Kyle Russ

At a clinic in Oakland, patients who once lived on the streets are helping to improve care for the unsheltered

By Xenia Shih Bion | CHCF

It’s just after noon on the third Wednesday of the month, and at the Trust Health Center in downtown Oakland, California, patients are sharing pizza around a conference table. Meet the Trust Partners, the clinic’s patient-based board of advisers. The role of the eight-member board is to provide patient feedback to assure that the clinic stays meaningfully connected to the community it serves.

One of the partners, William Terry, tells the group about the years he was homeless, living in a run-down minivan. The unregistered van was such a wreck that whenever he moved it for street cleaning, it left a trail of oil. In eight and a half years, he never got a ticket. “I should be in the Guinness Book of Records,” he said with a laugh.

Terry can reflect with humor on his time living on the streets because now he has an apartment, thanks largely to the Trust Health Center. This Federally Qualified Health Center (FQHC), which is operated by LifeLong Medical Care, opened in November 2015 to serve adult residents of Alameda County who have no home or who are at risk of losing their home. LifeLong provides primary care services, mental health care, and social services support.

Lifelong has a separate governing board overseeing the entire organization that meets the Health Resources & Services Administration’s requirement that the majority of a health center’s board must be its own patients. By law, patients must hold a majority on Lifelong’s governing board. Trust Partners offers an additional way to obtain specialized input from patients who have lived on the streets.

Paida Ndemera, who manages the Trust Health Center, said it provides care for approximately 2,000 patients each year. Due to the unstable circumstances and schedules of those who are homeless, she estimates that fewer than 1,000 of them are actively engaged, meaning they visit the clinic at least three times in a 12-month period.

The nearby nonprofit Homeless Action Center, which offers free legal assistance to people who are homeless, often refers clients to the clinic. “They’re just a block away,” Ndemera said. “You don’t even need to cross the road.” And yet, because of the complex circumstances of their lives, many of its clients never make it there.

The Trust Partners helped the Homeless Action Center staff understand this challenge by explaining that public spaces can be intimidating and unwelcoming for people who are experiencing homelessness. “When I would go to Alta Bates . . . we would go to a small waiting room, and I would be smelling really bad,” Terry recalled. “And the people in the waiting room, they’re not in my situation, so I would stick out like a sore thumb. So that made it hard to go there. . . . You deal with so much disrespect from the public.”

For people who are homeless, many of whom have had negative health care experiences, it can be hard to trust providers or care delivery systems.

The clinic is a welcoming and caring environment, but for people who are homeless, many of whom have had negative health care experiences, it can be hard to trust providers or care delivery systems. To help would-be clinic patients overcome these barriers, the Trust Partners arranged for someone to go to the Homeless Action Center and accompany clients to the clinic. They know that even a two-minute walk can feel much safer when you are with someone who has had a similar experience and helps ensure you won’t be judged or disrespected.

In Clinic We Trust

Since the beginning, the goal of the Trust Health Center is to be “an intentionally created community where people without their own safe space feel welcomed and accepted.” Its founders knew that patients’ perspectives had to be baked into the clinic’s decisionmaking process and the design of its services. They credit the Center for Care Innovations (a CHCF grantee) for helping them launch Trust Partners as a key part of their patient-engagement strategy.

Isobel Harvey, RN, MSN, was the center manager when the clinic opened, and she worked closely with CCI to develop the Trust Partners. “We were serving a group of people who are some of the most marginalized in our society and very frequently don’t have a voice, don’t have control over their own lives,” she said. “What you think people need or want, versus what they say — there’s always something to learn from your patients.”

It’s very enlightening speaking to them and hearing what really is going on in the clinic.

—Trust Health Center Manager Paida Ndemera

Ndemera succeeded Harvey in 2017, and she attends Trust Partners meetings to listen to their feedback and opinions on proposed changes to the clinic. The meetings are “a space where they feel comfortable talking about anything and everything,” Ndemera said. “It’s very enlightening speaking to them and hearing what really is going on in the clinic.”

Occasionally patients come into the clinic and act aggressively, threatening other patients or staff. The staff contemplated adding security, but some clinic workers worried that having a security guard would make the clinic feel unwelcoming. According to Harvey, some staff felt that “if the clinic is really called Trust, then we need to trust our patients so that they can trust us.”

But when the Partners discussed it, they surprised Harvey by recommending the clinic hire a security guard to keep the peace in the lobby area. In addition to the guard, they posted ground rules at the entrance — including a reminder to treat other patients with respect. The security presence has decreased the number of fights in the waiting room, making it a calmer and safer space for patients who deal with instability on a daily basis.

The Trust Partners also informed the staff that the public restroom in the lobby area was being used for drug deals and drug use. Applying the principle of harm reduction, the clinic installed a sharps disposal container in the bathroom.

