Street Medicine is the delivery of individually tailored health and social services to people experiencing unsheltered homelessness (PEUH) in their own environment. Because Street Medicine has historically existed on the margins of the medical field – run as part time teams with volunteer staff - and because of that individually tailored approach, the field lacks universally recognized measures of success.

Due to the COVID-19 pandemic, participation in recommended routine screening declined across the country – in the first six months of the pandemic alone there were 10 million missed cancer screenings. As a result of this decline, individuals are not receiving appropriate early screening and diagnosis, resulting in an increase in cancer diagnoses at advanced stages of the disease. Delayed diagnosis is expected to lead to a higher cost of care, loss of productivity, and increased morbidity and mortality that would have been avoided with appropriate screening.

Whole Person Integrated Care (WPIC) is a section within SF DPH’s Ambulatory Care that brought together programs serving people experiencing homelessness (PEH)/transitioning out of homelessness to provide coordinated and integrated care. As part of WPIC’s development, our Urgent Care (UC) clinic integrated with Street Medicine’s Open Access clinic. Two-thirds of the patients are PEH, and the program addresses both urgent needs and transitional primary care for individuals who are unconnected to care and not getting their needs met elsewhere in the system.

Care coordination among patients with severe mental healtillnessesss has been a long-standing challenge. Patients seen in mental health clinics oftentimes have inadequate control of diabetes, hypertension, and dyslipidemia. In addition, more than 60% of this population also suffers from co-occurring substance use disorders. Without addressing these chronic medical problems, patients with poorly managed medical conditions often were lost to follow-up.

Background: Substance abuse by pregnant women is a public health crisis. In, 2019, the U.S. was in the grips of an epidemic, with >70,000 opioid drug overdoses. In 2020 ED visits for opioid abuse went up 45% and studies have estimated an almost 30% increase in opioid overdoses. This has resulted in an ever-increasing number of babies struggling with highly traumatic abstinence (NIDA).

The two largest patient groups in California are Kaiser members (9 million) and patients served by California’s FQHCs (7 million), but you could not find two more dissimilar health systems. Kaiser and nearly all other health systems organize their providers in medical groups; FQHCs are private non-profits that employ and support their providers independently. The separation between individual FQHCs results in inconsistent access and quality, an inability to retain talent and resources, and diminished voice in the broader health care system.

Chronic diseases (eg: heart disease, stroke, DM, kidney disease, cancer) account for 5 of the top 10 causes of death in our country. Obesity is a well-known risk factor for all these chronic diseases, and we have almost 40% of US adults and 20% of children obese in the US, and the COVID pandemic has only worsened these trends. We currently have outstanding innovations in the field of medicine that focus on medications, delivery methods, and surgeries, yet our communities continue to struggle with chronic disease management and increasing rates of obesity.

Rather than seeing COVID-19 as an insurmountable obstacle, I, along with my team at Community Health Centers of the Central Coast (CHCCC), Inc., viewed it as an opportunity to accelerate the pace of innovation. To better meet the needs of the community, the CHC Behavioral Health and Psychiatry Departments are committed to moving beyond brick-and-mortar clinics to a ‘click and mortar’ clinic in the sky, the Cielo Center for Integrated Health. Like many health centers CHCCC quickly shifted to virtual care not long after the pandemic emerged.

“Lost to follow up” is a too-common refrain in the ambulatory healthcare setting and is particularly problematic in primary care, whose focus and value lie in an ongoing, longitudinal relationship with the patient. Academic primary care practices often care for socially or medically complex patients and may lose 25-45% of patients to follow-up. Patients, PCP teams, and the system are all impacted differently by this challenge. Patients can experience a decline in their health status and poor outcomes if they cannot access care in ways and at times that are convenient for them.

In 2020, there were 700 overdose deaths in San Francisco, which was more than double the number of COVID deaths. Though the proximal cause of death is Fentanyl, 60% of those who died were using methamphetamines, which means that many of those deaths may have been prevented by targeting stimulant use. UCSF Citywide serves nearly 2000 people annually with serious mental illness (SMI), homelessness, and institutionalization (long-term locked psychiatric hospitalization and incarceration).