"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
Context: As of 2018, an estimated 53,000 individuals were experiencing homelessness throughout Los Angeles County.i Nearly one-third describe their health as poor, and the American Public Health Association reports that 73% of individuals experiencing homelessness nationwide describe ≥ 1 unmet health need.ii Student-run free clinics (SRFCs) represent one effort to extend healthcare to the homeless community and other vulnerable groups – in fact, the number of SRFCs nationally has more than doubled from 111 in 2005 to 208 in 2014.iii The UCLA Mobile Clinic Project (MCP) is one such SRFC founded approximately 20 years ago to improve the health and wellbeing of homeless and vulnerable individuals in Los Angeles County. True to its name, MCP does not operate out of a building or fixed indoor space; rather, it is an outreach effort providing streetside medical and social services. While this structure enables MCP to better meet patients on their terms and in their environment, it also curtails the scope of services that MCP is able to provide onsite. As a result, MCP often must send patients to follow up with outside service providers when they have more specialized health and social needs that extend beyond what MCP can offer.
These recommendations are not conventional referrals – MCP providers simply offer information to patients regarding walk-in hours and give directions to sites. Although the conventional “outreach and referral” model works in theory, an array of interpersonal and structural barriers prevent patients from completing referrals and receiving services for which they are eligible. These barriers include lack of transportation, difficulty completing paperwork, and negative experiences with healthcare providers.iv,v Patients routinely shared experiences of being turned away, talked down to by providers, and even having police called on them when seeking care. Recognizing a need for further support and advocacy, MCP staff created the Companion Care program in 2016 to alleviate obstacles to healthcare and improve health equity for our patients.
Companion Care uses student community health workers - companions - to accompany patients through every step of establishing care and attending their medical appointments. Given the unique barriers that individuals experiencing homelessness face, patient navigation services can mitigate logistic challenges posed by traditional healthcare settings and have been shown to improve quality of life and reduce health systems costs.vi, vii, viii, ix Homelessness researchers have noted the importance of community health workers and navigators in promoting positive health behaviors and long-term, trusting connections to systems of care for people experiencing homelessness.vi,x Thus, Companion Care works connect patients to the existing continuum of care in order to provide more stable, lasting solutions to their health and social needs.
Design: Student Volunteers: Companions are UCLA students who have previously volunteered for one year with MCP as outreach caseworkers; this ensures a degree of interpersonal and structural competency with vulnerable populations. Students serving as outreach caseworkers previously had limited opportunities to remain involved with MCP following their fixed one-year term, despite expressing significant interest in continuing to work alongside the homeless community. Companion Care intentionally recruits companions from this population to provide additional opportunities for service for exceptionally committed students. Applicants commit to volunteering with Companion Care for at least one year. Students do not receive academic credit or pay. The current volunteer cohort consists of 37 companions, with oversight by faculty advisors and a leadership committee of public health, medical, and undergraduate students. Training involves multiple sessions that address the concept of accompaniment, program logistics, and situational case studies to help volunteers strategize for complex situations. Companions are also required to attend monthly meetings to continue learning about homelessness and public health through lectures and seminar-style discussions.
Patient Recruitment: Each week, two companions attend MCP’s clinic and eligible patients are recruited (Figure 1) to fill 1-3 standing appointment slots guaranteed at our partner clinic. At MCP, companions assess health needs, establish goals, and identify barriers to care (Figure 2). They then schedule same-week appointments with trusted providers at a partner clinic and assist financially and logistically with transportation arrangements (Figure 3). When possible, companions provide appointment reminders via email or phone; these same companions will then accompany enrolled patients to partner clinics.
Figure 1: Companion Care Eligibility
Figure 2. Companion Care Client Intake Form
Figure 3. Companion Care Program Flow
Partner Clinics: Companion Care partners with local clinics that specialize in primary care for underserved communities. These clinics operate on a sliding scale with fees waived for most homeless patients. Prior to establishing formal relationships with partner clinics, Companion Care leadership meet with clinic staff and observe clinic operations to ensure suitability for Companion Care patients. Per partnership agreements, clinics set aside 2-3 guaranteed appointment times for Companion Care patients each week. The Companion Care leadership team and community clinic staff routinely meet to troubleshoot and discuss opportunities to improve Companion Care for all stakeholders.
Accompaniment: Companions are with patients for each step of their appointment: traveling with them to clinics, assisting with paperwork, sitting with them in exam rooms, and directly advocating with physicians. Assistance with on-site health insurance enrollment is provided for those who are eligible but not yet covered. Following the visit, companions strategize follow-up plans with patients - providing support as needed and reminders for follow-up visits. Companions also work within partner clinics’ existing services to connect patients to resources like social workers, substance counseling, and HIV care.
Impact: No two Companion Care appointments are alike—services are tailored to each patient’s unique situation. Though formal data was not collected on referral success rates by MCP prior to Companion Care’s inception, many patients anecdotally described challenges in utilizing MCP’s conventional off-site referrals, leaving a gap between the mobile clinic and Los Angeles’ broader service system. In terms of healthcare utilization, only 20% of Companion Care patients at the time of enrollment reported having consistent primary care providers – 12% utilized the emergency department for care, 20% used community clinics sporadically, and 48% received no care whatsoever (other than MCP). Companion Care alleviates common barriers with transportation subsidies, guaranteed appointments, and same-day insurance sign-ups, and addresses more specific barriers with the presence of companion advocates. Based upon preliminary program data collected from August 2017 to March 2019, 180 MCP patients have been enrolled in Companion Care. 66.1% of enrolled patients successfully arrived at the clinic for their appointments, and 68% of enrolled patients felt that they would have been unable to attend their appointments without Companion Care. More formal data collection is ongoing and described in later sections.
