LOS ANGELES — On an unusually cold and rainy Los Angeles afternoon, physician assistant Robert Finch is crouched in front of a man living in a pedestrian tunnel. It’s the first time they’ve met, after a local nonprofit asked Finch and his colleagues on a street medicine team to check in on the man’s mental and physical health. A few minutes into their conversation, Finch offers the man a black handheld GPS tracker on a lanyard to wear around his neck.
With the offer comes reassurance: the tracker is completely optional, and solely so the health care team can check up on him periodically for routine visits or in case of medical emergency. Patients can press a button to send a pre-programmed, customizable message to the team, such as letting them know they’re OK, or requesting help as soon as possible.
The man accepts the free device, as do many of the unhoused patients the Healthcare in Action street medicine team visits each day, zig-zagging around Los Angeles in a white van stocked with common medicines, clean needles, and other supplies and outfitted with a small exam bench in the back.
For many Americans, even the mention of location trackers invokes fears of surveillance, or an invasion of privacy. But for hundreds of Los Angeles’ unhoused — people living largely off the grid, along freeway underpasses or shifting between temporary encampments — these trackers from a trusted local street medicine team offer a crucial lifeline to health care they feel they can’t get anywhere else. It’s a reflection of trust, and comfort that providers who know them will find them if they need wound care, suffer heart attacks, or move away from their usual dwelling, sometimes due to increased police presence.
“It’s reassuring that they use the trackers,” one patient, who introduced herself as Rockelle, told STAT. To her, it was a sign that the health care team — which had already helped her get needed medication and secure a place on a housing program waitlist — intended to come back to check on her. “We don’t have much trust with unfamiliar things, but I feel like if [they’re] patient enough to go out on a limb for us, we’ll see that it’s genuine,” she said.
Many unhoused patients can’t access, or sometimes avoid, traditional providers. Rockelle and other patients said they often face stigma from clinicians and even other patients when they seek health care. Many traditional clinics don’t take walk-ins, or connect unhoused patients to the social services that would help them get healthier. Taken together, the result is that people who are unhoused tend to get less preventive care, and visit emergency departments and hospitals only when their conditions escalate into a crisis.
“Getting a colonoscopy when you live outside is just not going to happen,” said Catherine Parsekian, a physician assistant at Healthcare in Action. It’s also difficult for patients who don’t have phones to keep track of appointments. “It’s really hard to have a good sense of time when you live outside,” she said. The team, which treats roughly 10 patients a day, makes sure to remind people they see of the current day and time when they visit.
Healthcare in Action is a division of the SCAN Group, an organization that also includes the nonprofit Medicare Advantage insurer SCAN Health Plan. The plan contracts with California Medi-Cal managed care organizations to cover Medi-Cal patients. A state program called California Advancing and Innovating Medi-Cal, known as CalAIM, provides some of Healthcare in Action’s operational revenue.
The street team’s directive is to offer spot physical and mental health care and also link patients up to primary care or services like housing assistance. If they’re successful, they keep unhoused Medi-Cal patients — many of whom are also seniors — out of the emergency room, driving down their costs, said Sachin Jain, chief executive officer of SCAN.
SCAN spent more than $10 million on Healthcare In Action in the past year — that budget largely comes from SCAN’s own investment and outside contributions — and has treated more than 1,000 patients so far. Fifty of those formerly unhoused patients now have housing, and 90% are currently in a database for housing placement. SCAN is now planning to expand the program from Los Angeles out to San Mateo.
“Investment in intensive primary care behavioral health could, I think, lead to lower overall health care costs that could be redistributed to actually get people into housing and other types of support,” Jain said.
Low-cost technology, like the GPS trackers or solar chargers to keep a person’s phone connected, helps the team fill the gaps as they work to respond to each patient’s needs. On the same day Finch gave a tracker to the man in the pedestrian tunnel, community worker Joana Salas spent about half an hour on the phone with a doctor’s office scheduling an appointment for a patient who was living in an RV and didn’t regularly use his cell phone. Later she coordinated transportation to and from a government office so he could pick up needed paperwork.
