This week, enforcement of San Diego’s new homeless encampment ban begins. The move is the latest in an ongoing slew of actions by cities attempting to address public safety.
A recent study in the Journal of the American Medical Association projected that sweeps force people away from essential services and are likely to lead to substantial increases in overdose deaths, hospitalizations and life-threatening infections. During COVID-19, street medicine emerged as the first line of defense for people without housing.
Though the origins of street medicine can be traced back decades, it has become more formalized in recent years. It entails delivering medical care to individuals experiencing homelessness or living in poverty, whether on the streets or in shelters. Such programs have been shown to provide significant cost savings and be a cost-effective way to improve health outcomes and reduce disparities in underserved populations.
Fierce Healthcare explored how different types of technology, such as mobile electronic health records (EHRs) and GPS trackers, are facilitating these efforts around the country.
Post-pandemic Medicaid redeterminations threaten care access
While there is little insight into how many unhoused people are insured nationally, data from the National Health Care for the Homeless Council suggests that among community health centers serving the population, two-thirds of patients are insured (PDF).
The end of the public health emergency kicked off Medicaid redeterminations. Though uninsured rates hit an all-time low at the top of the year, the Kaiser Family Foundation estimated in April that up to 24 million people could lose Medicaid coverage due to redeterminations.
“It’s not the patients that are difficult. The healthcare system is really not set up for them."—José Luis González, M.D., medical director at Healthcare in Action
People experiencing homelessness and Black and Latino people have historically been disproportionately impacted by the Medicaid churn. Though states must communicate with Medicaid beneficiaries about redetermination, coverage may be discontinued if the government does not have correct contact information.
Healthcare in Action (HIA), a nonprofit medical group focused on street medicine, operates in California, a state that accounts for more than half of all unsheltered people in the U.S. Medicaid redeterminations are underway in the state, and the vast majority of those HIA encounters on the street are eligible for insurance, executives said.
“It’s been keeping us up at night a little bit,” HIA’s medical director José Luis González, M.D., told Fierce Healthcare. Though HIA can work with plans to identify patients up for redetermination, the list that plans are working from are not exhaustive and complicate their efforts.
“It’s just another barrier. The default should be that they have insurance,” González said.
When an individual gets disenrolled, HIA will often still encounter them and give them treatment. But enrollment or activation can take months, especially if the patient has come from a different county or state. In the meantime, HIA takes losses on the services it provides.
“It’s a huge loss. That’s one of our biggest problems,” González said.
How technology is enabling street medicine efforts
Critics of street medicine have a number of concerns, including unavailability of EHRs and data tracking systems on the streets. But some companies are stepping in to fill that gap.
NextGen Healthcare, a cloud-based tech provider, claims to be the largest EHR vendor serving federally qualified health centers (FQHCs). Last month, the tech company agreed to pay $31 million to settle allegations that it violated the False Claims Act. NextGen said the settlement agreement does not include any admissions of wrongdoing.
Between care in the clinic and on the streets, “there’s all kinds of logistics that are involved with this that are somewhat specific,” NextGen’s chief medical officer Robert Murry, M.D., told Fierce Healthcare. Street medicine teams are typically multidisciplinary, consisting of clinicians, behavioral health or harm reduction specialists and social workers.
The NextGen Mobile app, connected to NextGen’s EHR, aims to make providers more efficient and help them close patient encounters faster. Street medicine teams can use the app to identify a person and verify their insurance status, Murry said. Visits can be documented verbally in the app, which will then flow into a patient’s medical record. Providers can also use the app to log photos of wounds and write electronic prescriptions.
NextGen’s EHR also integrates with medical devices and wearables, which care teams can track in the app. However, due to a lack of privacy, it’s uncommon for people experiencing homelessness to have such devices, Murry said.
HIA has firsthand experience with that hurdle. Initially giving patients without housing cell phones, the provider soon realized they were at risk of getting lost, stolen or sold. Keeping them charged was another challenge. So HIA switched to GPS trackers instead, with a battery large enough to last weeks or even months at a time. Through these trackers, HIA can stay connected to patients.
Neighborhood Health, a FQHC in Tennessee, sees about 1,500 patients annually. As a partner to several homeless missions, Neighborhood Health had clinics in those buildings that were forced to close during the pandemic.
“We could not stop providing those services, and that’s when the street medicine program was born,” Anthony Villanueva, chief information officer of Neighborhood, told Fierce Healthcare.
The clinic quickly realized “it just would not work to bring your traditional laptop,” Villanueva said. “We wanted to make everything as real time as possible.”
By leveraging NextGen Mobile, Neighborhood Health patients on the streets were able to have a fully documented visit and be on a traditional schedule in the EHR, without care teams coordinating with the brick-and-mortar clinic staff. “Without a product like NextGen Mobile, to get that to happen would take either pen and paper or phone calls,” Villanueva said.
HIA relies on health information exchanges and laptops with cellular connectivity to check medical records and record services outside the clinic. Its mobile vans also have hot spots.
The provider is also exploring using drones to deliver medications to shelters. “They often have difficulty going out to pharmacies for transportation reasons,” González said.
EHR vendor Epic has similar capabilities to NextGen. Its smartphone and tablet apps allow for providers to document health history, medications, care teams and other data. One street medicine program operated by Lehigh Valley Health Network leveraged these features and saw a reduction in ED usage. The features also reduced inpatient days by more than 80% and readmissions by nearly 70%, resulting in a $3.7 million increase to its bottom line in 2017, according to reporting by The Washington Post.
NextGen argues another benefit of a centralized digital system is data analytics, which providers can use to make an economic case to payers. According to Murry, it allows them to say, “We are keeping them out of the ER and here’s the ROI on that.” NextGen also has a nationwide community health collaborative, which offers data benchmarking, comparative analytics, reporting services and a forum for community health centers.
Street medicine is a powerful tool to meet patients where they are and ensure they don’t fall through the cracks of the U.S. healthcare system, González said.
“It’s not the patients that are difficult. The healthcare system is really not set up for them,” González said. For instance, patients without housing and transportation cannot access their medicine.
“It’s not an unsolvable problem,” González said. “It’s an unsolvable problem in the current system.”