HealthSan Bernardino County's street medicine team aids unhoused

San Bernardino County’s street medicine team aids unhoused

Overview: Kristen Malaby, a Fontana native, was injured in a warehouse in 2017 and found empowerment in organizing nature trash cleanups across the region. She encountered unhoused people in the process and brought them food and clothing. In 2022, she was hired by Healthcare in Action as a Peer Navigator, forming the first street medicine team in San Bernardino County. The team provides wraparound services, including medical care, preventative care, and housing assistance, to the region’s unhoused population. The team is the only street medicine team serving the county’s unhoused community with wraparound services.

Aryana Noroozi

After Fontana native, Kristen Malaby, was injured working in a warehouse in 2017, she spent more time outside to cope with her disability and the changes it brought to her life. She found empowerment in organizing nature trash clean ups across the region, and encountered unhoused people in the process. 

According to the San Bernardino County 2023 Continuum of Care Homeless Count and Survey Final Report, there were 4,195 adults and children counted as homeless in San Bernardino County. 

Malaby began bringing unhoused individuals food and clothing.

Early last year at a city council meeting, where Malaby often voiced her experience working with unhoused people in the community, she was approached by Eddie Menacho. 

Menacho is a physician’s assistant and regional medical director, who manages and trains new teams at Healthcare in Action, an organization of healthcare professionals, community health workers and social workers who provide medical care to unhoused individuals across California. They travel directly to homeless communities – whether it is in encampments where they live or in a location they’d like to meet, such as a shopping center or parking lot, a practice known as street medicine. 

Under a new partnership with Inland Empire-based insurance provider, Inland Empire Health Plan (IEHP), Healthcare in Action was able to expand their outreach to San Bernardino. Menacho, who led the expansion, recognized the connection and trust Malaby built with the community. He asked if he could shadow her and get to know the community, and offer them access to medical care. 

After working together for months, Menacho brought Malaby onboard as a peer navigator, forming Healthcare in Action’s first street medicine team in San Bernardino County. In the past year, Malaby was promoted to care management supervisor of the Inland Empire region, in which she stays in contact with patients across the region and helps the team determine when and where patients need care.

Since February 2023, their team has served 443 unhoused individuals in the city of San Bernardino alone.

The services they provide range from substance abuse and mental health treatment, to diagnoses and acute and chronic illnesses, to treatments including preventative care services similar to primary care clinics. This includes electrocardiogram (EKG) tests, blood draws, point of care tests, incisions, drainage and wound care.

Eddie Menacho, Healthcare in Action regional medical director (seated), meets with the  street medicine team, outside a van that doubles as a clinic, before they begin seeing patients across San Bernardino on May 1, 2024.  (Aryana Noroozi for CatchLight Local / Black Voice News)

Through their partnership with IEHP, the team is able to take patients to appointments, pick up medications, assist in access to further healthcare, and support patients in their efforts to acquire housing, either temporary or permanent. This care falls under the umbrella of Enhanced Care Management (ECM), a benefit that became effective in January 2022.

Patients who qualify for the program include those who are homeless and have complex health and/or behavioral health needs and those with a serious mental illness or substance use disorder with complex social needs, among other eligible factors.

“With Enhanced Care Management, the street medicine team can go directly to the patients and advocate for them [and] provide them with their medications. They actually go to the pharmacy, pick up medications [and take them] to the homeless [patients],” said Pooneh Navab, a practice coach with IEHP’s Enhanced Care Management (ECM) team. “They provide so much support that wasn’t available prior to enhanced care management.”

The work of Matthew Wray, director in IEHP’s Health Services Special Initiatives, supports the initiative and upcoming street medicine efforts. He is tasked with building a network of providers who can serve various populations such as the unhoused.

“We have a large volume of homeless members who are eligible for the Enhanced Care Management benefit,” Wray said. “We need providers who specialize in serving a number of different homeless populations with unsheltered individuals being one of them.”

Healthcare in Action has been one of the “primary go-to” providers for the region’s unsheltered population. According to Wray, IEHP quickly recognized Healthcare in Action as leaders in this work as they recognized their efforts in LA County.

IEHP connected Healthcare in Action with their partners in Riverside County and they were eventually awarded a grant to provide street medicine services throughout the five supervisorial districts of Riverside County.

“In about two years, they definitely have a presence now within our two counties,” Wray said.

San Bernardino city and county offer a variety of resources – shelter and housing, rent assistance, meal and shower access, tenant rights information, crisis support, and even a street team who conducts outreach with these resources. However, the Healthcare in Action team is the only street medicine team serving the county’s unhoused community with wraparound services. 

