there and saying hello. And then again, sort of philosophically it’s meeting people where they are and not coming in with any like prejudices. Just coming in saying like, ‘Look, you’re in a situation; it looks awful. We just want to help whether there’s substance use involved, mental health problems involved. We just want to help anywhere we can.’

“And I think that’s a big thing is when people know that you’re not like judging and you’re not coming in with these prejudices, then they open up. And when we start offering things, whether it’s medical care or harm reduction materials, we start offering these things that are just tools of help, then people are almost always receptive to that. And so they open up, and because we’re able to build and maintain meaningful relationships, they let us do like some pretty impactful stuff in their lives.”

Perry “Bear” Lucky

Accompanied by his four dogs, Perry “Bear” Lucky walks down the pathway near the Kern River to meet the street medicine team on rounds every Thursday. He comes up to grab a coffee, food for himself and his dogs, and other hygiene products the team gives him. He said he’s lived in the area for three years after being imprisoned for 18 months for burglary. Lucky says he has been in and out of prison five times and has spent most of his life on the streets, and dealt with heroin addiction since he was 12. After release, Lucky began living in a tent in a dirt field next to Highway 99 and reverted to heroin use. But then he met Beare and his team when he approached his campsite and offered lunch. The two began talking, and Beare left him with a box of Narcan, which Lucky was thankful for. That was the start of a weekly interaction. After weeks, Lucky said he began to trust Beare and open up because he was finally tired of using drugs and needed help. Beare said he and his team began using Sublocade injections. As of February, Lucky said he had remained over 100 days sober, crediting the injections and the street medicine team. “I am grateful, I’m very grateful,” Lucky said. “Beare goes out of his way to help people, and it’s a blessing from God.” 

This project, a collaboration between CalMatters and CatchLight as part of the CatchLight Local CA Visual Desk. Photographs and text by CatchLight Local Fellow Larry Valenzuela. Contributors include Kristen Hwang, Miguel Gutierrez Jr., Jenny Jacklin-Stratton and Mabel Jimenez.