Taking It to the Street

The next project the partners plan to tackle is street outreach. Ndemera said 50% to 60% of the clinic’s new patients come through word-of-mouth referral, and the Trust Partners want to visit nearby encampments to educate residents about the clinic’s services. In effect, the Partners would serve as community health workers (CHWs), frontline workers whose experiences help them connect and build trust with the community they serve.

While people who are homeless might be skeptical of medical professionals, they often trust individuals like Jerry Smith, who first came to the clinic after five years on the streets. The clinic helped him get back on his feet, first tending to a leg wound he endured for three years and then providing him with housing assistance.

Smith is a Trust Partner, and he feels a responsibility to help people who are unsheltered get the physical and mental health care they need. When he was living on the streets, he and his best friend, James, did everything together — recycling cans and bottles, building shelters, looking for a place to wash their faces. After Smith went to the clinic, he tried to convince James to go too. He told James how welcoming Trust staff members were, how other patients wouldn’t stare, how the clinic’s services could help him get off the streets for good. “You have to come with me,” Smith begged.

James never made it off the streets. Smith heard from a friend that James took his own life.

“Things could have changed,” Smith said. “Now it makes me want to go and try harder to get people’s attention.”

Original Article

By Nina Bai | UCSF

It was a cold and rainy day when the doctor found Alvin on the streets of Oakland, months out of jail, off his psychiatric medications and considering taking his own life.

“I was at my wit’s end. I was tired of getting high. I was tired of not being on my medication, not being normal,” he said.

Alvin had become a dark statistic: one of nearly 3,000 people living unsheltered in Oakland and one of the 45 percent who report problems with psychiatric or emotional conditions.

When psychiatrist Aislinn Bird, MD, MPH, and her street medicine team discovered Alvin on that gloomy day, he also became another statistic: one of the 14 percent of homeless in San Francisco and Alameda counties who receive mental health services.

Bird is the staff psychiatrist at the LifeLong Medical TRUST Clinic, which provides physical and mental health care for the homeless in downtown Oakland, and the founder of the StreetHealth program, part of Alameda County Health Care for the Homeless. Every weekday morning, a team of doctors and social workers visit homeless encampments, handing out basic necessities like clean socks and granola bars, but also medications to treat depression, anxiety and nightmares from post-traumatic stress disorder. People aren’t always receptive, but the team comes every day offering help, hoping to build enough trust that people will visit the clinic for care.

“The StreetHealth Team came through and it was a match made in heaven,” Alvin said of his first contact with Bird. “They saved me and I did the best I could to go into the clinic.”

Bird and the TRUST Clinic are one example of public psychiatry services. The homeless population living on the streets in the Bay Area are the most visible of public psychiatry needs ­– but also just the tip of the iceberg.

“Public psychiatry is the mental health care in the safety net,” said Christina Mangurian, MD, MAS, who co-founded and co-directs the UC San Francisco Public Psychiatry Fellowship at Zuckerberg San Francisco General Hospital. “So think about it as the system where people who are uninsured or have public insurance, like Medicaid, can get psychiatric treatment.”

While Bird, who is an alum of the UCSF fellowship, and others are working daily to serve the psychiatric needs of the underserved, nationwide there is a growing demand for these types of services.

Increasing Need for Mental Health Professionals

There is increasing recognition that mental health care can be key to improving overall health outcomes and may be a doorway through which someone can then access the help they need.

“This is happening everywhere,” Mangurian said of the increasing attention being paid to the need to address mental health issues. But she notes inequities in access to care. “As treatment for mental illness gradually becomes less stigmatized, people with means can find care in the private sector. But for those without means, especially the poor and marginalized, the public sector needs to expand to provide the care needed by this population.”

One problem is that there are fewer psychiatrists available to care for the most vulnerable. Forty percent of psychiatrists now work in private practices that accept only cash. The rest – the number of psychiatrists working with public sector and insured populations – has declined 10 percent from 2003-2013, according to a report by the National Council Medical Director Institute.

[F]or those without means, especially the poor and marginalized, the public sector needs to expand to provide the care needed by this population.

CHRISTINA MANGURIAN, MD, MASUCSF professor of psychiatry

Reasons for the decline include low rates of reimbursement, burdensome requirements for documentation, restrictions on sharing information that can better coordinate care, and high rates of burnout.

And, of course, there’s the pay – especially in areas with high costs of living, like the Bay Area.

“So why does a psychiatrist choose to go to work in the public sector when they could work somewhere else for $50,000 or $100,000 more a year?” Mangurian said. “They do it because they find meaning in this work and because they are dedicated to social justice and equal care for all populations.”

The Road to Public Psychiatry

Bird calls her work at the TRUST Clinic and with the StreetHealth team her “dream job.”

Her road to public psychiatry started across the Bay from Oakland, in East Palo Alto, where she worked as an elementary school teacher out of college. There she saw her young students struggle with dental problems, obesity, severe allergies and other consequences of having poor access to health care. She decided to go to medical school to provide hands-on care, thinking she might become a family doctor.