Wraparound services focus on the individual needs, challenges and strengths of each client’s case.  Case managers and social workers implement wraparound care by creating customized, intensive, and individualized care plans that are, put plainly, delivered through teamwork.

At the core of the team’s unique model of care – and delivering it successfully – is a nuanced understanding of their patient’s lives and the importance of meeting them where they are.

Healthcare in Action’s Care Management Supervisor of the Inland Empire region Kristen Malaby poses for a portrait on the banks of a homeless encampment in San Bernardino on May 1, 2024. After independently serving the unhoused community for years, Malaby was approached by the organization to serve as a bridge between the community and healthcare providers. (Aryana Noroozi for CatchLight Local / Black Voice News)

Lead PA Carolina Ajca (right) and Healthcare in Action Regional Medical Director Eddie Menacho (center), talk to Raylen, a patient who lives in an encampment in Rialto during their visit on May 1, 2024. Ajca asked Raylen about his current medications and conditions while recording notes and offering him  a specialist referral. (Aryana Noroozi for CatchLight Local / Black Voice News)

Over the last five years, the total number of persons counted as homeless in San Bernardino County has steadily increased. The 2023 San Bernardino County Homeless Point in Time Count survey indicated a 25% increase in homelessness from the previous count. 

During their annual homeless count, both sheltered and unsheltered individuals are tallied. Sheltered individuals refer to those who spend the night in emergency shelters, or in transitional or temporary housing. Unsheltered individuals refer to those who sleep on the streets, in cars or in abandoned buildings.

“What Healthcare in Action and street medicine teams do is if they find a member, they try to connect them to the benefits CalAim website or call IEHP and try to enroll them again into Medi-Cal,” said Navab. “Sometimes, these members have not been seen for a couple of years. And so they’re not aware of their Medi-Cal [benefits].”

Menacho explained that they typically see four to eight patients in the span of four hours and that it is critical to be time efficient in street medicine. As the team travels between locations in San Bernardino County in their van, which also serves as a space to treat patients, they chat fondly about those they treat.

Meet Dominique 

Dominique poses for a portrait outside of the encampment where she lives and is receiving treatment from the Healthcare in Action Street Medicine team in San Bernardino on May 1, 2024. Dominique is seven months pregnant. Different from the care she receives from Healthcare in Action, Dominique recalled having to wait hours for a blood test at a clinic earlier in the week. (Aryana Noroozi for CatchLight Local / Black Voice News)

Dominique is seven months pregnant with her tenth child, who will be her first daughter. She lives in an encampment in San Bernardino. Nearby are several other groups of tents. She relies on the Healthcare in Action team to support her with medical care access. 

“I’ve been here for five years, so they’ve become my family,” Dominique shared. “We’re not here to cause problems, cause harm. We’re trying to just live, to survive to our best abilities, and get up out the situation, if possible.”

A state-wide study conducted between 2021 and 2022 by the University of California, San Francisco (UCSF) reported, “One quarter (26%) of those assigned female at birth age 18-44 years had been pregnant during this episode of homelessness; 8% reported a current pregnancy.”

Malaby described the barriers to care for unhoused pregnant women she serves, like Dominique. 

“Access to nutritious food is a huge barrier….,” she said. Access to clean water and to restrooms is also a luxury, especially when dealing with morning sickness and frequent urination, Malaby described.

“She needs to be seen often. She doesn’t have a vehicle, she doesn’t sometimes have a phone. How do you call and make those appointments, get to those appointments? Malaby asked rhetorically. “You’re ultimately a target at all times. You’re pregnant. You’re not able to defend yourself. People will still try to sexually victimize you.”

Inside a van that doubles as a mobile clinic, Desteny Benson (right), a clinical support partner at Healthcare in Action, takes the temperature of Dominique, a patient in San Bernardino on May 1, 2024. (Aryana Noroozi for CatchLight Local / Black Voice News)

Dominique recalled having to wait hours for a blood test earlier in the week at a clinic. During her visit with the street team and after describing her symptoms, lead physician assistant (PA) Carolina Ajca ordered a test for Dominique to determine the cause. The team stayed parked near her encampment and waited while Dominique took the test in her tent. 

“You can’t just let being homeless stop you,” Dominique said. “It all depends on how you carry yourself because a lot of people don’t know I’m homeless.”

Dominique currently works at a laundromat and leads a narcotics support group for her community at the encampment. The support program she runs often sees between 70 to 100 people each week, from her own and neighboring campsites. They cook and share stories. 

“I just get up, clean up, and I go check the other campsite to make sure everything is cleaned up,” she said about her daily routine. Dominique shared how sometimes she’ll get money together to help others purchase tents or tarps.

