USC Street Medicine Surpasses Growth Expectations, Hitting Multiple Milestones to Start 2024

The USC Street Medicine program has hit multiple new milestones to start 2024, notching 1,000 patient visits in January for the first time ever while also expanding from what was once a nascent program, with only one full-time employee, to one that now deploys five fully-staffed teams providing health care to people who are unhoused throughout the city of Los Angeles.

Accelerated growth 

January’s numbers highlight the fact that patient visits have doubled since just July of last year, according to Brett Feldman, the program’s director and co-founder and an associate professor of family medicine at Keck School of Medicine of USC.

“The progress in general is something I thought I’d see in my lifetime, but not this soon,” said Feldman.

A key factor driving this faster-than-expected growth was a multi-year effort by USC Street Medicine and the Street Medicine Institute to petition the Centers for Medicare and Medicaid Services (CMS) to create a reimbursable place of service (POS) insurance code for health care given in the street. Approved in June of 2023 and put into effect nationwide in October, that change is helping to transform street care, which, according to Feldman, had gone more than 70% un-reimbursed prior to the new POS code’s implementation.

“We’ve actually been able to house 30-40 percent of the people we’ve seen,” Brett Feldman said. “If their physical health has improved, they’re more likely to be successful with housing.”

Game-changing Federal recognition of street medicine

Since lack of health care is itself a major driver of homelessness, recognition of street medicine plays a crucial role in not only caring for, but ultimately housing the unhoused, said Feldman. “We’ve actually been able to house 30-40 percent of the people we’ve seen,” he said. Building trust with the homeless while giving them care also helps individuals successfully find and keep housing, he added. “If their physical health has improved, they’re more likely to be successful with housing.”

Creating a nationally scalable model 

The POS code is the first step in providing a reliable funding source, which is essential to making this care scalable nationally.

“Part of scalability is sustainability,” said Feldman. The model was not sustainable “when we were not able to get reimbursed and were reliant entirely on grants and philanthropy,” he said. Reliable funding not only enables a national blueprint for care, but a way to house more individuals successfully.

California’s collaborative solution

In California, street medicine was dealt a seemingly tough blow in October of 2021 when Governor Gavin Newsom vetoed The Street Medicine Act (AB369), legislation that would have forced the California Department of Health Care Services (DHCS) to reimburse care given outside of traditional clinical settings. But as part of his veto, Newsom sent the bill to DHCS, charging them to develop a system enabling street medicine providers to bill public insurers.

Feldman says this collaboration with DHCS has created a far better outcome than legislation alone would have.

“This way, the system has really been developed collaboratively,” he said. “We’ve built a strong relationship. That gets you farther than legislation.”

Growing number of street medicine programs

Thanks in large part to this collaboration, the total number of street medicine programs statewide has also more than doubled in a year, going from 25 last year to 60 in March 2024. Growth has been further aided by grants like the $1.5 million given to the Keck School of Medicine by Health Net, one of the state’s longest-serving and most experienced Medi-Cal partners, helping fund efforts to train other programs throughout the state. Now, there are over 140 organizational members of the CA Street Medicine Collaborative, the state-wide organization hosted by USC Street Medicine. 

“The importance of recognizing street medicine and equitable rates for street medicine is that it recognizes the people we serve’s right to life since they rely on us to survive,” said Feldman.

Optimizing the model 

While the spate of recent milestones is encouraging, challenges remain. Chief among them is the fact that despite paradigm-shifting new POS codes, the actual dollar amounts of reimbursements remain out of step with costs.

The code changes, “had to happen first,” explained Feldman. “Now we exist, but the rates are not equitable. The challenge we’re still facing is getting the rates right.”

The further expansion of care teams is also encumbered by recruitment challenges. Each clinical team is comprised of a medical practitioner, a nurse and two community health care workers, as well as floating staff that moves between teams. According to Feldman, community health care workers are crucial to the success of street medicine but the positions are uniquely challenging to fill, requiring individuals with “lived expertise” in the form of first-hand experience with homelessness, the justice system, or addiction.

“The only reason why this works this well is them,” said Feldman. “They’re our bridge to heath and the street.”

Equity

For Feldman, structural funding changes and growth in scalable models for care are ultimately about equity.

“It’s not equitable that people experiencing homelessness also struggle to get access to a doctor,” says Feldman. “The importance of recognizing street medicine and equitable rates for street medicine is that it recognizes the people we serve’s right to life since they rely on us to survive. Not providing equitable reimbursement rates means new programs won’t survive, abandoning patients who’ve entrusted their lives to us.”

To learn more about USC Street Medicine visit keck.usc.edu/street-medicine.