During one recent routine check-up, a patient who needed a blood draw later that day mentioned that her phone was dying — so the team gave her a solar charger, then waited near the encampment until her battery was full and they knew she could receive a call from her Lyft driver later that day. Finch performed a heart scan on another patient with heart failure and substance use disorder on the van’s exam bench using a portable ultrasound, and the image was displayed on an iPad.
Healthcare in Action started handing out the GPS trackers, which are sold by Cube, last year. They are especially useful for patients who aren’t likely to be in the same place from week to week, Finch said. Patients can upload a photo if they choose, and staff use an app to track their current location and where they’ve been, including if they leave a certain area. Patients who take the trackers tend to wear them around their necks or keep them in their pockets.
Location history can reveal useful medical information, too: A substance use disorder patient who begins to visit a certain area known to be a drug source might tip the team off that they need to check in more frequently, for instance.
Some patients, of course, don’t want to use the trackers for fear of surveillance — and the staff doesn’t insist if they’re not willing. Law enforcement has not asked SCAN for access to the data, and the team does not share it with outside parties, they told STAT.
“I always couch it in a conversation about privacy,” Finch said. “It’s simply a way for us to find you, to make sure you have access to the resources you need and quite frankly deserve…Some people jokingly compare it to an ankle bracelet, but they’ll accept it,” he said.
The staff also has access to a local database called the Homeless Management Information System, a state-mandated system that lets users look up when individual patients have received social services. That information helps the staff assess what social needs patients might have. And if they’ve gone missing, it can also give them a window into where they were last seen.
The key to building trust, even with technology, said Finch, is viewing care as “patient-led,” instead of “patient-centered”: Patients should determine what they need, and providers should listen. Sometimes, that means letting a heart failure patient decide whether he wants to seek follow-up care outside the van’s routine visits. Other times, it means not challenging a patient’s claims when they are experiencing delusions, but gently suggesting a medical check-up.
Rockelle said that the team has built trust simply by being willing to help with seemingly minor but overwhelming tasks, paying attention to individual needs, and visiting often.
She has seen other mobile medicine teams fall short, she said: One threw away food that was slightly past its expiration date, even though the patients they were helping said they desperately needed it. Another delivered on-the-spot medical care, but never helped coordinate future visits or even social programs like housing, which can be a prerequisite for other safety net programs. Rockelle said it’s a common misconception that people who are unhoused don’t want to jump through the hoops for affordable housing — rather, she said, the problem is that the sign-up process can be extremely confusing and convoluted.
More people face these challenges each year. Almost 70,000 people don’t have homes in Los Angeles County, per its census last year, with significant spikes in neighborhoods like Venice. And despite Mayor Karen Bass’ plan to address homelessness without relying on law enforcement to sweep encampments, some still live in fear of police, forcing them to move more frequently.
Not all of the team’s tech experiments have taken off. An idea for telehealth visits faltered when staff realized patients wouldn’t always have reliable access to WiFi, or even a place to take the call. SCAN also tried handing out phones to some patients who didn’t have them, but they were often lost or stolen or sold, according to Jain.
“It’s very easy for me and you to kind of sit at a white board and imagine solutions that might work, but there are real world barriers that don’t become clear until you try things,” he said.
It’s all intended to help patients who have been marginalized and excluded from traditional health care — either because of social stigma, or barriers like lack of phones or permanent addresses — to get healthier.
“We’re essentially home health, if you reframe your thinking,” Parsekian said. “The fact that we can come to them, and really try to do what we can in the moment and figure out what’s keeping them from going to a more traditional setting, and try to game plan that with them, is why I think street medicine exists.”
Correction: A previous version of this story misstated the relationship between Healthcare in Action and SCAN Health Plan.