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Issue Brief

CHCF

 

DECEMBER 2022

A Game Changer for Street Medicine:
Key Takeaways from New Medi-Cal Guidelines

treet medicine is a critical but underutilized model

for delivering health care to people experiencing

unsheltered homelessness and connecting them
to social services, including housing. In November
2022, California's Department of Health Care Services
(DHCS) released an All Plan Letter that provides new
guidance to Medi-Cal managed care plans that will
make it easier for communities to establish, maintain,
and fully leverage street medicine programs. This
issue brief lays out the major implications of this new
policy, as well as key issues that remain.

What Is Street Medicine?

Established in the early 1990s, street medicine is the
provision of health care and social services directly to
people who are unsheltered in their own environment
and outside of the four walls of a traditional brick-and-
mortar clinic or hospital setting.

As the Street Medicine Institute explains, "The fun-
damental approach of street medicine is to engage
people experiencing homelessness exactly where they
are and on their own terms to maximally reduce or
eliminate barriers to care access and follow-through.
Visiting people where they live - in alleyways, under
bridges, or within urban encampments - is a neces-
sary strategy to facilitate trust-building with this socially
marginalized and highly vulnerable population. In
this way, street medicine is the first essential step in

achieving higher levels of medical, mental health, and
social care through assertive, coordinated, and collab-
orative care management."

Street medicine exists on a broader continuum of
medical outreach that also includes care provided at
shelters, mobile medical units, and medical RVs. While
each of these approaches is important in its own right,
this brief focuses specifically on street medicine and
new opportunities to expand that model of care in
California.

Street Medicine in California

Over the past few decades, street medicine has
evolved from a grassroots movement to an estab-
lished area of medicine, with programs in existence
both nationally and internationally. In California, there
are at least 25 street medicine programs in opera-
tion. These programs are primarily clustered around
the San Francisco Bay Area and Los Angeles, though
other programs exist in communities such as San
Diego, Bakersfield, and Redding.

Nearly half of these existing programs are associated
with a Federally Qualified Health Center (FQHC). The
rest have a variety of sponsoring organizations from
hospitals, health plans, academic institutions, and
local governments.

COMING SOON. In early 2023, CHCF will publish a new landscape report on street medicine in California from authors Brett J.
Feldman, MSPAS, PA-C; Corinne T. Feldman, MMS, PA-C; Alexis Coulourides-Kogan PhD, Sonali Saluja MD, MPH, FACP; and
Michael Cousineau DrPH at the Keck School of Medicine of the University of Southern California, Division of Street Medicine.
Variation exists across California's street medicine pro-
grams. Each has created unique ways to reflect local
circumstances and meet the needs of people experi-
encing homelessness within their communities. Most
programs use team-based approaches to provide a
mix of primary care, urgent care, and care focused
on unmet social needs. There is also widespread use
of peer professionals and community health work-
ers to help with outreach, engagement, and care
coordination.

To date, most programs in California have relied on
grant funding to cover the cost of providing services.
That is true even of health center-based programs,
where Medi-Cal reimbursement for street-based ser-
vices continues to be the exception rather than the
norm. Historically, there was no Place of Service Codes'
that providers could use for care delivered outside a
facility. In addition, street medicine providers had no
clear guidance or precedent for how to contract with
Medi-Cal managed care plans and bill for services.

Two big changes have the potential to help provid-
ers of all types develop and sustain street medicine
programs. First, in late 2021, DHCS released a new
billing notice for street medicine providers that clari-
fied that both enrollment in Medi-Cal and delivery of
service could happen outside of traditional health care
settings in fee-for-service Medi-Cal. This helps people
get enrolled in Medi-Cal and means that services pro-
vided by street medicine providers can be reimbursed
before someone is enrolled in managed care. Second,
the agency provided guidance in the form of an All
Plan Letter, to help Medi-Cal managed care health
plans and local providers take advantage of opportu-
nities to deliver street medicine in their region.

All Plan Letter: A Game Changer
for Street Medicine

On November 8, 2022, DHCS released an All Plan
Letter pF) to Medi-Cal managed care health plans
on the use of street medicine to address the health
needs of Medi-Cal members experiencing unsheltered
homelessness. The purpose of an All Plan Letter is to
provide clarification and guidance to managed care
plans affected by any Medi-Cal policy change. All Plan
Letters are the means by which DHCS conveys informa-
tion or interpretation of changes in policy or procedure
at the federal or state level. It provides instruction to
managed care contractors on how to implement these
changes on an operational basis. In this case, it clarifies
for street medicine providers exactly what they need
to do to participate in Medi-Cal managed care.

