In the nation’s most ambitious effort to address social needs, a $12 billion Medi-Cal initiative now provides services for the unhoused including stable housing navigation, rent deposit aid and street medicine.
At a virtual news briefing for ethnic media on May 2, a state Department of Health Care Services (DHCS) leader, a homelessness health care director and a community provider shared how they’re using Medi-Cal to help Californians experiencing and at risk of homelessness lead healthier lives.
New Medi-Cal programs for the unhoused
“When we’re talking about Medi-Cal transformation, we’re talking about bringing services to our unhoused members to meet them where they’re at in life,” said DHCS Homelessness and Housing Policy Advisor Glenn Tsang.
“Instead of asking them to navigate the bureaucracy of the clinic,” he added, “we go to them at the shelter, the street, the encampment, and you connect them to housing support and health care in two ways: Enhanced Care Management and Community Supports,” both launched in January 1, 2022.
California Department of Health Care Services Policy Advisor for Homelessness and Housing Glenn Tsang discusses his response to concerns about the cost of Medi-Cal’s expanded healthcare services.
Through Enhanced Care Management (ECM), unhoused or at-risk members are assigned a lead care provider who connects them to medical services at a local clinic as well as social services including transitional housing programs, and basic needs like clothing and food.
Community Supports (CS) “swim upstream to address the social factors driving adverse health,” Tsang explained. “If an unhoused member is constantly getting care in the ER, we treat the health conditions driving this. For instance, how can we reasonably expect an unhoused member with diabetes to store insulin if they don’t have a refrigerator or apartment? How can we help them well before, say, the amputation of a leg?”
Among the 14 CS programs under Medi-Cal are housing transition navigation services including housing search and application help; security deposit aid; tenancy sustaining services like landlord mediation; short-term post-hospitalization housing; recuperative care; day habilitation for social skills and daily activities like using public transit; and street medicine from trusted community providers now reimbursed under Medi-Cal plans.
“We’re seeing more and more states follow our preventative lead in recognizing that housing is an incredible determinant of one’s health,” Tsang said.
Among at least 19 states directing Medicaid funds into housing aid, for instance, Arizona is spending $550 million primarily to cover six months of rent for unhoused members. Oregon is spending over $1 billion on housing services including emergency rent aid, while Arkansas will spend $100 billion on housing aid.
In January 2024, Tennessee, West Virginia, Montana and New York received federal approval to follow suit.
“183,000 Californians are experiencing homelessness right now, and personally, I think that that number is underestimating the total, with so many people couch surfing or one family fight away from being unhoused,” Tsang added. “It’s crucial that we funnel our resources through the community workers providing care to those who most need it.”
Community housing support as health care
“What a community care worker can do through these new programs is break down barriers to the patient’s health,” said Amber Middleton, director of the HOPE Program addressing homelessness at Shasta Community Health Center (SCHC) in northern Shasta County.
Amber Middleton, director of HOPE Program, Shasta Community Health Center, discusses the challenges of expanding Medi-Cal services to California’s unhoused population, particularly those who have been harmed by or have reason to mistrust the system.
“We need to be soft on people and hard on systems that create housing and wage deficits,” she continued, “especially since most of us in the US are one medical emergency away from being at risk of being unsheltered … Our goal is to create access points in all areas where those needing care might be, rather than waiting for things to get so bad that they’re having to seek out services.”
These access points include a clinic at the local homeless shelter, a 20-bed medical respite program with personal case managers, six month short-term post-hospitalization housing, stable housing navigation and transition aid, deposit aid, tenancy support and a mobile street medicine program providing key needs like wheelchairs, medication and oxygen as well as basic needs like clothing and food.
SCHC also has a Consumer Advisory Board made up of individuals who are or have been unsheltered, meeting bimonthly “to give us feedback on our practices, and to do community outreach,” said Middleton. “Many members started in one of our programs, so the needs of the population we’re serving directly inform our care.”
“Because, understandably, not everyone is willing to accept our care right away, it’s crucial that our community health workers have related experience of homelessness, or come from the neighborhoods we serve, because that’s how they build trust,” said Brian Zunner-Keating, director of the UCLA Homeless Healthcare Collaborative, which has provided over 9000 clinical evaluations to nearly 5000 individuals on the streets of Los Angeles County since January 2022.
“For many people, the best we can do is say hello, give them a warm smile and offer them water, snacks and a hygiene kit for a few weeks if they’re not ready,” he explained. “After a few weeks of this, or after talking to their friends who received care, they might start to open up about their needs. Our team may make connections by talking in-language, or asking if they’re Dodgers fans, or asking for help — ‘This is my first time on this block, who’s in the neighborhood and what’s the typical day like here?’”
Brian Zunner-Keating, MS, RN and director of the UCLA Homeless Healthcare Collaborative, shares how his organization was able to bring an elderly man much-needed healthcare and get him off the streets.
“We get such a wide variety of patients,” Zunner-Keating said. “One elderly gentleman we served was living in an alley, could barely walk or see, he used a shopping cart to get around, his teeth were in such poor shape that he couldn’t chew, and he was panhandling to buy milk every day … While we provided him immediate care, we also got him insurance for advanced care. I’m happy to say that he now has glasses, a full set of dentures, a hip replacement, and is living in a shelter where he feels supported as he works on getting permanent housing.”
“Even providing more simple care can be life-changing,” he continued. “Another patient was very worried about how tired she felt all the time, so we talked to her to learn about what was going on in her life, got her simple blood tests and medications. Over the weeks, her mood and health improved, but a month later, she stopped contact for a few weeks — which is not untypical, as our folks tend to move around a lot.”
“When she did call us, we were so excited,” he said. “She told our team: ‘I just want to tell you how you saved my life, because my depression got the best of me and you showed such generosity and care and I will forever be thankful. She told us she had just gotten housing that day.”
“She didn’t have complex needs, just a few simple tests and medications,” he added. “But we usually can’t just walk up to somebody and say, ‘Do you need to see a doctor?’ What works so much better is to make a caring human connection, making sure that they feel seen and heard. That gives them the motivation to seek care.”
