Why mobile medicine needs clinician, peer navigator teamwork

Transcript - Why mobile medicine needs clinician, peer navigator teamwork

Benjamin Kaska:            The peer navigator is the soul of the program. It provides a degree of authenticity that, without a peer navigator, is really challenging to conjure.

Eric Barrera:                  I was in a similar situation of most of our patients, believing that I was probably going to die homeless and addicted. The person who helped me that really changed my life.

Sara Heath:                   Hello and welcome to Healthcare Strategies. I'm Sara Heath, an executive editor with Xtelligent Healthcare Media and the lead editor on our patient engagement website. We're here to talk today about street medicine and how healthcare providers partner with community health workers or peer navigators to meet unhoused patients where they're at in the community. California is facing a mounting housing and homelessness problem, with the latest numbers from the Public Policy Institute of California estimating around 187,000 people being unhoused in the state.

                                    Among other challenges, high rates of homelessness pose a serious public health threat. According to the CDC, unhoused people are at higher risk for infectious and non-infectious illnesses including mental illness, substance use disorder and heart disease. But unlike patients who do have stable housing, unhoused populations are particularly hard to reach, making it difficult to move the needle on health outcomes. At Healthcare in Action, a part of Scan Group's family of companies, healthcare providers and community health workers, called peer navigators, work together to deliver street medicine and move patients to a more stable health status.

                                    Here to talk with us about HIA's mission and work, and particularly how clinicians and peer navigators work in tandem, are Ben Kaska, a PA who serves as the organization's VP of Partnerships and Development, and Eric Barrera, one of the organization's lead peer navigators. Thanks for joining us today guys.

Kaska:                           Thank you so much for having us.

Heath:                          So if we could maybe start kind of high level hearing a little bit about the role that HIA plays in your community, and then if you guys could kind of move into talking a little bit how you each got started working with the organization.

Kaska:                           Absolutely. Thank you. So my name is Benjamin Kaska and I'm a physician assistant and I'm the VP of partnerships and development for Healthcare in Action. And Healthcare in Action is a street-based, mobile, primary care organization that braids three services together: enhanced care management, housing navigation and clinical medical care. We were founded in 2021 and we are in six counties: San Mateo, Los Angeles, Orange County, San Diego, Riverside County and San Bernardino County. We have 20 established street medicine teams and 19 fully equipped street medicine vans. So, think of a Ford Transit van or a Sprinter van that has been converted into a mobile doctor's office and it has point of care testing, HIV, hepatitis C, CBC, A1C.

                                    All the point of care testing that we can get our hands on, it has. As well as point of care ultrasound device, point of care EKG device. We also have medications that we can dispense from the van itself. We do not carry any controlled substances. On the van, we typically have a physician assistant and a clinical support partner that's either a nurse or an MA or an EMT or an LVN and a peer navigator, which is a lead care manager for the person that we are serving, for the person experiencing homelessness. Historically, we've served over 8,000 patients and in 2024 alone we served 6,400 patients. Most of the patients that we serve have longitudinal follow-up and we become the primary care provider for these patients.

                                    We work with managed care plans to ensure that the person is able to utilize [the] full scope all of their medical services, while also braiding in the enhanced care management and the housing navigation to fully embrace the patient and move their care forward towards ultimately permanent housing. So that is what Healthcare in Action does in the community. We also do some other things as well. We do outreach and engagement, so our staff, our peer navigators and our clinicians go out to encampments to where people are experiencing homelessness and outreach and engage them into our services.

                                    We also offer contracts with hospitals where we provide a 30-day post-acute care medical service for folks specifically experiencing homelessness with really acute medical conditions to ensure that they are bridged and have successful follow-up and don't bounce back to the emergency room unnecessarily. So that's Healthcare in Action in a nutshell. And the way that I got involved in Healthcare in Action is I first volunteered at a federal qualified health center, a brick and mortar when I was in college and I learned about becoming a PA. I became a PA, went to the USC PA school, and then I came back and I was hired by that same FQHC, federally qualified healthcare center, that I volunteered with when I was in college.