The All Plan Letter from DHCS has the potential to
dramatically expand the scale and spread of street
medicine in California. There are three key reasons
why DHCS' latest guidance has the potential to be a
game-changer for street medicine in the state. The All
Plan Letter:

> Provides a stable and flexible source of funding for
street medicine programs

» Enables street medicine teams to deliver whole-
person care

> Makes it easier for people experiencing homeless-
ness to access their full range of Medi-Cal benefits

Providing a Stable and Flexible Source

of Funding

Until now, street medicine programs had to cobble
together funding to cover their costs. That lack of pre-
dictable, stable funding made it hard for established
programs to sustain and grow and for new programs
to launch. With the All Plan Letter guidance, there is
now clarity on the multiple ways providers, commu-
nity-based organizations, and local governments can
get reimbursed for street medicine in partnership with
Medi-Cal managed care plans in their region.

 

California Health Care Foundation

www.chcf.org 2
Plans can now contract with different types of street
medicine teams and allow them to bill for providing
care in the streets. Previously, a provider delivering
street medicine had to be part of a brick-and-mortar
primary care facility, like an FOHC, in order to even
consider billing for their care. That is no longer the
case. This guidance now enables street medicine
teams affiliated with academic centers, hospitals, and
community-based organizations to bill for primary care
even if they aren't affiliated with a traditional brick-and-
mortar primary care clinic. Notably, a street medicine
provider will not have to be the primary care provider
assigned to the member by the managed care plan in
order to provide care and get paid. The person can
now become a referring or treating provider and will
not need a specific authorization to provide services.
This provision also helps in cases where street medi-
cine teams do not want the responsibility of delivering
all the requirements of a primary care medical home,"
as outlined in the All Plan Letter.

Another change is that in the past a Medi-Cal mem-
ber experiencing homelessness had to personally call
and request to be assigned to a particular primary care
provider. Under the All Plan Letter, a street medicine
primary care provider can call the plan together with
the member, and both make the request to become
that person's assigned primary care provider. For pro-
viders contracted as both a referring and a primary
provider, this change makes it much easier to ensure
that they are getting reimbursed for patients they are
treating in the streets, especially given that it can take
up to 30 days for a new primary care assignment to
start.

Enabling Street Medicine Teams to Deliver
Whole-Person Care

Under CalAIM, Enhanced Care Management is a
new statewide Medi-Cal benefit designed to facilitate
whole-person care. Specifically, it enables Medi-Cal to
cover the cost of a care manager to coordinate clini-
cal and nonclinical care and services across multiple
systems (namely physical, behavioral, dental, devel-
opmental, and social services), making it easier for

patients to get the right care at the right time. People
experiencing homelessness are one of the popula-
tions of focus for Enhanced Care Management.

Under the new policy, managed care plans may now
contract with street medicine providers to become an
Enhanced Care Management provider. This change
will allow street medicine programs to get reimbursed
for important functions like care coordination and to
cover the cost of important nonclinical members of
street medicine care teams, like community health
workers, neither of which have historically been bill-
able services. That in turn will give street medicine
teams the tools and capacity to not only provide direct
primary care but to also manage their patients' full
range of needs, including specialty physical or behav-
ioral health, pharmacy, housing supports, and other
social services.

Making It Easier for People Experiencing
Homelessness to Access the Full Range of
Medi-Cal Benefits

Before this new policy, street medicine providers could
provide direct care, but many did not have the full
scope that a designated primary care provider would
have under managed care rules. For example, they
could not refer patients they care for on the street to
physical or behavioral health specialists or for impor-
tant diagnostic tests. Instead, they would need to call
the primary care provider assigned to the patient by
the managed care plan and ask them to put through
the referral. If the primary care provider did not know
the patient, they would ask the patient to come see
them before intervening, inevitably leading to delays
in diagnosis or treatment.

By allowing street medicine providers to become des-
ignated primary care providers, unhoused Medi-Cal
members will now have easier access to the full range
of their Medi-Cal benefits, beyond direct primary care
on-site. This opens up the possibility for street medi-
cine patients to have many more of their needs met in
a timely manner and in a much more person-centered,
responsive way.

 

A Game Changer for Street Medicine: Key Takeaways from New Medi-Cal Guidelines 3
Areas to Watch

DHCS's new guidance removes many barriers and
creates new opportunities for the sustainability and
spread of street medicine. Still, there are several areas
to watch as implementation unfolds.

What Are the Practical Realities of Launching
New Street Medicine Programs?

