In the face of unusually hot weather in San Francisco, I stood there that spring morning sweating through my work pants, dress shoes and collared shirt along with the rest of the passengers on the crowded, downtown-bound Muni train. But I didn't mind — this was an unusual workday for me.
As part of a clinical rotation focused on underserved medicine at the medical center where I train as resident physician, I was assigned to temporarily play a unique medical role that, less than a decade ago, didn't even exist.
I was assigned to help look for Mr. Johnson.
Mr. Johnson (not his real name) is a 62-year-old homeless black veteran with untreated HIV, uncontrolled diabetes, active alcoholism and crippling post-traumatic stress disorder from his time serving in the Vietnam War. With a penchant for missed clinic appointments and a proclivity to visit the emergency room for all medical needs, Mr. Johnson's poorly coordinated care and misappropriated use of health care resources was acknowledged by an innovative community-outreach committee based out of the San Francisco Veterans Affairs Downtown Clinic as something needing urgent change.
Using funds from a national multibillion-dollar investment in patient-centered primary care for veterans, Dr. Amy Noack, medical director of the Downtown Clinic, and her five-member interdisciplinary team serve the homeless veteran community of San Francisco. They do so by recognizing the needs of high-risk patients and going directly into the streets to provide them with individually tailored care.
This highly coordinated effort has one main goal: improve medical access and social support for the homeless veterans of San Francisco.
And it seems to be working.
According to a recent monthly report of the national Homeless Patient Aligned Care Team (H-PACT) model, which includes Noack's efforts, there has been a 22 percent decrease of emergency department visits and a 28 percent decrease in hospitalizations of enrolled homeless veterans in just a six-month period. With the average cost of an emergency room visit at about $1,300 and mean hospitalization costs at $11,000 per patient, the ability to reinvest these substantial cost savings in social support and primary care of our nation's homeless vets could prove to be a game-changer in the way we deliver underserved health care.
How has such a small team of professionals with limited resources managed to improve care coordination and circuitously bend the cost curve of these high medical utilizers in such as short period of time?
It all starts with people like Charlene Phipps.
For the past year, Charlene has been working as a social worker for the Downtown Clinic's H-PACT program, the same team working with Noack to serve the homeless veterans of San Francisco. Working with a caseload of up to a few dozen homeless veterans with serious untreated physical and mental conditions, she spends much of her days coordinating with jails, emergency rooms and shelters in order to get her patients housed and cared for.
The rest of her time is spent on the streets, seeking high-risk homeless veterans in need of basic medical and psychosocial support with the goal of reconnecting them to primary medical services and housing resources.
Mr. Johnson happened to be one of those high-risk veterans.
I met Charlene at the clinic that Tuesday morning without any idea of our intended game plan. How does one find a wandering homeless man in a city of almost 1 million people?
Charlene didn't appear the least bit concerned. After all, this is what she does for a living.
She grabbed the keys to the dumpy clinic car and motioned me to follow. And just like that, we were on our way in search for Mr. Johnson.
I couldn't help but ask where our first stop would be.
“The Tenderloin, of course,” she replied.
The Tenderloin is a 50-block neighborhood in downtown San Francisco. Historically known for its famous jazz clubs and for being one of the first gay-friendly neighborhoods in America, the area is now infamous for it's high rates of poverty and crime. Tucked neatly between the theater, shopping and political districts of downtown, one can see America's vast socio-economic disparity simply by driving a matter of blocks.
As I sat quietly processing the mass of homeless people seen sprawled among several blocks of one of the most innovative and socially conscious cities in America, Charlene speculated out loud on the exact location of Mr. Johnson.
“Our first stop should be near the Glide Memorial Church, where they serve free meals to the homeless,” she said. “I hear that he goes there sometimes. You know, they have been serving the homeless three free meals every day for years now. Breakfast, lunch and dinner. Many of our homeless population are dependent on such programs to stay fed.”
She continued to point out the various landmarks of the Tenderloin, including shelters and hotels with single-room-occupancy hotels where many underserved San Franciscans find temporary and permanent housing.
Completely enthralled with the on-the-fly lectures on social welfare, I was surprised when Charlene, in the midst of describing the painstaking process of acquiring housing for the homeless, parked the car.
“OK, let's begin the search. You can put your work bag in the trunk.”
Begin the search? I silently protested. Have we not been searching in the safety of our car all along?
My wallet and smartphone felt heavy in my front pockets as we began our foot patrol in a neighborhood known for the highest rates of violence and drug activity in San Francisco. Racial and socio-economic stereotypes flooded my mind, a mix of shame and fear distracting me from purpose. I felt like a perfect target for any and every criminal offense.
Charlene, on the other hand, might have been window shopping for domestic goods.
She sauntered along, stopping at various corners and stores to ask about Mr. Johnson's whereabouts. Often she would tap unconscious- appearing individuals sprawled out in the middle of the sidewalks to ensure that they were not in immediate danger. Other times, she offhandedly asked the identity of men that fit Mr. Johnson's profile.
“Hey, are you Mr. Johnson? No? OK have a good day.”
Some people knew of Mr. Johnson and pointed to the direction they had last seen him. Others suggested various shelters and food dispensaries that were often frequented by the homeless in that area.
Conversations were ended in civil pleasantries.
“Stay out of the hot weather.”
“God bless you.”
I was only in the beginning stages of processing my naivete when Charlene nonchalantly announced:
A block ahead, a disheveled- appearing older man sat on a flipped-over red shipping crate along the shaded side of the sidewalk.
Despite the rising heat that late morning, Mr. Johnson was clothed in several layers of tattered materials. A few plastic bags strewn around his person contained all of his belongings.
He turned his head slightly to the direction of Charlene's calls and gave a slight nod in acknowledgment before re-establishing his vacant gaze to the middle of the road.
“Hey, Mr. Johnson,” Charlene said. “We've missed you at the clinic.”
Small-talk ensued between patient and provider. The appointment was in session.
No blood tests were drawn that day. No stethoscope required. Diagnosis and therapy was purely in the form of words: encouragement, education and reassurance.
By the end of the brief intervention, Mr. Johnson seemed to better understand that housing was not simply an attempt for authorities to control him and that his HIV wasn't simply an exposure, but a chronic infection with serious consequences.
He did not want to come into clinic that day but wouldn't mind if we checked on him again and told us where to find him.
He thanked us for the visit.
It has been a few months now since finding Mr. Johnson. Since that time, he has continued to connect with the VA system and is currently getting regular psychiatric treatment and HIV care along with financial assistance for housing.
The heat has died down and I'm back at my own office, caring for underserved patients in my safety-net clinic. Fortunately, most of my patient panel is housed and seen at the clinic with some regularity.
But I can't help looking through the list of my patients for the names I only partially recognize. The ones with missed appointments and with no documented address or telephone number. Have these patients simply switched providers? Did they find stable housing and food access? Are they receiving the appropriate medical and mental services they require?
I doubted all this.
And suddenly, I missed Charlene.
Brian Secemsky is a resident physician in the Department of Internal Medicine at UC San Francisco. Follow him on Twitter at @BrianSecemskyMD and at briansecemskymd.com.