Dominique returns to her tent in an encampment with a urine sample kit in San Bernardino on May 1, 2024. After describing symptoms, Dominique’s provider, Lead PA Carolina Ajca, ordered Dominique a test to determine the cause. (Aryana Noroozi for CatchLight Local / Black Voice News)

Healthcare in Action’s Care Management Supervisor of the Inland Empire region Kristen Malaby (right) talks to Dominique, a patient, after a medical visit to the encampment where Dominique lives in San Bernardino on May 1, 2024. (Aryana Noroozi for CatchLight Local / Black Voice News)

On May 1, 2024, Clinical Support Partner Desteny Benson drives the Healthcare in Action van through San Bernardino to meet a patient. Today, the patient decided that she would like to leave the streets and find housing. In these cases, the team says they must move quickly to provide support. (Aryana Noroozi for CatchLight Local / Black Voice News)

Meet Raylen

Raylen poses for a portrait at the Rialto encampment where he lives on May 1, 2024. He explained that he has been dealing with grief and financial problems. Raylen met the street team when they approached him and asked if he would like to receive services. (Aryana Noroozi for CatchLight Local / Black Voice News)

Raylen, a Pasadena area native, met the Healthcare in Action’s street team when they approached him and asked if he would like to receive services. He became unhoused after his mother passed away four years ago. 

“It’s really helped me out,” he remarked on the care he receives, both for general and mental health. Each day Raylen tries to work on his hygiene and “do certain things to get back to normal society.”

According to the 2023 San Bernardino County homeless count, 44% of unsheltered adults were chronically homeless (homeless for a year or more) and had a disabling condition such as mental illness, a chronic health condition or a physical disability.

The street team administers Abilify, the brand name for Aripiprazole, via injection once a month to Raylen. An Aripiprazole injection is given as a treatment for bipolar disorder and other mental conditions in adults.

“The last two years… I’ve been dealing with the grief and stuff, trying to get my income back together, just financial problems,” Raylen said.

At the Rialto encampment where he lives, Raylen receives a monthly injection of Abilify on May 1, 2024. The street medicine team has found medicines by injection to be more feasible for their patients as they do not have to store them nor remember to take a daily medication. (Aryana Noroozi for CatchLight Local / Black Voice News)

Bikes are stacked at a homeless encampment beside a Golf Course in Rialto on May 1, 2024. Raylen, a patient of the Healthcare in Action street team, has a passion for fixing bikes and does so for his encampment community. (Aryana Noroozi for CatchLight Local / Black Voice News)

Providing care where needed

The team is familiar with their patients encountering barriers to care and housing such as no documentation, discrimination or poor credit history. The street medicine team’s Enhanced Care Management approach ensures that their patients do not have to move into transitional housing or even leave their community to receive care.

According to IEHP, prior to their partnership, Healthcare in Action relied heavily on federal and state grants that weren’t always reliable or long term. 

“Because of ECM, street medicine can occur long term and expand in scope of services and the amount of staff members,” Navab said.

The Healthcare in Action team walks to an encampment next to a Golf Club in Rialto on May 1, 2024. (Aryana Noroozi for CatchLight Local / Black Voice News)

Most programs in California have relied on grant funding to cover the cost of providing services. Nearly half of the existing street medicine programs are associated with a Federally Qualified Health Center (FQHC). The rest have a variety of sponsoring organizations from hospitals, health plans, academic institutions and local governments. 

Historically, there was a lack of Place of Service Codes that providers could use for care delivered outside a facility. Street medicine providers had no clear guidance or precedent for how to contract with Medi-Cal managed care plans and bill for services.

In November 2022, California’s Department of Health Care Services (DHCS) released an All Plan Letter providing new guidance to Medi-Cal managed care plans making it easier for communities to establish, maintain and fully leverage street medicine programs.  

Members of Healthcare in Action talk to Raylen at the encampment where he lives in Rialto on May 1, 2024. Team members had a consultation with  Raylen and offered him a specialist referral. (Aryana Noroozi for CatchLight Local / Black Voice News)

The California Health Care Foundation (CHCF) described this as a “game changer.” 

IEHP recognizes the comprehensive care Healthcare in Action has provided since this initiative started, but acknowledged that with the quality level of care they deliver to homeless populations, it will take awhile to increase their enrollment numbers.

This Black Voice News project is supported by the USC Annenberg Center for Health Journalism, and is part of “Healing California,” a yearlong reporting Ethnic Media Collaborative venture with print, online and broadcast outlets across California.

Source: Black Voice News

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