Existing street medicine programs are best positioned
to take advantage of the new street medicine guid-
ance. Without Medi-Cal reimbursement, it has been
difficult to sustain those programs, let alone grow their
reach. The new policy largely solves that sustainability
problem. Starting a new program, however, is a much
bigger lift. Providers and communities that want to
launch new street medicine programs will need more
intensive, up-front capacity-building support. Under
the American Rescue Plan Act, California has $1.3 bil-
lion in Housing and Homelessness Incentive Program
(HHIP) dollars to incentivize Medi-Cal managed care
plans to invest in new homeless service programs.
Plans should consider using some of those funds to
develop new street medicine programs. CalAIM's
PATH CITED dollars could also be leveraged for street
medicine teams that contract with or intend to con-
tract with managed care plans to provide Enhanced
Care Management contract with or intend to contract
with managed care plans to provide Enhanced Care
Management.

What Can Be Done to Reduce the
Administrative Burden?

Street medicine providers will have to clear several
administrative hurdles before they can take advantage
of these new Medi-Cal reimbursement opportunities.
For example, they will have to set up billing systems,
as well as systems for data collection and data shar-
ing. While these steps might be easier for hospitals,
FQHCs and academic medical centers, they could
pose a bigger challenge for independent provid-
ers and community-based organizations. It is worth
exploring how funding programs like HHIP and PATH

could be used to provide technical and financial assis-
tance to help street medicine programs solve their
administrative challenges.

What If an Unsheltered Patient Is Already
Assigned to Another Primary Care Provider?
In the rules embedded in many claims systems, only
the designated primary care provider can get paid
for primary care services. In many cases, Medi-Cal
members are auto-assigned to a provider. If a street
medicine provider tries to treat that person and wants
to get reimbursed for it, the provider would either
need to get paid without being the primary care pro-
vider of record, or get that person to call their plan to
have their provider changed (and that often doesn't
even take effect until the first of the next month). The
All Plan Letter suggests a workaround: encouraging
plans to set up street medicine providers as con-
tracted or referring providers through direct contracts
that supersede any delegated arrangements. Even
with the fix, one could argue that this arrangement is
needlessly complicated and that the added complex-
ity itself could be a barrier to the effective deployment
of street medicine.

Will Reimbursement Rates Cover the Actual
Cost of Street Medicine?

Delivering street medicine is more expensive than
providing care in a health care facility. Street medicine
providers also tend to a greater array of health and
social needs than traditional primary care providers
do. The All Plan Letter does not include guidance on
rates, but existing reimbursement rates may not be
enough to cover the costs of street medicine. It may
be, however, that this rate shortfall could be mitigated
if street medicine providers also signed up to be an
Enhanced Care Management provider. This action
would help offset the costs of the types of coordina-
tion and support that come from other team members,
like community health workers and care coordinators.

 

California Health Care Foundation

www.chcf.org 4
What Are the Particular Implications for Street
Medicine and FOQHCs?

Due to specific payment rules for FOHCs, it is pos-
sible that the rate that FOHCs would receive for a
primary care visit at their facilities is higher than the
rate they would receive for a street medicine visit.
The difference could inadvertently create a disincen-
tive for FOHCs to deploy or grow street medicine
programs. The Alternative Payment Methodology
under development may offer a solution, given that it
grants FQHCs more flexibility in who delivers services
and where they are delivered. The issue is worth moni-
toring as the street medicine guidance and payment
reforms for FOHCs are implemented over time.

How Will the All Plan Letter Impact Other
Models of Care for People Who Are
Unsheltered?

Providing care to unsheltered Californians will neces-
sitate an approach that includes a panoply of different
health care delivery models, like mobile medical units
and medical RVs. DHCS's new guidance, while a game
changer for street medicine, does not address con-
tracting and billing for other mobile health models. It
will be important to track the growth and impact of the
various models and ensure that those with the most
potential to improve health and housing outcomes
have every opportunity to grow and scale.

About the Foundation

The California Health Care Foundation (CHCF) is
dedicated to advancing meaningful, measurable
improvements in the way the health care delivery
system provides care to the people of California,
particularly those with low incomes and those whose
needs are not well served by the status quo. We work
to ensure that people have access to the care they
need, when they need it, at a price they can afford.

CHCF informs policymakers and industry leaders,
invests in ideas and innovations, and connects with
changemakers to create a more responsive, patient-
centered health care system.

 

Endnotes

1. Place of Service Codes are two-digit codes placed on health care
professional claims to indicate the setting in which a service was
provided. POS information is often needed to determine the
acceptability of direct billing of Medicare, Medicaid, and private
insurance services provided by a given provider.

2. The primary requirements of a medical home are: basic case
management (with transition to basic population health
management when effective); care coordination and health
promotion; support for members, their families, and their
authorized representatives; referral to specialists, including
behavioral health, community, and social support services,
when needed; the use of health information technology to link
services, as feasible and appropriate; and provision of primary
and preventative services to assigned members.

 

A Game Changer for Street Medicine: Key Takeaways from New Medi-Cal Guidelines 5