Calif. street medicine program reflects on 4 years of service
An expansion of Medi-Cal funding has helped Clinica Sierra Vista deliver medical care to the homeless population
By John Donegan
The Bakersfield Californian
BAKERSFIELD, Calif. — As they slowly back onto the parking lot, you can hear the groans in the axles of Dr. Matthew Beare’s Honda Element. Years of climbing onto sidewalks, off-roading along riverbeds and combing underpasses have taken their toll.
But it’s part of the philosophy that Beare, a physician at Clinica Sierra Vista, has adopted to bring on-the-spot medical care to homeless people in Bakersfield, at no cost to the patient.
“Instead of asking patients to step out of their world and into ours, we step out of our comfort of our world and into theirs,” Beare said.
He leads a six-person street medicine team that has since 2019 brought direct care to the 100 or so patients living along the Kern River bed. Every Thursday, after a supply stop at the county shelter, the crew rides to the riverside.
Street medicine crews see an average of 12 to 15 patients every Thursday, though Beare said that can jump to 30 on a busy day. Treatment includes almost everything you would see in a clinic — HIV, high blood pressure, diabetes — as well as wound care, particularly incisions and draining abscesses, and medication provided on the spot. Previously reliant on grants, Beare said the program is now billed through Medi-Cal, which makes it “self-sufficient.”
This morning, with the gates locked, the crew switched back and entered through the north side of the river, along a route they call Tammy’s Pass.
It’s near the Rosedale Inn, which sits in the evening shadow of the 24th Street overpass that crosses Golden State Highway. A turn onto an access road nearby takes the two vehicles onto an undulating dirt path with puddles from the recent tropical storm.
On either side is a field, charred black and barren from a recent fire, and the Kern River, swollen from recent rains and a record snowpack from the Sierra Nevada.
The first camp they spot explains the pass’s name. Tammy’s camp, positioned at the trailhead, consists of a reclining chair, a shelf and random furniture, all of which were covered with plastic-wrapped goods and a tarp.
Several hundred feet away, Beare points to a spot where he and his team came upon a woman being eaten alive by a pack of pit bulls. “That was a terrifying moment,” he recalled. They had to carry the woman, her extremities ripped apart, with a tarp to an ambulance by the entrance.
Forming a canopy over the camp are two overgrown fig trees that form a cove over a camping chair. With Tammy still asleep in her tent, the crew continues along the dirt clearing past the bridge.
About a dozen people, and another dozen dogs — some leashed, some not — are waiting. Many of their health problems stem from the elbows or knees down — swollen tissue, bumps or dog bites that slowly worsen due to infection.
“We used to have to drive along the river and stop at each encampment,” Beare said. “But now, we’ve been coming out for so long that the patients congregate. They know where we’re going to be.”
Staff members make their rounds, handing out lunch, harm reduction kits, Narcan and clean needles. Coffee is self-served at a table set up by Kern Medical Supply. One team member takes blood pressure readings, while another — a medical student — bandages an open wound on a man’s foot.
Beare rotates from patient to patient, prescribing medicine and performing checkups. By this point, he’s acknowledged by most on a first-name basis and can recognize his patients from a distance.
One woman, Christine, showed some scratches on her arm, complaining of an itch. In the two years she’s been in Kern, Christine has relished the street team’s Thursday visits.
“I really like it. I think it’s awesome that they do this,” she said. “Where I used to live before, in Phoenix, they didn’t have other people doing this.”
Like many of the state’s homeless, Christine has Medi-Cal. But without transportation, she can’t get to a clinic for exams.
Beare explains that when they started this program, the teams used to have to go from site to site, asking to provide care to people.
Encumbered by higher rates of addiction, mental health disorders and illness, homeless individuals are among the state’s neediest patients.
While 60% of the state’s homeless, according to the California Health Care Foundation, are registered through Medi-Cal, only a third, according to a 2021 analysis by the California Legislature, have ever seen a primary care provider.
One of the few ways they can efficiently administer psychoactive medicine is through a recently adopted long-acting injectable. Beyond that, little can be offered in the way of psychiatry. When they first started, the team brought along specialists. They quickly realized it didn’t work.
“We try to see as many people as we can in a day,” Beare said. “So our interactions might be a few minutes, and while they’re meaningful and heartfelt interactions, they’re still pretty rapid. And a behavioral health intervention could be talking for an hour just to get a baseline.”
This population, unsheltered yet insured, must go without unless they can connect with one of Kern’s teams. This drives up the number of visits to emergency rooms.
A big change, Beare said, has been funding from the new California Advancing and Innovating Medi-Cal, or CalAIM program, an expansion of Medi-Cal funding that, since June, has made the team self-sufficient. Previously, the clinic paid out of pocket or relied on grants to help fund its efforts, often resulting in supply shortages.
“It gives us a degree of sustainability,” Beare said. “It’s the single biggest game changer you have seen and will continue to see as street medicine teams.”
Signs of those are apparent in California and across the nation. According to the CHCF, only 24 teams existed as of 2022.
“I just talked to someone and they said it’s closer to 49 teams in California, which is crazy,” Beare said. “I remember when there were only 200 teams in the world — like in Calcutta, in London, everywhere. And now there’s 49 in California.”
Nationwide, street medicine teams are active in more than 60 American cities.