                                    I served nine years seeing patients at that FQHC. And while serving the patients in my 15- to 30-minute visits, I had quite a few patients that were unhoused. And I always felt that if I could just see where they lived, where they were putting their head at night, what they did during the day, I could tailor my care in a much more effective way to service their needs comprehensively. But because I was only getting a snapshot of them when they came in, I felt like I was fighting with my hands tied behind my back. So I was first introduced to street medicine while working at that FQHC, they started a street medicine opportunity, which I staffed and I loved it.

                                    I then got recruited to join Healthcare in Action, and that's when I really was able to embrace the street medicine approach and be able to see finally the patients where they are on the street with peer navigators like Eric Barrera here, who are just excellent and be able to provide that loving, comprehensive service to the patients who are our most vulnerable, who have an incredible amount of access challenges getting into a brick and mortar facility. I worked at an FQHC, I worked at brick and mortar. I think they're wonderful.

                                    I think we did an amazing job and I think there's a patient population that has a tremendous difficulty getting in and utilizing our more traditional service opportunities, and I think Healthcare in Action provides that other opportunity for a very at-risk subset of the population.

Barrera:                        All right. My name's Eric Barrera. I'm a lead peer navigator here at Healthcare in Action, and I've worked in this field for about 11 years. And most agencies tend to focus on a single area of service, either mental health, just medical, just homelessness or just substance use treatment. And I loved the idea of coming on board with Healthcare in Action because they really stand out. They support all of those areas and they have specialists in each one of those areas. We're really bringing healthcare and social services together in one place. How I got involved with HIA, it's kind of a long story. I'll give you the shorter version.

                                    I was at one time in the same situation as our patients. I had been homeless. I was battling a nasty addiction for about six years, and I thought I would die homeless and addicted out there. And I finally decided to ask for help. I went to a program, I think I was there about nine months. I had nine months of sobriety. When someone asked me if I'd like to volunteer to do this kind of work, do outreach, and I had already been through the system myself as far as trying to access shelters and treatment centers. And so that's how I got involved. I started volunteering with an outreach group and bringing people into the same program that I was in.

                                    I started seeing their lives change and before you knew it, I was employed full-time doing housing navigation for about seven and a half years, and I met a provider here at HIA. We started talking about each other's specialties and we really recognized how our strengths complemented each other. And so we came together and that's kind of what we all do here. We come together and ensure that everyone has access to the resources and the care that they need to improve their lives.

Heath:                          And I wanted to turn a little bit of attention to your role, Eric. I know that folks who work in kind of a peer navigator, community health worker, whatever kind of job title that you want to give it. You guys play a really critical role in being like the first point of contact for patients. So, I was wondering if you could talk a little bit more about what you do at HIA and some of what goes into being a peer navigator, both from an interpersonal standpoint or personal experience standpoint, and anything that you had to complete when you decided that this was a career that you wanted to pursue.

Barrera:                        Sure. Our peer navigators, they usually have some type of lived experience, either personally, or through loved ones, or just a deep passion for wanting to help people who have hit rock bottom. It takes people who really care about others to do this job because it could take you in all kinds of different directions. I was also in a similar situation as most of our patients having lost all hope, believing that I was probably going to die, homeless and addicted. And the person who helped me, he had never been homeless or he wasn't in recovery, but he cared. He cared deeply, and that really changed my life.

                                    The peer navigators, we do so many different tasks from just friendly check-ins, bringing our patients water, just trying to build rapport, to trying to schedule appointments and just help them access all the services that they need. And we act as a bridge between the patients and providers so that when the patient goes into these appointments, they don't feel intimidated or they feel heard and supported. Some of these are tough appointments, they can be tough intakes, and oftentimes if some of our patients go by themselves, they might get up and walk out in the middle of the intake.

