Health for the homeless along the river: 4 years in, street medicine reflects

Aug. 26—As they slowly back onto the parking lot, you can hear the groans in the axles of Dr. Matthew Beare's Honda Element. Years of climbing onto sidewalks, off-roading along riverbeds and combing underpasses have taken their toll.

But it's part of the philosophy that Beare, a physician at Clinica Sierra Vista, has adopted to bring on-the-spot medical care to homeless people in Bakersfield, at no cost to the patient.

"Instead of asking patients to step out of their world and into ours, we step out of our comfort of our world and into theirs," Beare said.

He leads a six-person street medicine team that has since 2019 brought direct care to the 100 or so patients living along the Kern River bed. Every Thursday, after a supply stop at the county shelter, the crew rides to the riverside.

Street medicine crews see an average of 12 to 15 patients every Thursday, though Beare said that can jump to 30 on a busy day. Treatment includes almost everything you would see in a clinic — HIV, high blood pressure, diabetes — as well as wound care, particularly incisions and draining abscesses, and medication provided on the spot. Previously reliant on grants, Beare said the program is now billed through Medi-Cal, which makes it "self-sufficient."

This morning, with the gates locked, the crew switched back and entered through the north side of the river, along a route they call Tammy's Pass.

It's near the Rosedale Inn, which sits in the evening shadow of the 24th Street overpass that crosses Golden State Highway. A turn onto an access road nearby takes the two vehicles onto an undulating dirt path with puddles from the recent tropical storm.

On either side is a field, charred black and barren from a recent fire, and the Kern River, swollen from recent rains and a record snowpack from the Sierra Nevada.

Tammy's Pass

The first camp they spot explains the pass's name. Tammy's camp, positioned at the trailhead, consists of a reclining chair, a shelf and random furniture, all of which were covered with plastic-wrapped goods and a tarp.

Several hundred feet away, Beare points to a spot where he and his team came upon a woman being eaten alive by a pack of pit bulls. "That was a terrifying moment," he recalled. They had to carry the woman, her extremities ripped apart, with a tarp to an ambulance by the entrance.

Forming a canopy over the camp are two overgrown fig trees that form a cove over a camping chair. With Tammy still asleep in her tent, the crew continues along the dirt clearing past the bridge.

About a dozen people, and another dozen dogs — some leashed, some not — are waiting. Many of their health problems stem from the elbows or knees down — swollen tissue, bumps or dog bites that slowly worsen due to infection.

"We used to have to drive along the river and stop at each encampment," Beare said. "But now, we've been coming out for so long that the patients congregate. They know where we're going to be."

Staff members make their rounds, handing out lunch, harm reduction kits, Narcan and clean needles. Coffee is self-served at a table set up by Kern Medical Supply. One team member takes blood pressure readings, while another — a medical student — bandages an open wound on a man's foot.

Beare rotates from patient to patient, prescribing medicine and performing checkups. By this point, he's acknowledged by most on a first-name basis and can recognize his patients from a distance.

One woman, Christine, showed some scratches on her arm, complaining of an itch. In the two years she's been in Kern, Christine has relished the street team's Thursday visits.

"I really like it. I think it's awesome that they do this," she said. "Where I used to live before, in Phoenix, they didn't have other people doing this."

Medi-Cal, reimagined

Like many of the state's homeless, Christine has Medi-Cal. But without transportation, she can't get to a clinic for exams.

Beare explains that when they started this program, the teams used to have to go from site to site, asking to provide care to people.

Encumbered by higher rates of addiction, mental health disorders and illness, homeless individuals are among the state's neediest patients.

While 60% of the state's homeless, according to the California Health Care Foundation, are registered through Medi-Cal, only a third, according to a 2021 analysis by the California Legislature, have ever seen a primary care provider.

One of the few ways they can efficiently administer psychoactive medicine is through a recently adopted long-acting injectable. Beyond that, little can be offered in the way of psychiatry. When they first started, the team brought along specialists. They quickly realized it didn't work.

"We try to see as many people as we can in a day," Beare said. "So our interactions might be a few minutes, and while they're meaningful and heartfelt interactions, they're still pretty rapid. And a behavioral health intervention could be talking for an hour just to get a baseline."

This population, unsheltered yet insured, must go without unless they can connect with one of Kern's teams. This drives up the number of visits to emergency rooms.

A big change, Beare said, has been funding from the new California Advancing and Innovating Medi-Cal, or CalAIM program, an expansion of Medi-Cal funding that, since June, has made the team self-sufficient. Previously, the clinic paid out of pocket or relied on grants to help fund its efforts, often resulting in supply shortages.

"It gives us a degree of sustainability," Beare said. "It's the single biggest game changer you have seen and will continue to see as street medicine teams."

Signs of those are apparent in California and across the nation. According to the CHCF, only 24 teams existed as of 2022.

"I just talked to someone and they said it's closer to 49 teams in California, which is crazy," Beare said. "I remember when there were only 200 teams in the world — like in Calcutta, in London, everywhere. And now there's 49 in California."

Nationwide, street medicine teams are active in more than 60 American cities.

Beare believes teams like his will reduce emergency room visits and readmissions that bog the state's Medi-Cal budget. According to the California Department of Health Care Services, more than half of the state's $133 billion Medi-Cal budget is reserved for the top 5% of users.

"It also builds a rapport between the medical community and people experiencing homelessness," Beare said. "It's undoing a lot of damage done over the years."

The next generation of medicine

It has also attracted the next generation of medical students who want to shed the formalities of a clinic setting.