Beare believes teams like his will reduce emergency room visits and readmissions that bog the state’s Medi-Cal budget. According to the California Department of Health Care Services, more than half of the state’s $133 billion Medi-Cal budget is reserved for the top 5% of users.
“It also builds a rapport between the medical community and people experiencing homelessness,” Beare said. “It’s undoing a lot of damage done over the years.”
The next generation of medicine
It has also attracted the next generation of medical students who want to shed the formalities of a clinic setting.
“This is what I’ve wanted medicine to be,” said Shahab Alnagar, a fourth-year student at California Health Sciences University in Fresno, who shadowed Beare for the first time Thursday. “Not appointment-based, you just walk up and take care of it on the spot.”
Yet as his team treats those wounds, new ones are continually opened.
The intersection of code and committee
Christine complained of harassment by local code enforcement, which is charged by the city to clear street encampments deemed a public nuisance. It’s an issue every five days, she said, with little room for negotiation.
“They won’t talk to us, just tell us we have to go to court and that we have to talk to Flood (Ministries),” Christine said. “But it’s not right away that Flood can get you out of here ... you have to wait years or months in order to get into housing. But that’s what they throw at us — talk to Flood, talk to Flood.”
Since each of the four shelters in Kern are regularly at or near capacity, Christine and others say they rarely have a choice of where they can stay. Bakersfield averages a 1% vacancy rate for affordable rentals, leaving housing options like downtrodden motels, which are arguably more dangerous than being outside.
And at an Aug. 22 city Housing and Homelessness Committee, Bakersfield Assistant to the City Manager Anthony Valdez reported that 71 individuals, on average, are turned away each week due to capacity limits at the Brundage Lane Navigation Center.
Over the years, Beare said, he and his team have increasingly been at odds with code enforcement.
“Encampments get moved a lot,” Beare said. “These camps would otherwise probably stay stable, but the city moves them a lot. And what’s disheartening for us to witness, is they will upend and bulldoze a camp when it’s 110 degrees outside — I’ve seen it happen, multiple times.”
While he doesn’t want to demonize code enforcement personnel, it’s hard to watch “a city government directly putting people at risk.”
“It’d be different if they said, ‘We found you an apartment, we want to help take you over there, let’s go right now,’ but that’s not what happens,” Beare said. “They put up a sign that says you have three days to get out of here ... we have different criteria for success.”
Phil Burns, the director of Bakersfield’s Building Division, which oversees code enforcement, said that among the four shelters in Kern, there’s always a bed available.
“I think there’s a misconception that these shelters are always full, 24/7. That’s actually not what practically happens,” Burns said. “Every day you have a certain amount of people in the shelter that leave the shelter, get placed in housing — so there’s beds that become available.”
His department is tasked with dealing with the 979 calls to service complaints made to code enforcement along the Kern River alone between Aug. 1, 2022, and Aug. 14, 2023.
When Flood Ministries, which is contracted with code enforcement to monitor shelter availability, goes out there and makes contact, they’re not just referring people to the BLNC, but also to the other shelters in the area — M Street Navigation Center, The Open Door Network and The Mission at Kern County.
Yet in the aforementioned meeting, it was stated that 197 people refused shelter service in July, while the BLNC alone turned away an average of 65 individuals each week of that month. And the city does not monitor the vacancy rates of the three other shelters.
“We only track our shelter,” Burns said.
Additionally, The Mission at Kern County is first-come, first-served. And the M Street shelter was closed to new clients last week after a COVID-19 outbreak.
“There’s things that may have some short-term impacts on availability, but in a general sense, we have way more individuals that refuse than ones that want to go to shelters,” Burns said.
Burns added that BLNC reserves some shelter beds for “service-resistant” homeless people who change their minds.
There is also no policy in place, according to Burns, that says code enforcement will not remove an encampment in the event of extreme heat or cold weather. He did add that in times of inclement weather, like rain, they’re generally not going out.
“But in the cold or the heat, we’re going to be out there — no different than any other day,” Burns said.
Since the city does not track shelter capacity at other sites, it cannot say for certain whether encampments are razed only when a shelter bed is guaranteed to be available.
“In our point of view, housing is available to that person,” Burns said. “That’s why we contract with Flood, to monitor that very issue.”
City of Bakersfield spokesman Joe Conroy said it’s not so much the intention to simply remove people from their encampments, but to get them to services.
“It makes most sense in inclement weather, whether it’s cold or hot, to get somebody into a shelter rather than being out in those elements,” Conroy said. “I’m racking my brain trying to think of a situation where it would make more sense to leave them in those elements than try to get them service.”
In the event that BLNC, for example, does not “have the processing power to get them in that day,” Burns said they will usually give that person another day at their encampment.
When encampments are razed, medications, documents, identification — things people need to access housing — are often buried or spilled into the river, Beare said.
Where the faded vinyl meets the stars
On the way out, they visited Tammy, who stood outside her tent, chatting with a man while another woman sat in the driver’s seat of a truck next to them.
“About 4 o’clock I can come over here because by then we’re in the shade,” she said. “And then I can sit in my chair.”
Since Beare and some of the others will be gone next week, the people here along the riverbed will be on their own.
After a year at this site, Tammy said code enforcement doesn’t bother her anymore. She spends her day waiting for visits, by friends or Beare.
On an average summer day, inside the cove with the buzz of cutter bees, she stretches out in her chair, which is patterned like the American flag, her head resting where the faded vinyl meets the stars.