                                    And so having someone there to support them is basically what we do and it really changes the outcomes. We try to help make sure that process goes smooth and the end result is really what the patient initially went there for.

Heath:                          I kind of want to grab onto a term that you used there, which was like building rapport. I wanted to hear a little bit about why it's so important, especially in mobile medicine, street medicine, why it's so important to build that rapport and have peer navigators on your team to make sure that you have that. What kind of goals are you guys looking to accomplish by having this multidisciplinary care team and all of that kind of stuff? And I'd love to hear both of your perspectives on this because I think having Ben and Eric speak to that will show us the full scope of what we're trying to accomplish.

Kaska:                           Absolutely. So, I love everything Eric said about the peer navigator and how important it is. From the perspective of a clinician seeing patients on the street, the peer navigator I've always said is the soul of the program. The program would be completely different without peer navigators. I view the peer navigator as the glue that holds the patient. It's the rapport building, it's the longitudinal care. It ensures a strong connection with the client. It provides a degree of authenticity that, without a peer navigator, is really challenging to conjure because authenticity, you either have it or you don't.

                                    And peer navigators are oftentimes the outreach and engagement arm of Healthcare in Action. And they go into encampments and they go into areas where homelessness exists and they bring patients in or clients in a really trauma-informed and loving way, in a way that they would want to have been spoken to. And I think that is really paramount to street medicine. In addition, the peer navigators handle a variety of patient needs, whether that's taking a patient to the lab, assisting the patient getting their medications, getting document ready, a driver's license, birth certificates, bench warrants cleared.

                                    The peer navigator is the utility player on the team that ensures that the rest of the care that the patient needs goes forward effectively and appropriately. And Eric mentioned it, taking patients to clinical appointments, specialty appointments where they may be turned away because our patients sometimes have had negative experiences in those other clinics and negative experiences in waiting rooms. So having this person to help be their buddy as they go through this process is vitally important to maintaining that longitudinal care and then specifically the multidisciplinary team and that rapport building.

                                    Without trust and without building rapport, the care continuum will just fall apart. One of the biggest problems we see in the brick and mortar clinic is patients following the instructions and the prescription or the care of the clinician. Following suit with the instructions is challenging to do even for a person who is housed. Much less it's extremely challenging for a person who's unhoused. And using the provider, the clinician, the peer navigator together ensures that we have a team that wraps around the individual and the importance in demonstrating that team-based approach is critical.

                                    From being able to ensure that the person has the right questions asked and customize tailored care for that individual as well as making sure that the medications and the treatment is followed through are vital to the success and ultimately the housing of the individual. For instance, some of the things that our team does is ensure that every single client that we interact with has a substance use screening done at intake, a behavioral health screening done at intake, and has a tailored clinical approach to exactly what they need done and it's patient led.

                                    This approach, this multidisciplinary approach, is leading to better overall outcomes and holistic care experiences for the patient.

Barrera:                        Building rapport, there's so many levels in that process because getting a patient to an appointment, it happens over several visits. We can go into a homeless encampment if, let's say, it's just one or two of us. The community members there, they can tell that we're not homeless and it's like going into their home. We've got to knock, announce ourselves, let them know that we're just here to see if there's anything we can provide, whether it's waters, snacks, and we start building that trust by just going in with something to offer versus going in and asking all kinds of questions.

                                    And so over time we visit them enough, we're able to start building that trust and do all those things that Ben had just mentioned.

Heath:                          I love you reminding myself and the audience that when you are visiting with these prospective patients, that you really are entering their home. And I think that's such an important reminder of what goes into some of this work, even just a reminder of the respect that's necessary. So, I really loved hearing about that. Moving on into... Go ahead, Ben.

Kaska:                           So, Sara, just one thing about that that I really love is that we definitely take the approach of we are going into your space and you are the driver of your care. We are here to help you by all means, but we are a guest in your space and we are happy to help customize the care that best fits you. These are the services that we offer, and we want to make sure that we get you to your end goal. If your end goal is permanent supportive housing, we want to get you there, which I really value.

