A New Model of Healthcare for the Homeless - Dr. Michael Hochman, Inaugural CEO of SCAN's Homeless Medical Group Initiative

DR. RISHI DESAI: Hi, I'm Rishi Desai. Today on Raise the Line, I'm happy to be joined by Dr. Michael Hochman, the inaugural CEO of SCAN's Homeless Medical Group Initiative. Under his leadership, the group uses a street medicine model to focus on the care of patients experiencing homelessness in California. He previously served as the inaugural director of the USC Gehr Family Center for Health Systems Science and Innovation, and is the founding editor of the 50 Studies Every Doctor Should Know book series published by Oxford University Press. Thank you so much, Michael, for being with us today. 

DR. MICHAEL HOCHMAN: Thanks very much for having me, Rishi. 

DR. DESAI: You have a fantastic and varied background, and obviously, a strong interest in understanding homelessness. I'm curious about what got you started on this path in healthcare and how it led you to where you are today. 

DR. HOCHMAN: Sure. I wish I had a great story about it, but it's as simple as, I loved taking care of patients when I was a resident. I particularly found myself drawn to the most vulnerable, the sense of gratitude you get from caring for underserved patients. I really enjoyed it. I spent some time working with the Indian Health Service and had a similar experience, and so when I finished my training, I decided I want to work in a public health system hospital. When I did my medical training in Boston, I had experience with the Boston Health Care for the Homeless Program. I saw the deep connections that they had with their patients. I worked for several years in Los Angeles at community health centers, and the Keck School of Medicine of USC. Some of my favorite patients to care for were the homeless because, again, if you can make a difference, get them on the right path, get the mental health and substance use conditions under control, a lot of times you can actually get their lives back on track. So when this opportunity arose to help start a medical group for homeless populations, it really appealed to me,

DR. DESAI: Maybe you can tell me a little bit more about SCAN Health Plan, how it began, and exactly what services are provided.

DR. HOCHMAN: Sure. So SCAN is one of those traditional grassroots health plans. It was started by a group of what are described as “angry seniors,” people who were just not happy with the health care options available to them in the 70s. They built their own cooperative health program in the 70s and evolved into a Medicare Advantage. SCAN is a not-for-profit. They take care of about 215,000 members in California, although they're in the process of expanding. The new CEO, Dr. Sachin Jain, began there about nine months ago. One of his visions was to get into the healthcare delivery space for certain high-risk populations, and one of those was the homeless population. So he was interested in starting this medical group, and we started talking about it, and here we are.

DR. DESAI: Talk to me about the new Homeless Medical Group Initiative specifically. I understand that back in Boston, you were intrigued by what you could do to help folks that were on the street. How did that lead you to be part of this initiative? 

DR. HOCHMAN: There are many very good homeless health care programs in the country, including Street Medicine programs, Boston Healthcare for the Homeless, Venice Family Clinic here in Los Angeles, JWCH, which cares for patients in Skid Row, and where I'm coming from at USC has an excellent street medicine program, the USC Street Medicine Program. But all of these programs have relied on charitable funding. There may be a little bit of fee-for-service reimbursement here or there, but for the most part, they're not built into a managed care framework that's sustainable. Certainly in California, in the commercial setting, a lot of groups have been very successful figuring out creative ways through capitated models, shared savings arrangements, and even full-risk arrangements to care for patients more effectively in a flexible model.  So the idea is to take this street medicine concept, put a managed care backbone on it, do capitated-risk-bearing contracts, and try to create a sustainable model that's both better for patients and cost-effective.

DR. DESAI: For folks that may not be so familiar with the needs of the homeless population, specifically where those needs are met, because obviously, it's not just in one particular setting; many homeless folks are trying to cobble together a framework across many different service providers, how does it work, practically speaking? What is it that they're getting from a day-to-day standpoint from your clinic that they otherwise wouldn't have gotten, and how does that differ? You mentioned Venice Family Clinic and Boston. How do those different models serve the same needs? 

DR. HOCHMAN: Well, at the highest level, there is no clinic with the street medicine program. We get rid of the four walls of a medical office building. We go out to the streets, and we find patients where they are, whether that be in a shelter environment, it could be sleeping on the streets under a bridge, in a tent, in an encampment. So that's probably the biggest difference.

