USC Street Medicine Team to Train Health Care Workers Around the State

On a rainy and blustery day, Corinne and Brett Feldman were especially grateful for a break in the downpour. It meant they could help some of the Angelenos who are unsheltered that they treat remove wet socks and get into dry shoes. Without that change, they knew they would have seen cases of trench foot, a medical condition that can occur during prolonged exposure of the feet to cold, damp, and often unsanitary surroundings.

The couple are part of the Keck School of Medicine of USC’s Street Medicine program, which began with their arrival in 2018. Brett serves as a physician assistant and division chief, and Corinne leads the program’s education and workforce. The program has grown to include 17 healthcare and community workers.

Recently, California-based Health Net, one of the state’s longest-serving and most-experienced Medi-Cal partners, awarded a $1.5 million grant to the program to allow the Keck School of Medicine to train other street medicine teams around the state in its interdisciplinary model. Health Net focuses on advancing health equity to provide the highest-quality care for some of the state’s most vulnerable populations, regardless of demographics or income. With their support, the medical school hopes that this street medicine delivery system will spread beyond California, eventually becoming a national model.

“Health Net understands that the best way to care for patients with complex issues is to meet them where they are, considering the full scope of their needs,” said Pooja Mittal, DO, chief health equity officer at Health Net. “That’s why we collaborate with organizations such as the Keck School of Medicine, to expand innovative programs that address physical, behavioral, social, and long-term health needs.”

“You hear a lot about evidence-based medicine,” Brett said. “But we work with reality-based medicine. You apply the evidence to what you see on the street. Health Net is using their years of experience implementing innovative initiatives to help create a system that offers treatment based on the reality of being on the street.”

That reality is a harsh one. While this is Southern California, winter can be cold, especially for the homeless population. “The first year Brett and I were here, in 2018,” says Corinne Feldman, a physician assistant and director of workforce development for the USC Street Medicine Program, “we had three cases of trench foot and one of frostbite.”

On this particular rainy day, Corinne said, before helping other patients into warm and dry clothes, “my number one seek-and-find this morning was one man whose blood sugar is almost 600 [non-diabetic blood-sugar levels typically range from 70 to 126]. He has a lot of wounds on his feet. He needed warm air on his feet and needed them wrapped.”

According to the 2022 Annual Homelessness Assessment Report to Congress, Los Angeles County has a population of roughly 44,500 people who are unsheltered, the largest in the nation. This group has a much higher morbidity and mortality rate than the average citizen, higher even than homeless men and women living in shelters.

Street medicine in general has long been something of a patchwork operation, funded through various government contracts and philanthropy, but falling through the cracks of more traditional health plans and providers, including Medicare. Providers were very rarely reimbursed, and there were no billing service codes. It existed largely outside the traditional medical infrastructure.

That changed last year, Brett said, when the Department of Health Care Services issued a way to bill for visits on the street. “This helps make street medicine sustainable,” Brett said. And it’s completely changed the picture of caring for people who are unsheltered.

“Street medicine has never been at such a crossroads of being accepted into the mainstream of medical care,” Corinne said. “We can actually give great care on the street. This is why this Health Net grant is happening right now, and it’s so important. Lots of people are interested in doing this work but might not know how. That, we can help with.”

Existing programs now need to build infrastructure to operate in a managed care model. The three-year Health Net grant will allow the USC team to help set up four new street medicine programs per year in areas where there are none, as well as hold workforce development sessions throughout the state.

While developing the necessary materials to train new street medicine teams, the existing USC Street Medicine team navigates LA’s avenues, stopping to ask people if there’s anyone they’re worried about, or where can they find a patient who needs medical help. At first, people were wary of the USC vans, having been let down by others’ care attempts in the past, Corinne said. “We had to continue to show up, be consistent with our presence and (more importantly) our humility, to show them that we could be trusted. Now, people stop us to refer us to their friends.”

Homelessness is not something we’ll solve, but we can treat people experiencing homelessness with empathy and compassion, she adds. “All people want is just to be seen, to be part of a community they feel abandoned by. It’s an exciting time to be part of street medicine.”