                                    And then the other part is using trauma-informed language and using questionnaires that are specifically meant to ensure that we are not offensive to the folks that we are working with, I think is also really critical.

Heath:                          That's so huge. I know that I might be going a little bit off script here, Ben and Eric, I would love for you to chime in where you find applicable as well. If you could talk a little bit about how you guys come to some of that language and what either research went behind it, how you collaborate with peer navigators to come into agreement about how you speak with patients. I think that would be super insightful for our audience.

Kaska:                           Absolutely. I'll start, Eric, I really want you to drive it home because I think that you're the subject matter expert here. What I would start with is that we have this mantra, which is that we are here to serve, not to judge. So there's no moral reason. There's no personal flaw that caused someone to become homeless. The person is experiencing homelessness at that time. And the questions that we ask are really intended just to drive at the what are you experiencing at the moment and what can we do to improve that experience. If you're having trouble keeping track of your medications, if you need help getting identification, if you need help finding stable nutrition, if you're not safe where you are.

                                    The language we use is customized to our patient population. And one of the acronyms that we use, it was developed by the USC Street Medicine team and it's called HOUSED BEDS. And it is a questionnaire that goes through all the different parameters that someone on the street could be experiencing. From safety to shelter, to substance use, to what you eat, how much you get to drink of clean water and where you use the restroom. These are all things that might not be applicable to the housed population, but are 100% applicable to the unhoused population. And then one last thing to mention is we understand that we are the safety net, that there's not another organization that necessarily comes behind us to serve this patient population.

                                    So, we take our work incredibly seriously. And when you mention that we are going to the person's home, I think it's important to, we take an approach of there's no such thing as someone who is called "service resistant." I really rebuke that term. I think that we just haven't offered the appropriate service to the individual. So, I think we also take that approach of, if we see a patient and they say, "No, thanks." That's a no, thanks today, but that might not be the same answer tomorrow or the next day. So, we don't think in the terms of service resistant populations.

Barrera:                        Ben said it perfectly. We're there just to be of service. There's no judgment. We've seen so much, not only in our day-to-day, but some of us in our personal lives that when we go in with that attitude is we're just there to be of service. If there's any way I could help, let me know. And sharing our own experiences with them also. The street lingo, sometimes it just comes out naturally out there and it's very helpful. As unnatural as I feel on a podcast sometimes or in an interview is the exact opposite of what I feel when I'm out there in an encampment and I can really connect with someone who's hit rock bottom.

                                    And like Ben said, if they're not interested in services today, that's just a no for today. They see us, they recognize us and tomorrow they'll wave hi to us and they'll know why we're there. And maybe the engagement produces different results that day.

Heath:                          That makes a lot of sense. I wanted to shift gears about how you guys as a care team work together. If you guys could talk a little bit about kind of the relationship between everybody on the team and how you guys collaborate and work together and maybe some of the things that you think make for good collaboration across care team members.

Kaska:                           Eric, do you want to go or do you want me to take the first-

Barrera:                        Sure. You drive this one home because the relationships between all of us, there's a lot of genuine friendships here at HIA. The doctors often prefer to be addressed by their first names, creating a really down-to-earth atmosphere amongst the patient and provider and colleagues. We really work together. I was in the Marine Corps and it's similar to field medics there. PAs are our boots on the grounds, they're the field medics. And together we act as each other's eyes and ears in the field. And whenever we see that there's a need for whatever specialty services we're experienced in, we jump in.

                                    And there's so many crucial components to how HIA operates, even admin support. Admin support is crucial, I feel like this doesn't happen unless the I's are dotted and the T's are crossed and everything's submitted. HIA really recognizes the important roles from top down to every level. Each team member really has to own their role, and we do, and we jump in and help each other out because I've never heard one of our team members say, "That's not my job." And that's the kind of relationship we have here.