Another big difference is, when you're homeless, your goals of care are very different. Your top priorities. It's not necessarily getting a mammogram or a colonoscopy that's most important to you, but it's how do I get food, shelter? How do I keep myself and my family safe? 

So our priorities are very different. In addition, more than half of ER and hospital visits among homeless patients are for a primary diagnosis of either mental health or a substance use condition. So, mental health and substance abuse services have to be front and center, even in a primary care model. 

DR. DESAI: So, in that setting, you're going to, let's say, an encampment, and you walk from one tent to another. You're checking in with folks. You recognize that maybe there's a need around mental health or substance abuse. What's the next step? So you do that intake assessment. Where do these folks then get sent for the help they need?

DR. HOCHMAN: I think that that's the model that these traditional street medicine programs like Venice, USC, and Boston have done. They go to encampments. They find patients. They treat them directly there in the streets, drain an abscess. If they can develop a relationship, eventually start them on medications for psychiatric conditions. 

If they do need to go to the hospital, refer them there. What's a little bit different about what we're trying to do is we're trying to take patients who are enrolled with a health plan, whether that be a Medicare plan or a Medicaid plan. We follow them longitudinally in the way that many of these innovative commercial groups like Oak Street or ChenMed, or CareMore have done. 

When they get hospitalized, we visit them in the hospital. We come up with a discharge plan for them, whether that be going to a recuperative care facility or a boarding care, some transitional setting, or maybe there's no option for them to be with a roof over the head, and we just come to meet them under a certain bridge at a certain time. 

But I think one thing that is the same about what we're doing in Boston and Venice, is it's all about getting that trust and that relationship. Homeless patients so often have distrust of the healthcare system for various reasons. With time, you've got to re-establish that trust to really be able to help them. 

DR. DESAI: So, in terms of longitudinal care, obviously, there are technological barriers, like they may not have a cell phone, or they may not have any way of even contacting you when they're going to an ER, or they're taken to an ER. How does that literally happen? How does someone know, "Oh yeah, this is an opportunity for me to contact Michael, because this person is here, and I know that they have a relationship with Michael, so he would want to know."

DR. HOCHMAN: Well, first, I'm going to tell you something that will define exactly what the problem you're highlighting is. The USC Street Medicine Program, if they see a patient in a hospital, the LA County USC Medical Center, they'll make a plan to see them after discharge, and they have about a 50% success rate of connecting with them. Usually, that's, "I'll meet you under the bridge on 3rd Street at X time tomorrow," and more than half the time they're not there initially, but if you wander around, you might be able to find them. Their success rate is about 50%. So the question is, how do we get up to 70 or 80% success rate finding them?

A number of these programs have experimented with giving patients cell phones, and there have been some mixed results there. It's gone really well with patients who don't have major mental illness or substance use issues. But for those who do, too often, the phones are becoming destroyed, stolen, or lost. So you have to make sure you give that cell phone to the right patients to help with that connection. 

We're also talking with some digital companies to see if there's sort of a less expensive tool, like, "I've fallen, and I can't get up button," that allows two-way communication. That way, if the phone is lost or destroyed, it's only a $30 investment that you've lost instead of a several-hundred-dollar investment. But you put your finger on one of the biggest pain points and challenges of caring for homeless populations in a longitudinal way. 

DR. DESAI: I stumbled across that one obviously, just thinking through the challenges that you must be facing. What are some of the other ones that you know of that you can share with us? What are some of the other big problems you're trying to solve in taking care of these folks? 

DR. HOCHMAN: Another big one is how to provide mental health and substance use services in a street medicine model. Simply put, there are not enough mental health and substance use resources; there are not enough psychiatrists and therapists. We're going to have to train primary care clinicians, generalists, including nurse practitioners, physician assistants, and peer navigators, to provide mental health services—not technically mental health services, but many of the things that experts in mental health would do, and then reserve those patients with the most severe situations for getting that direct care. 