It was during her psychiatry rotations at the VA in Long Beach, working with people with serious and persistent mental illness, that she saw how for this population, a psychiatrist often serves as someone’s main doctor and their advocate. She also saw that many of the obstacles to mental health care were systemic, from poverty to the lack of integrated care in hospitals.

“Unfortunately in medicine and in society, there’s a lot of stigma and judgement of folks who have behavioral health symptoms. So I got to see the psychiatrist really make sure that their patients got the care that they needed in other medical fields, but also linking them with case management and helping with housing. I really liked that broad spectrum that you can do as a psychiatrist,” she said.

Her interests led her to the one-year UCSF fellowship program, from which she graduated in 2017. During the program, fellows are placed at clinical sites where they get hands-on experience working with underserved populations such as the homeless or children in foster care. Bird was assigned to the TRUST Clinic, where she landed a job after her fellowship.

In her three years at the clinic, she co-created the StreetHealth team and has worked to increase awareness of PTSD among the homeless in Oakland. Like any psychiatrist, Bird has patients who sometimes don’t show up for their appointments. But for her patients, many of whom are homeless, the missed appointments are due to tents flooding in the rain, the lack of phones or emails to receive reminders, or a visceral fear of stepping inside a building after a lifetime of living on the streets.

The most common condition she sees in her patients is PTSD. Mental illness is not the main reason most people become homeless – it’s lack of affordable housing – but the daily traumas of living on the streets certainly exacerbate behavioral issues.

For some, coming into the clinic is the first step to turning things around. A few days after Bird met Alvin on the streets, she was excited to see him in the clinic’s waiting room. Now she sees him regularly, he’s back on his medications and has moved into a shelter.

Another of Bird’s patients, who goes by Pastor Preston, had been living outside in downtown Oakland for several years, sometimes just a few blocks from the clinic. A veteran, an ordained minister, and now 62, Pastor Preston has long dealt with depression and PTSD.

“If you’re depressed and you don’t know what’s going to happen, say even an hour from now, it can bother you,” he said.

It was the StreetHealth team that finally convinced him to get help. They connected him with a program to get free dentures and his new set of teeth gave him enough “super self-esteem” that he was finally able to walk into the clinic. Now he comes to the clinic several days a week for psychiatric care, primary care, therapy sessions and even haircuts.

He also was able to find housing.

Now he tells people he sees suffering on the streets to give the clinic a try, even if they just come in to use the free showers.

Looking at the Big Picture

Treating PTSD in patients is important – but so is recognizing that it is an issue in the first place.

When Bird was a fellow at the clinic, she saw a lot of trauma among her patients, but there was no systematic screening for PTSD for the homeless population. Screening was mostly focused on depression. She went on to implement a screening process for PTSD, which has helped target care and monitor progress.

This type of bigger-picture thinking is a vital part of what the UCSF Public Psychiatry Fellowship teaches.

“We really try to give the fellows the tools that they need to start looking at things at a population health level. I ask them to start by using their clinical experience to identify problems in our system, and then look at available data as a scientist to quantify the extent of the problem and identify particularly vulnerable subgroups. By examining the data closely, they can really start building services that target needs of particularly vulnerable groups,” Mangurian said. “What really sets us apart from any of the other public psychiatry fellowships in the country is a strong research component.”

The big-picture thinking has enabled many of the 25 alumni to go on to leadership positions across the Bay Area and the nation.

“You learn the logic behind the system and its flaws; you also learn that systems are constructed, which means that you can have a hand in changing it. The fellowship teaches you that you can change it,” said Fumi Mitsuishi, MD, MS, who was in the first class of the UCSF fellowship in 2011.

She is now the director of Citywide Case Management, a division of UCSF’s Department of Psychiatry that contracts with the San Francisco Department of Public Health and other agencies to provide outpatient care for some 1,200 people with serious mental illness in the city.

People and Process

Many of the UCSF program fellows say they were attracted to psychiatry because it’s one of the few fields of medicine that still allows clinicians to really get to know their patients. They chose public psychiatry because they want to help the underserved and want to make impactful, structural change.

Public psychiatry means meeting people where they are, literally and figuratively. No doubt, the work is not easy.

“It is hard on my heart,” said Bird. “It’s hard to go home to my warm house knowing so many of the patients I care about are out on the street when it’s cold and rainy and they don’t have anyone.”

She and many of the public psychiatry fellows say they are driven to do this challenging work by the belief that health care, including mental health care, is everybody’s right.

“Everyone has somebody they love or care about who suffers from mental illness,” Mangurian said. “And since at UCSF we’re focused on health equity, the question then becomes how can we build a system that delivers high-quality mental health care to not just those who we know, but everyone, especially those who are the most vulnerable.”

Original Article