Kaska:                           I love that, and I can't agree with it enough. Healthcare in Action, because we have our three braided services -- the enhanced care management service, the housing navigation service and the clinical medicine service -- we take full ownership of the patient start to finish, top to bottom. So, we braid those services together. And if we're not providing it to the patient, the patient's likely not getting it. So, we take full ownership. And exactly to Eric's point, no one says, "Well that's not actually part of my job." It's an all-play. Our clinicians will go pick up medications. Our clinicians will get patients to sign consent forms.

                                    It's an all-play, full-court press for the patient's well-being. I think also maintaining trauma-informed care ratios. So, our peer navigators get capped at about 40 patients a caseload -- that gives them enough time to really know every detail of that person's care and not get overwhelmed with 200-300 clients that they can only know one inch deep. They have 40 clients that they know a hundred feet deep and the clinicians have 200 patients, give or take. So, the clinicians, when I was at my previous primary care practice, I had over a thousand, almost 2,000 clients or patients.

                                    I wasn't able to know each client by memory as well as I knew each one of my clients and my patients in Healthcare in Action. So, this added level of intimacy for our patients with knowledge and well-being allows us as a care team to work together to ensure that there are no gaps that are being left unaddressed. We also relentlessly advocate on behalf of our patients, and that yields extremely excellent results. So, for example, I love doing good care, good medical care, and what I love even more is being able to care for my patients better than how the national average is cared for, for the housed population.

                                    So, for instance, of all the patients that we've screened for hypertension, 85% of them are on a hypertensive treatment. The national average for the housed population is 63%. So, we are doing better than the housed population. For the housed population, of all the people that are being screened for a mental health condition, about 47% of those who screen positive for a mental health condition in the housed population are getting treatment. With Healthcare in Action, it's 61%. So, we're doing a better job.

                                    And then for substance use disorder treatment, this one's my favorite, for the housed population who has screened positive for a substance use disorder condition, approximately 7.1% of the folks in the housed population are receiving an appropriate treatment, and Healthcare in Action is 42% are receiving a treatment and taking it consistently. So, this care team model is meant to ensure that no gap is left unaddressed and that, as Eric said, this works because we don't have a really formal hierarchy where our clinicians... Whoever knows the patient best, inform us because it's about patient well-being, not some hierarchy that we're trying to establish.

Heath:                          I love that. And I think you started to get into this a little bit with some of those stats, but I'd love to hear a little bit about how this teamwork and collaboration, how we then move that into better patient experience and, as you were alluding to, better patient outcomes.

Kaska:                           Well, one statistic that we are very proud of is for our patients, for the 6,500 patients that we saw in 2024, over 56% of them were seen five or more times. So that indicates a longitudinal care. And then of those patients that were seen five or more times, 28% of them had an improvement in their housing outcome that year. So, this collaboration between the enhanced care management, the housing navigators, and the clinician, when all rowing the canoe in the same direction or all encouraging and supporting the patient in the same direction towards permanent sustainable housing, an improvement can be achieved.

                                    And we don't stop just when we house the patient, we continue to ensure that that person has housing sustainability and tenancy and does not fall out immediately after gaining this. And then once appropriate, we then transfer that person over to another organization that might be more suited to serve someone who is housed.

Barrera:                        And we can see the relationships between the patient and the PAs or the patients and the doctors and the patients and the peer navigators. Whenever there's a win each one of us has this connection with that patient and we're like, "Yes, there's really..." And you don't get that in a brick-and-mortar setting. Nobody really knows about the patient's progress in other areas. And HIA is just phenomenal when it comes to teamwork and communication. We really share all the patient's information with each other so that when a patient is referred to me, I already have a good understanding of their situation.