So what do I mean by this? Well, we envision having nurse practitioners who can provide some counseling services, even if it's not perfect CBT, something along those lines. Providers who are comfortable administering antipsychotic medications, potentially even long-acting antipsychotic medications, where it's not the psychiatrist prescribing, but there's a psychiatrist guiding it, guiding a primary care clinician to do it.

DR. DESAI: There was recently a change with the Biden administration around loosening regulations for Suboxone, as you're aware. Also, Methadone can be quite useful in this setting as well. I'm curious to get your thoughts on that regulatory change. Has that affected how you all practice what you do?

DR. HOCHMAN: Well, personally, I'm very much a believer in that, loosening the restrictions. I think we can't let perfect be the enemy of the good. The concerns are appropriate in that people need to be adequately trained to prescribe these medications, so bad outcomes don't happen. But the bigger bad outcome we have now is a lot of people who need the services who aren't getting them. So I think we did need to move the goalpost a little bit, and loosen those restrictions to make it easier and allow primary care clinicians to deal with this really desperate and acute need now.

DR. DESAI: Are there other policies that are being debated right now, or discussed, that you feel from your standpoint could really help advance the care for homeless folks or folks experiencing homelessness?

DR. HOCHMAN: Yes, there are certainly some policy ones. One is that, historically, medical dollars need to be spent for medical services. You can't, for example, use healthcare dollars to pay for a recuperative care facility after someone's discharged from the hospital. If you have a patient who's getting admitted to the hospital for heatstroke, and they can't afford an air conditioner, you can't pay for an air conditioner for that patient, yet we would get so much more bang for the buck, so much more value, from spending money that way. So one change is to have a little greater flexibility on the use of healthcare dollars for health-related social services. Another big one is, and I think we're moving in the right direction, more flexibility with how care is provided through telemedicine or street medicine services. I mean, there are rules, like for Medicaid in California right now, if you don't have a place of service, you can't bill for it. Technically, if you bill for a street medicine visit, that's not allowed. So we need to loosen that up. 

We also need to be more generous. We have to realize that there are certain high-risk populations, like, homeless populations, that do require a higher reimbursement rate because it's going to lead to downstream savings down the road. So if we can shift, instead of typically 7% of health plan dollars going to primary care, maybe we pay 30% of the total dollars to primary care. It's going to actually overall, though, reduce the total spending. So I do think there needs to be higher capitation for groups caring for vulnerable patients like this. 

DR. DESAI: Yes, I didn't realize that you couldn't get reimbursed unless there's a place of record. It's surprising to me. I'm curious, are there key community assets that you've leveraged to support the health care needs of people who are homeless? If so, which ones have you leveraged?

DR. HOCHMAN: The obvious one is the housing services sector. I'm most familiar with what's available locally in Los Angeles. There's a coordinated entry system called the Los Angeles Housing Services Authority or LAHSA. It's a state and county organization. The problem is, like many things in social services, things are siloed. Patients try to go into the housing system, but their healthcare needs aren't met. If the mental health and substance use aren't controlled, the housing doesn't go well because the patient isn't able to get through all the hoops that need to be gotten through. Then, when they get in the house, it just doesn't go well for a variety of reasons that you might imagine.

Our bet here is that by going at it from a healthcare side, getting to know the patients, getting the trust, and understanding the hoops that need to happen to get in the housing system, that we can be the liaison that can facilitate that for the patient when they're ready to make the move, and be more successful than the traditional approach.

DR. DESAI: I won't say we're coming out of COVID, but as we're through what hopefully is the worst of it, what are some things that you think the COVID crisis has revealed about our healthcare system? What are some key steps that you think we could take to strengthen it, keeping in mind the focus on homelessness? 

DR. HOCHMAN: Well, one big one is telecare, which is not directly relevant just to homeless populations, but to any population. People have been talking about, for decades, the opportunities with telecare, and it wasn't until we had a crisis that we actually did it in large numbers. The world didn't end, and patients love it. That's going to be a change for the good. 

We need similar radical rethinkings of how we deliver care, doing away with rules that—I don't want to call them silly, because they were put in place for good reason: you need a place of service to provide care, or that you can't use health dollars for certain things—there are good reasons for all those rules. But to really take a step back and rethink some of the rules and regulations in place to make common sense happen. My CEO at SCAN, Sachin Jain, has this term, "radical common sense," and I think that's what we need in healthcare.

