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“From the Four Walls of a Clinic.” Caring for Homeless Patients During the Covid-19 Pandemic

When Covid-19 led to increased need, San Francisco Community Health Center formed teams to provide care in the city's Tenderloin district.

A member of San Francisco Community Health Center's Street Team examines a patient. (Photo courtesy of SFCHC)
A member of San Francisco Community Health Center's Street Team examines a patient. (Photo courtesy of SFCHC)

In San Francisco’s Tenderloin district, where tech-industry wealth brushes up against some of the city’s most vulnerable communities, the San Francisco Community Health Center provides everything from lifesaving medications to hot meals for its patients.

Ming Ming Kwan, the health center’s chief operating officer, born and raised in the city, describes a neighborhood that’s seen increasing levels of poverty and homelessness in recent years. “I have personally watched the situation in the Tenderloin, and the homeless situation, become more and more devastating,” she said.

And in response, San Francisco Community Health Center (SFCHC) has stepped up – and often out – to meet the needs of its neighbors, becoming not just a health care provider but a stable source of community support.

Many of the health center’s patients – roughly one-third of them are experiencing homelessness or are marginally housed – stop by daily to receive medication. Some depend on the meal programs there for a daily hot meal, and in some cases, “their meal with us is the only meal they have that day,” Kwan said.

That’s in addition to providing a full slate of medical, dental, and behavioral health services.

“I see them getting people housing, I see them making sure that they’re all fed, that their medications are all taken properly,” said Martina Travis, a nutritional aide at SFCHC.

Travis explained that the health center helped her find housing and recover from a substance use disorder. “Ever since then, I’ve gradually moved my way up…helping others the way I was helped myself,” she said.

Then Covid-19 struck.

“Are you going to be there tomorrow?”

Like health centers around the country, SFCHC responded by moving the majority of health care appointments to telehealth.

The health center’s daily drop-in programs, one for homeless or marginally housed individuals living with HIV, another for the transgender community, were turned into “grab and go” services that allowed patients to access hot meals and daily medications.

For many homeless patients, who lacked access to a digital device, the change meant a significant disruption to much-needed services – and an increased risk of falling out of care. While the health center supplied some patients with devices, it still wasn’t a viable option for many.

At the same time, said Lance Toma, the health center’s CEO, other programs aimed at Tenderloin residents were experiencing reductions in hours or services.

“The one question is just, ‘Are you going to be there tomorrow?’” Toma said.

Stress about the pandemic, a lack of access to services, and increased number of tent encampments – a city report found that the number of tents in the Tenderloin increased 285% between January and April – were accompanied by an increase in feelings of distress and substance abuse. In addition, patients began reporting increased incidents of violence.

And although the city made rooms available for quarantine and sheltering in place, Toma said that the rules around eligibility weren’t always clear to the health center’s patients. Some felt resistant to leaving the streets temporarily and adopting a completely different lifestyle. For patients with substance use disorders, the housing represented an additional challenge.

Stepping Up, Stepping Out

According to Toma, SFCHC was used to thinking outside the box – and even the health center. “The structure of having to make an appointment when you’re marginally housed or just barely surviving…it’s really hard, and so we’ve always had to challenge ourselves,” he said.

And the health center had had a positive experience employing a mobile team before, helping HIV-positive patients who were experiencing homelessness or marginally housed reduce their viral load – the amount of the virus that can be measured in the blood.

Staff had felt increasingly motivated to find new ways to serve a growing need. And now was the time. SFCHC began sending two mobile teams out into the Tenderloin.

One, called the Street Team, assesses patients, provides wound care, and distributes hygiene kits, food, water, and harm reduction supplies. Another, the Wellness and Retention Team, keeps up with existing patients to minimize disruptions to their care.

“I’ve been just astounded by what they’ve been able to do,” Toma said. The street teams “just built trust in a moment when everything felt really unstable and unreliable for our homeless community.”

A SFCHC staff member distributes pamphlets to people in San Francisco's Tenderloin district. (Photo courtesy of SFCHC)
A SFCHC staff member distributes pamphlets to people in San Francisco’s Tenderloin district. (Photo courtesy of SFCHC)

Many of the people staff members talk to haven’t had positive experiences seeking medical care in the past, said chief medical officer Dr. Alisson Sombredero. “They carry some medical trauma; they have not been well treated in the medical institutions,” she said.

For these patients, street medicine may be an improvement: “We are decentralizing care from the four walls of a clinic to an environment that is more their environment. “

A temporary situation

SFCHC has been providing case management for years, helping patients reach goals that they identify, whether it’s finding housing or reducing a viral load. “It’s all about hearing their priorities and not trying to force our own priorities on them,” Kwan said.

But for patients moving into temporary housing during the Covid-19 pandemic, the abrupt change in circumstances brought new and unique challenges.

Many of SFCHC’s patients found the process of finding a room difficult, or weren’t sure if they qualified, Toma said. For eligible patients, staff members acted as navigators, helping them find places.

Some needed medication-assisted treatment to help them wean off drugs. Others had to choose between staying in their current living situation, with a partner or surrounded by a community, and moving to a new location.

And sometimes, the change in circumstances was just difficult on its own. “We try to prepare folks for what it’s like to move out of the streets and into the room,” Toma said. “Our staff are constantly working with our clients to help them stay in their room but sometimes folks will just leave.”

And for those who stay, SFCHC staff members are concerned about how their patients will cope with leaving temporary rooms for life on the streets, when temporary housing programs come to an end.

“We just keep plugging away”

Staff members are careful to remember that their homeless and marginally housed patients have their own experience of and perspective on the Covid-19 pandemic. Dr. Sombredero said that her patients definitely want more information about the coronavirus, and want to know how to keep safe.

But patients who experience homelessness “have a different way of seeing their day-to-day life,” Dr. Sombredero said, with ongoing challenges around food, shelter, and safety taking priority.

And while the Street Team works diligently in the community, Kwan said it’s impossible to keep up with everything that’s needed, whether it’s medical care, hygiene kits, or even water. “We’ll never have enough, but we just keep plugging away,” she said.

For the staff members interviewed for this story, their dedication remains unflagging, even as the pandemic drags on.

“It’s a really stressful situation, and I’m glad I’m a part of it,” Travis said.

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