In addition to its patient impact, a key aspect of Companion Care is the growth provided to student volunteers and healthcare workers who serve the patients. As future health professionals, the student volunteers gain valuable insights into the challenges individuals experiencing homelessness face in traditional clinical settings (Figure 4). They learn to advocate for their patients and work constructively with clinic personnel to accommodate unique patient needs. Companion Care’s involvement in care helps streamline the clinic appointment. The program’s familiarity with its partner clinics, including their staff and services, allows staff to plan ahead to effectively tailor visits. Assessing health literacy, needs, and goals prior to the appointment facilitates the physician encounter. The program’s future evaluation system is designed to capture information from companions, patients, and partner clinic physicians to identify Companion Care’s impact on all program participants.
Figure 4. Companion Care Story: A Patient and Her Cat
- Patient accompaniment programs provide a low-cost, high-impact supplement to outreach services. Though they require significant energy to initiate, programs like Companion Care amplify the reach of clinics at minimal financial cost.
- CHW programs are not only transformative for patients - they impact the CHWs themselves as well as the health system in which they operate. Our program serves patients while simultaneously providing companions with fulfilling educational experiences and elevating the standard of care at our partner clinics.
- One size does not fit all. Each patient’s needs are unique, and thus the scope of accompaniment that companions provide must be individually tailored to avoid paternalism and encourage empowerment.
- Patients know best. The first to notice gaps in services - and to put forth solutions - are patients. Our quality improvement primarily comes from soliciting patient feedback on their experiences with us and other health services.
Sustainability & Scale-up: As a student-run program, Companion Care is a low-cost, sustainable intervention with significant potential for expansion and impact. Student volunteers provide Companion Care with a motivated workforce that gains first-hand knowledge of public health, social work, and advocacy, and in return companions receive professional development and mentorship opportunities from an existing network of UCLA-affiliated professionals with no cost to the program. Companion Care initially relied on MCP for funding, but the project is now financially independent through UCLA grants and partnerships with Los Angeles clinics, strengthening our sustainability and scope.
In the future, Companion Care intends to expand beyond primary care, as many patients communicate additional needs. Current expansion plans, which are based upon ongoing needs assessments informed by feedback from current patients, include mental health and LGBTQ initiatives and social service partnerships. To better inform protocols and improve practices, Companion Care is also conducting a formal research study to determine the program’s impact on patients’ health outcomes and experiences navigating the healthcare system as well as to generate evidence supporting similar health models for vulnerable groups. Companion Care also plans to facilitate focus groups with past and current patients regarding strengths of the program and ways to improve care for future patients. Companion Care ultimately aims to recruit individuals who have previously experienced homelessness to serve as companions to patients, training them by pairing them with current companions, and utilizing their lived experience as a path for employment and service.
As Companion Care is growing to form initiatives that address a wide variety of needs, it is also working to form a stable foundation for other student-run clinics to model in the future. Companion Care eventually hopes to share its journey and timeline on a digital platform that documents the initial difficulties and obstacles that, upon resolution, strengthened the program.
Acknowledgements: Companion Care is funded by a Homelessness Assistance and Prevention grant awarded by the UCLA Fielding School of Public Health - we sincerely thank them for their support. Furthermore, we express sincere gratitude to all our clients and our companions for their trust, openness, and humility in embarking on this journey for better health and for better lives.
1. David Geffen School of Medicine at UCLA.
2. UCLA Fielding School of Public Health. 3 - UCLA.
i. LAHSA. (18, July 23). 2018 Greater Los Angeles Homeless Count - Data Summary Total Point-In-Time Homeless Population By Geographic Areas. Retrieved September 3, 18, from https://www.lahsa.org/documents?id=2000-2018-greater-los-angeles-homeles...
ii. Baggett, T. P., O'Connell, J. J., Singer, D. E., & Rigotti, N. A. (2010). The unmet health care needs of homeless adults: a national study. American journal of public health, 100(7), 1326-1333.
iii. Smith, S., Thomas, R., Cruz, M., Griggs, R., Moscato, B., & Ferrara, A. (2014). Presence and characteristics of student-run free clinics in medical schools. JAMA, 312(22), 2407-2410.
iv. Campbell, D. J., O’Neill, B. G., Gibson, K., & Thurston, W. E. (2015). Primary healthcare needs and barriers to care among Calgary’s homeless populations. BMC family practice, 16(1), 139.
v. Skosireva, A., O’Campo, P., Zerger, S., Chambers, C., Gapka, S., & Stergiopoulos, V. (2014). Different faces of discrimination: perceived discrimination among homeless adults with mental illness in healthcare settings. BMC health services research, 14(1), 376.
vi. Davis, E., Tamayo, A., & Fernandez, A. (2012). “Because somebody cared about me. That's how it changed things”: homeless, chronically ill patients’ perspectives on case management. PloS one, 7(9), e45980.
vii. Jezewski, M. A. (1995). Staying connected: The core of facilitating health care for homeless persons. Public Health Nursing, 12(3), 203-210.
viii. Reilly, S., Graham‐Jones, S., Gaulton, E., & Davidson, E. (2004). Can a health advocate for homeless families reduce workload for the primary healthcare team? A controlled trial. Health & social care in the community, 12(1), 63-74.
ix. Sarango, M., de Groot, A., Hirschi, M., Umeh, C. A., & Rajabiun, S. (2017). The role of patient navigators in building a medical home for multiply diagnosed HIV-positive homeless populations. Journal of Public Health Management and Practice, 23(3), 276.
x. Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Hirsch, G. R., Willaert, A. M., Scott, J. R., ... & Fox, D. J. (2010). Community health workers: part of the solution. Health Affairs, 29(7), 1338-1342.