                                    And when I refer a patient to another provider, I try to make sure they have all of the information that I have because we've all experienced being bounced around from different providers and having to explain ourselves or explain our situation every time we meet with a new doctor or something. And imagine dealing with that on top of dealing with addiction or homelessness or trauma, it can be very frustrating for some of our patients. And HIA is really committed to giving patients that better patient experience. Some of our surveys and the feedback that we get from our patients is really heartwarming and it reminds us why we do this kind of work because it can be frustrating.

                                    Sometimes the things that we see can be heartbreaking, but then right when you think you've had enough, you get this email or a text message or a message from a patient that says, "Man, thank you for everything you've done. This is what's happening in my life now and I'm reunited with my kids. My kids came to stay the night." This work has been amazing.

Kaska:                           I love what Eric is saying. We think we're doing a great job, as you can tell, but we are open for feedback and we frequently ask our patients and survey our patients asking what we could do more of or less of to make us a better organization. And we did patient satisfaction surveys to ensure that what we think we're giving our patients is actually something that they desired. And in 2024 when we did our patient survey, we came out with a net promoter score of 86, which shows extreme patient satisfaction. It demonstrates that patients enjoy working with us.

                                    And I always like to quote that Netflix has a net promoter score of 67, and Netflix is considered to be a business with a lot of loyalty and customer satisfaction. So, a net promoter score with HIA of 86 puts this in the top 1% of customer satisfaction rates. So, we're very happy with that. But at the same time, we don't just want to say, "That's good enough." So, we constantly provide our patients with patient questionnaires and patient feedback to ensure that if there's something that we could do better that we are listening to exactly the people and patients that we serve.

Heath:                          That's crazy to hear about the net promoter score because if you think about a population where trust is maybe a little bit lower, to have a population that's going back to their friends and their acquaintances and saying, "I recommend this service." That's monumental in any patient population, but especially in one that's typically underserved. So that's nuts to hear about.

Kaska:                           That is a big tenet of HIA is do not over promise and under deliver. These folks have been victims of people saying, "I'll serve you. I'll support you. I'll help you." And then the folks don't show up. So, showing up is incredibly important for our HIA and our staff.

Heath:                          Awesome. I know that we are coming up on time a little bit, producer Kelsey, please don't kill me, but I would love to hear each of these two mention, just one thing that you feel like if you could recommend it to one of your peers doing mobile medicine, what would it be?

Kaska:                           I think I know where I can start. I think in all forms of medicine and especially street medicine, remembering that if a patient is ever upset, that it's likely out of fear, it's likely that they're scared, it's likely that they're hurt, in pain. And it is our job to not treat the labs, not treat the numbers, not treat the productivity scores, but to treat the individual and make sure that the patient comes first and treat the person with love and compassion.

                                    That is what I would send out to my colleagues. And whether they're street medicine or brick and mortar care, that is something that I love to see and hope all clinicians operate with, compassion and love for the patient that they serve.

Barrera:                        I think Ben said it perfectly, come with compassion and love. And I've been asked, especially with people who are new coming into this field, "I don't really know what to do or what I should do," or "What's your day-to-day like?" And I like being able to explain it to them in a way that is the same way you would help your elderly grandfather or someone with a disability get to an appointment. There might be some stressful times, but you just do the next right thing and you do it with love and compassion. And like Ben said, don't take anything personal because we don't know what they're going through sometimes.

Heath:                          I love that. Well, thank you guys both for joining us today. I think that this was so insightful and it's definitely a topic that we don't get to cover that often on the podcast, so I'm glad that we are bringing this to our audience.

Barrera:                        Thank you for having us.

Kaska:                           Thank you so much for having us.

Heath:                          Of course. Awesome. And thank you to our audience as well.

Kelsey Waddill:             And thank you listener for tuning in. If you liked what you heard, head over to Spotify or Apple and drop us a review. We'll be choosing some of our reviews to be read on the show in appreciation, so keep listening through to the end because you might get name-dropped. See you next time. Music by Kyle Murphy and production by me, Kelsey Waddill.

Waddill:                        This is an Informa TechTarget production.