DR. DESAI: Maybe that's a good segue. We're always trying to teach on our platform; we care deeply about filling in learning gaps. Going through traditional medical education, I know that there were a lot of foundational gaps in how I understood the world. Obviously, in your practice, you've come across many of the things that are myths or misunderstandings around homelessness. If there's anything that you could share with us—broadly, myself, the audience— around any common things that you feel we should all learn about or know about to fill in one of these gaps in knowledge.

DR. HOCHMAN: Right. Well, I'm going to answer that by talking about one of the big debates in homeless healthcare right now. The two extremes are: a housing-first approach, that until we get patients housed, we can't deal with their medical needs. We'd be much more efficient if we just devoted our efforts and resources to get them housed, and then we'll start taking them to provide health care. The other extreme is, we just need to care for people where they are on the streets, not worry, keep the medicine and housing separate, and focus on the health care needs. 

I think, like so many things, the answer is probably somewhere in between. I do think that if you try to just house someone who has active schizophrenia or is using methamphetamine, it doesn't go well. Until you get the mental health under a little better control, the housing process is not going to go well. By the other token, you can never get someone truly healthy until you get them with a roof over their head. So I think there needs to be a greater linkage. But I'm optimistic that the healthcare sector can bridge this gap by being very savvy about the housing services, but caring for patients where they are.

DR. DESAI: Right now, in California, where do you think the pendulum is at? Do you think, in general, policymakers are favoring the housing-first extreme, that side of the equation, or the “treat-them-where-they're-at” approach?

In California, we've spent billions and billions of dollars over the last several years building new housing. For those of you familiar with California politics, in LA, there was a Measure H which was about a billion dollars worth of new housing units. I'm sorry, Measure HHH. H was just services for people who are in high-risk housing environments. The number of houses that have been built for these programs has been several hundred or a thousand, and there are 70,000 people on the streets right now. There's a sense that it's a bottomless pit. You just keep investing money, and we can't build houses fast enough. 

I think this has caused is a little bit of a rethinking of the housing-first approach, that we need to think differently. It can't just be just throwing money at the problem, build houses, and it will solve the problem. We need to get creative and think about how our healthcare system can manage. I think the pendulum was very much in the housing-first approach, and it's shifting to where I think it should be, which is somewhere in the middle. 

DR. DESAI: Got it. That's, that's really wonderful context, and I appreciate you diving into the details on that. We have a lot of folks that are early-career health professionals in our audience that are students that are aspiring to a career. They may look at your career and think, "Gosh, that's something that really resonates with me. That really is exactly the kind of thing I want to be doing." What is your advice to folks that see where you're at today and think, "How can I get there?" What would you tell them?

DR. HOCHMAN: Well, this is my philosophy. This does not mean it's the right or the only path to do it. I think, early in your career, you try to get experience in a variety of different settings. If you're interested in housing and healthcare, homeless healthcare, try to work in a community health center where you're exposed to these patients, see how the existing framework works. But then also try to get some other perspectives. Try to learn about managed care organizations. There are a lot of people who can put two different pieces together, that can create something new and innovative. 

Early in your career, don't be afraid to jump around, try different things out. Then once you start getting a little bit experienced, that's when you can start having your own ideas and programs with enough information so that they actually do something meaningful. But you're not too embedded yet in the system that you're not creative anymore. That's my advice. 

DR. DESAI: That's awesome. It's very sage advice. On that point, I'd love to thank you for walking us through what you're doing. I think what you're doing is incredibly important, and certainly, here in California, we see this all the time. It's a crisis. I'm in Northern California, in Oakland, where we see the same challenges that you're dealing with in LA. Obviously, many urban centers are struggling with today as well. So, thank you for that incredible overview and synopsis of where we stand right now with handling this challenge. 

DR. HOCHMAN: Well, thanks, Rishi. I am a big fan of Osmosis. Keep up the good work. 

DR. DESAI: Thank you. I'm Rishi Desai. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.