Multiple Efforts to Provide Health Care to Populations Experiencing Homelessness

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The San Francisco Department of Public Health (DPH) offers medical care to people experiencing homelessness throughout District 10. Two programs, Street Medicine and Shelter Health, play a predominate role in these efforts. 

According to Rachael Kagan, DPH communication director, Street Medicine is mobile, serving people sheltering in encampments, roads, parks, and under bridges. Street Medicine also responds to the Healthy Streets Operations Center, which opened in 2018 to offer coordinated, real-time, responses to camps and unhealthy street conditions. In addition, Street Medicine treats individuals with addictions at clinics and syringe access sites. 

Shelter Health operates from shelters and navigation centers, including the Central Waterfront and Bayshore facilities. The two programs share a team of 43 professionals, comprised of doctors, nurse practitioners, nurses, psychiatrists, health workers, social workers, peer counselors, and administrative staff. Both programs are funded by Medi-Cal and the City and County of San Francisco’s general fund. 

“Shelter Health clinics are nurse-run and friendly, with health care staff that visit each site at least two days a week. When a person walks in the door, they’re treated like a primary care patient right away,” said Kathleen Shuton, Shelter Health director and a registered nurse.  

The clinics treat minor ailments, such as colds, as well as serious concerns, like emergent, urgent, and chronic disease management. Getting patients to accept care can require resourcefulness and creativity.  

“You need to build trust,” said Shuton. “We have really special nurses and staff. Clients will talk to them when they never wanted to talk to a health professional before. We show that we care, we’re non-judgmental and we’re there for them. Sometimes you start by offering a client socks, shampoo, or a snack. Later you might ask a client their goals, like, “Where do you want to live?”” 

DPH data indicates that the number of patients experiencing homelessness who received care at Zuckerberg San Francisco General (ZSFG) has been steadily rising, as has the number of times an individual is seen.  In Fiscal Year (FY) 2016-2017, 9.1 percent of ZSFG patients had no permanent home, a percentage that rose to 9.4 percent in FY 2017, and 9.5 percent in FY 2018. 

A handful of ZSFG residents and University of California, San Francisco (UCSF) fellows train with Street Medicine and Shelter Health.  “We can only accommodate a few students, two residents in primary care and internal medicine, three addiction medicine fellows, and three addiction psychiatry fellows,” said Dr. Anita Barzman, psychiatrist for Street Medicine and Shelter Health and volunteer clinical faculty at UCSF’s Department of Psychiatry. “Every year, we also accommodate dozens of other miscellaneous visitors who learn from the team, including premed students, medical students, and doctors from other centers.” 

According to Barzman, doctors want to work with the homeless population.  “They arrange their schedule to do rotations with us. We provide a multi-day orientation that includes a tour of several sites where they will treat patients,” said Barzman. “Doctors in training help coordinate care. For example, they may see a patient who is being treated in SF General for a substance abuse issue. Later they may see the same patient who has been discharged to Ward 93, an outpatient opiate treatment program.” 

Dr. Christine Soran, a UCSF assistant professor, said her year as an addiction medicine fellow with Street Medicine taught her to “meet people where they’re at. Often when I asked people who I saw in Bayview and Hunters Point where they were staying, the vast majority of them were not staying in any one place. I learned to be flexible with my approach. Treating all patients, but particularly those experiencing homelessness, means learning that their goals may be different from yours.” 

Soran said her patients needed flexible hours, a space to store their possessions while getting treatment, and affirmation. “First and foremost, it’s important that patients feel respected and shown that their opinion matters,” said Soran.

Drug treatment can play a significant role in providing care to patients experiencing homelessness.  Dr. Triveni DeFries, a UCSF assistant clinical professor who trained with Street Medicine and Shelter Health, said patients sometimes use stimulants like methamphetamine to stay alert. “They’re concerned their belongings, which can include important medications, may be stolen. Patients may walk around all night to stay awake.  People experience a lot of life trauma. Offering awards, prizes and even money for engaging in care may work. You’ve got to grow relationships that build trust,” said DeFries.

According to Barzman, trusting others and staying sober isn’t easy for patients who have been assaulted or had traumatic brain injuries. “Their ability to think things through has been affected. They may also suffer complications caused by different addictions. These cause different problems,” said Barzman. 

Eileen Loughran, DPH drug user health programs coordinator, estimates that there are 24,500 injection drug users in San Francisco. Loughran oversees a DPH team that participates in encampment health fairs alongside Street Medicine and Shelter Health, the Department of Homelessness and Supportive Housing, Glide Church’s HIV/Hepatitis C Virus Harm Reduction Services, and San Francisco AIDS Foundation Syringe Access & Disposal Services.  

“The monthly events are like popup health clinics at encampments,” said Loughran. “We have done several health fairs on the Southside in 2019. At these events, our medical teams treat people for issues like wounds, vaccinations, birth control, HIV care, and addiction,” 

Loughran said Street Medicine and Shelter Health have helped patients start a course of Buprenorphine, a prescription drug to treat narcotic dependence, linking participants to a primary care physician.  “The Homeless Outreach Team is able to work closely with medical teams and connect people to beds in navigation centers or shelters,” said Loughran. 

Loughran said DPH, Glide, and San Francisco AIDS Foundation staff visit public housing complexes to provide HIV/HCV/Sexually Transmitted Disease testing, overdose prevention education, and harm reduction services. During the calls, individuals can get connected to other health services, including primary care.  Staff visit Sunnydale on Mondays, Potrero Annex-Terrace on Wednesdays, and Hunters View on Fridays. 

“DPH also funds and oversees syringe access and disposal sites where drug users can access clean syringes and dispose of dirty ones,” said Loughran. “These programs help reduce the spread of HIV and Hepatitis C. They reduce the amount of syringes on sidewalks,” 

According to Shuton, when a patient at a navigation center or shelter has a substance abuse issue it’s factored into their treatment plan.  “At larger navigation centers, like Bayshore, we have an addiction medicine specialist on-site once a week,” said Shuton.

Dr. Andreas Mitchell, a second-year resident physician at UCSF, said it’s critical for hospitals and clinics, including ZSFG, to provide care and referrals to patients experiencing chronic homelessness. Patients without shelter “have a lot of urgent, competing priorities. Many patients don’t have anyone to take care of them after leaving the hospital. We want to offer the most supportive and compassionate care we can, for as long as we can, regardless of the patient’s readiness to engage,” Mitchell said.  

Barzman said providing care in a navigation center helps a person experiencing homelessness build a pathway to permanent shelter. “The housing may not be a nice, new apartment in Dogpatch. It may be a single room occupancy unit in the Tenderloin or the Mission. One of the hard parts of helping patients transition is that there may no relationship to where they are living now and where they’ll find housing later,” said Barzman.

Mitchell said the well-being of people experiencing homelessness could be improved by increasing the number of beds in medical break facilities. “The Medical Respite and Sobering Center at 1171 Mission Street has about 75 beds. If I could do any one thing to help people who were homeless, I would double the size of that center. There people can recover and get assistance like wound care and nursing services from nurses and nurse practitioners,” said Mitchell.

Mitchell also thinks the City should increase the number of shelter beds.  “Every day at SF General, social workers, case managers, care coordinators, and doctors get together to discuss patients who are near discharge. We talk about whether we’ll be able to get someone a shelter bed. It’s always 50/50. I have patients who’ve been on the housing waitlist for years. Although I am still in training, I want to do more than discharge people back to the street,” said Mitchell.