When we first encountered Daniel, we didn’t have a medical van. Back then we drove our own vehicles around town, searching for people who needed care. Daniel fit the bill. He was in his late 30s, had a lengthy criminal record, and had been living on the streets of Long Beach, California, for two years.
Just a few months before we met him, Daniel had been shot three times during a fight with his employer. Surgery saved his life, but it also left him with a chronic wound in his lower abdomen, hernias related to unsealed surgical incisions, and urinary incontinence.
The wound was as wretched as it was painful. To make it through the day, Daniel turned to cannabis, alcohol, and fentanyl. Unshowered and heavily tattooed, he looked like someone you’d see on the nightly news doing something scary. In other words, he was the kind of person who desperately needed our help.
In 2021, the SCAN Group launched Healthcare in Action (HIA), an organization that provides street medicine to unhoused people in California through the framework of managed care. The program was the brainchild of SCAN CEO Sachin Jain, who argued that homelessness was a health care concern. By leveraging existing resources and aligning incentives, Jain aimed to transform the health care landscape for homeless individuals, ultimately improving their quality of life and well-being.
Four years later, HIA is a success. It has operations in 18 California communities across six counties, where it has provided comprehensive, compassionate care to almost 8,000 patients. There are no current benchmarks to evaluate the care and treatment of health issues among unhoused individuals for comparison purposes. However, our progress is promising. As of August 2024, 67.5% of our patients with hypertension were receiving antihypertensive medications, 49.7% of patients with opioid use disorder were being treated with medication-assisted therapy, and 51.9% of patients with mental illness were receiving medication for their condition.
Significantly, 57% of our patients have at least five visits with a member of the HIA staff each year. That’s a good thing: Our goal is not just to treat acute symptoms. Instead, we strive to provide comprehensive care and manage chronic conditions — just like any health provider would.
We believe we have demonstrated that, by unlocking existing revenue streams, it is possible to meet the health care needs of the unhoused population. But getting here hasn’t been easy. Here are some lessons we’ve learned along the way.
1. Be patient with your patient
Many people believe that unhoused people don’t want help and would prefer to live on the street to other available options. This notion is ludicrous. Homeless people are like any others: They are proud, and they want to be treated with respect. When people accuse them of personal failure and offer them housing in dangerous shelters where they’ll be vulnerable, they understandably refuse.
In our experience, most patients want to say yes to services that they feel assured will help them. Each time we did something for Daniel that produced a positive outcome, he agreed to a further intervention. We started by treating his abdominal wounds. Then he agreed to see a urologist, who prescribed medication to help him control his bladder. Next, he worked with one of our psychiatrists to transition from fentanyl to methadone. We then arranged a consult with a surgeon who could repair the injuries in his abdomen. After a year of working with us, Daniel moved into his mother-in-law’s home in north Los Angeles County, where he still lives.
Daniel’s progress is remarkable, but not entirely surprising. Many well-intentioned individuals become frustrated by the fact that transitioning unhoused people into permanent supportive housing is neither quick nor simple. Every day, our goal is simply to reduce our patients’ suffering a little bit. We have learned that if you can get people to take small steps — taking their medication or seeing a specialist — eventually they will take bigger steps. As we often remind ourselves on our toughest days, if we don’t give up, they won’t, either.
2. Don’t go it alone
The current health funding system for street medicine falls short in meeting the extensive needs of homeless people. However, this challenge presents an opportunity for creative solutions and partnerships. At the state level, California’s CalAIM initiative enabled us to add community health workers, peer navigators, and clinicians to our street medicine teams. Municipalities such as the City of West Hollywood and Riverside County have entered into contracts with Healthcare in Action through which we care for people living on their streets. Health insurers such as CalOptima and Molina Healthcare have likewise contracted with HIA to care for their unhoused members.
In what we believe is a first of its kind arrangement, HIA entered into a unique partnership with Cedars-Sinai Medical Center to provide care to unhoused patients after they are discharged. Jonathan Schreiber, Cedars-Sinai’s vice president of community engagement, told us he was initially skeptical of HIA’s approach because it de-emphasized housing. But after seeing how the program could provide stable care for patients — and that some were indeed connected with housing — he came to believe in it. “Not everyone is ready to be housed, but we need to make sure that everyone can be cared for in a high-quality way that improves their health while connecting them to the broader health system,” Schreiber said.
Based on the success of the partnership, Cedars-Sinai made a subsequent grant to HIA, enabling it to bolster teams that serve communities near the hospital and its affiliate medical centers.
3. Hire people with lived experience
Since its inception, HIA has gone out of its way to hire people who themselves have been homeless. Peer navigator and housing specialist Eric Barrera, who has been with HIA since its inception, became homeless after serving in the military. “I had a rough transition back to civilian life and started self-medicating with drugs and alcohol,” he told us.
We’ve seen that people like Eric tend to connect more easily with patients and have had success earning their trust. “Homeless people believe they’re inadequate and unworthy — things we once believed about ourselves that are untrue,” he said. He also serves as a resource for health care professionals, fostering a shared language and perspective that enhances the quality of care for homeless individuals seeking health care services.
4. Embrace technology
Our goal is to provide patients with consistent medical care. But unhoused people often move around a lot. Locating them can be more difficult than treating them. At first, we tried giving patients cellphones, but they often got stolen or confiscated during encampment sweeps.
So, with the voluntary consent of patients, HIA attaches GPS tracking devices to their belongings. The devices, which can be turned off, have a three-week battery life and no street value.
What’s more, all of our staff have 5G-enabled computer devices that enable them to document care anywhere in the field. They allow them to view patients’ electronic health records and put in pharmacy orders right away, just like medical staff do for patients in clinical settings.
5. Build trust, improve housing
Although Healthcare in Action’s mission isn’t primarily focused on housing, the program has observed a significant correlation between improved health and stable housing situations among its patients. Among patients we have seen five or more times, 23.4% have had an improvement in their housing status. All told, HIA has placed nearly 400 people into permanent or temporary housing.
These outcomes align with accumulating evidence that integrating health care services with housing programs enhances the likelihood that people who are homeless will successfully transition into shelters, interim housing, or permanent housing.
Healthcare in Action’s success in supporting housing stability can be attributed to building trust between patients and health care providers. When homeless people receive compassionate, person-centered care from providers who understand their unique challenges, they feel supported and empowered to make positive changes in their lives.
For three years, we have faced failure, rejection, setbacks, and self-doubt. Nevertheless, like so many of our patients, we continue to persevere. About 186,000 Californians — about a quarter of America’s homeless population — live on the streets. Older adults make up the fastest-growing segment of this group. Their homelessness no doubt has many causes. But we can say with certainty that it is almost always experienced as a health care issue. Only by addressing it as such can we alleviate suffering, improve lives, and take meaningful steps toward reducing the overall impact of this great societal problem.
Indu Subaiya, M.D., M.B.A., is the CEO of Healthcare in Action. Benjamin Kaska is vice president of clinical operations for Healthcare in Action.