Updated Jan. 4, 1:55 p.m.
In a south Natomas parking lot, the sun shone on wet asphalt and piles of decomposing leaves. A brilliant blue day had emerged from the wreckage of a mid-December storm, and 10 volunteers stood in a loose circle in the morning light.
Some volunteers were there for the first time, others had been coming to “The Island,” a homeless encampment abutting the American River, every other week for months. Two volunteer leaders, medical students wearing navy sweatshirts with a gold Sacramento Street Medicine logo, split the group of mostly undergraduate and graduate students into two teams: outreach and medical.
The outreach team got to work assembling a wagon full of supplies: water, hand warmers, wipes, socks and granola bars. It had been cold for weeks, and the city and county had both activated extreme weather plans to help people stay warm. During the winter of 2021, eight people died from hypothermia on Sacramento’s streets, part of an unprecedented number of homeless deaths city-wide.
Groups like Sacramento Street Medicine are hoping to help cut that number down, and help some of the city’s most marginalized people access desperately-needed care. The 3-year-old nonprofit is part of a growing, state-wide network – one that’s being formalized for the first time. Experts say California, which has the highest population of unsheltered homeless people in the country, is leading the way with investing in on-the-ground work to address the needs of the demographic.
In the parking lot, the medical team, including Sacramento Street Medicine founder and physician assistant Anthony Menacho, went over the list of patients for the day. Menacho’s organization follows many of the models for street medicine outlined by physician assistant Brett Feldman, the Director of Street Medicine at the Keck School of Medicine of USC, with whom Menacho trained until 2019. Feldman’s model for a street medicine group includes a clinical provider, a nurse and a patient advocate.
As one of the foremost experts in the field, Feldman has helped standardize much of what street medicine is, so there can be policy modeled around it. He says his approach is “patient-led,” and relies on being able to dispense medicine and advice in a patient’s environment, not in a doctor’s office or even a mobile clinic. This is important, he said, since many unhoused people don’t trust health care systems, often with valid reason.
Plus, he added that there are innumerable barriers for people living on the streets to access care. People might be wary of having their belongings stolen, or they may not have available transportation or enough money. They might be worried about where they’re going to sleep that night, or where they’ll find food, water, or a place to use the bathroom, never mind how they’ll get treatment.
“Instead of going through all these barriers, all they have to do is remember not to leave their encampment and just stay where they are and street medicine will come to them,” Feldman said. “And if they don't remember, that's okay, because we'll look for them.”
The lack of available, immediate health care means that oftentimes unhoused people don’t get the medical treatment they need. There’s also a financial cost to the community: Unhoused people are also more likely to utilize emergency services, due to myriad factors, including a lack of health insurance and knowledge of other options.
The city and county of Sacramento recently acknowledged the need to embrace street medicine practices in their five year plan to address the area’s homelessness crisis. Part of the plan includes sending teams of mental health and substance use workers out to encampments to diagnose people on the spot and get them into treatment, a course of action that was recommended in the report accompanying the city's 2022 Point-in-Time count of homeless residents.
On Dec. 11, in the Natomas parking lot, Menacho’s group followed Feldman’s model and added one more member, a scribe, taking notes on a tablet. The group of four separated from the outreach team and headed toward the encampment, following the Garden Highway before veering down a path that led to a forest along the American River. All five patients on the list lived in tents, or tent structures, in the forest, among dozens of other people.
At the tent of the first patient, second-year medical student Johann Park separated from the group and approached the opening.
“Knock-knock,” Park called out. “Sacramento Street Medicine! Anyone home?”
After a minute passed with no response, Park called again. Again, no response. It was the same story at the tent of the second patient. Menacho said this response is par for the course with street medicine. Sometimes people are around, sometimes they’re not. What’s important, he said, is that his team is out there again, showing up when they said they would, and being seen by the people living in the area.
“They could just be at a shelter,” Menacho said. The ground underfoot was still sodden, and the tents around seemed deserted. “Yesterday was bad.”
That morning the wind whipped through the trees spreading yellow leaves, and the cold penetrated, but it wasn’t raining. Walking on the trail toward the next patient, the team met a woman going the opposite direction, ensconced in a long black puffer jacket. The group exchanged hellos, and then Menacho realized it was the team’s second patient, a woman with dog bites healing on her arms.
Team members decided the trail was an OK place to check out her wounds, and the woman peeled off a few of her many layers of clothing. The team made quick work of changing the gauze on her arms.
“They’re much better,” Menacho said of the bite marks.
Menacho’s team listened attentively as the woman described her wide-ranging medical history. They asked about her primary care physician, and she said she needed help getting reconnected with them. The conversation turned to what was next for her – how she hoped to eventually live in a house and reconnect with her grandparents, living in Puerto Rico. The team told her they’d see her in a few weeks, and after thank yous, she continued on her way.
“The most important thing with respect to street medicine is just hearing these folks, being on the ground and learning from them what they need,” Menacho said.
He added that the patient should probably see specialists for other symptoms she’s described, but that he can’t refer her to one. She needs to go through her primary care provider (PCP). Menacho said the team’s next goal is to have the patient navigator help her get connected.
Feldman said that in an ideal world, teams like Menacho’s would be able to refer the patient to the specialists, and not have to go through her PCP, as has been mandated through Medi-Cal requirements. His aim is for street medics to be authorized to provide referrals at the exact time the patient needs one.
That goal is coming into reality: A new all plan letter from the Department of Health Care Services permits street medicine practitioners like Menacho to have more leeway when it comes to referrals, prescriptions, treatment and reimbursement for unhoused Medi-Cal patients.
For Feldman, this is huge: “For the longest time in street medicine, we were kind of seen as these rogue, subversive radicals who would just go on to the street and weren't part of the existing system, and in some ways were kind of viewed the same way as our patients are viewed by society,” he said.
“And now, with these new innovations, the system is not not just bringing street medicine in, but is actually bending to include street medicine with its mission and values and philosophy intact.”
However, the advisory is still new, and questions about functionality, sustainability and scope will need to be addressed as managed health care plans embrace the changes.
Back at The Island encampment, Menacho’s team connected with the only other available patient on their list, a longtime resident of the camp who was looking for an HIV test. She filled the group in on some news she’d heard through the grapevine, and recommended that they bring STD tests in the future.
“Relationships like that end up being incredibly invaluable for our organization,” he said, adding that it’s taken years for the woman to feel comfortable with his group.
Although only two patients were seen, Menacho’s team counted the day as a win. They reconnected with the outreach team and walked back to the parking lot to debrief. It was their last outing for the year, and Menacho said they plan to start the new year with renewed vigor.
Over the past three years, his team has grown quickly. The organization has a board, as well as medical and outreach volunteers that number over a hundred. He says each year the volunteer interest is overwhelming, and they’ve had to close the application early to accommodate.
“The solution to homelessness is, is a home, right? So the goal is to eventually bridge to that,” he said. “But, you know, if we can play a small part in providing medical care and taking care of their physical and psychological needs just by being here, then we do so.”
The group plans to keep visiting six Sacramento encampments regularly, and to keep expanding. Although the work is time-intensive and slow-going, Menacho said he suspects his team is a crucial component in keeping people connected to care and the community.
Those interested can find more information about getting involved with the organization here.
Correction: A previous version of this story incorrectly identified the organization which sent the all plan letter giving more leeway to street medicine practitioners for referrals, prescriptions, treatment and reimbursement during treatment. It has since been updated.
We've updated this story with details about the location where Sacramento Street Medicine convenes.
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