Central Health is creating a bridge in medical care with new clinic for homeless patients

Yahoo

27-03-2025

Daniel Perez says he almost died three times a year ago because of an opioid overdose. One time he ended up in a hospital intensive care unit.
After the hospital, Perez relapsed and was jailed before being sent to Integral Care's diversion program. Integral Care is the public mental health, substance use and intellectual disabilities services provider for Travis County.
The diversion program brings people to mental health and substance abuse care centers instead of the hospital or jail. Integral Care has converted a former Ronald McDonald House into a 24-bed respite center that opened in October and where participants receive mental health and/or substance abuse care for up to 90 days.
Beginning in February, the respite center also started receiving weekly medical care from Central Health's Bridge Clinic program.
Central Health, which is the hospital district for Travis County and provides medical care for people making less than 200% of the federal poverty level by using property tax dollars, launched a physical Bridge Clinic in June at Central Health's Capital Plaza Specialty Clinic at 5339 N. Interstate 35.
The Bridge Clinic's focus is on providing medical care to the unhoused population instead of sending them to a hospital emergency room for treatment that a primary care doctor should provide.
The clinic is a partnership with Austin-Travis County Emergency Medical Services. Patients can either find their way there, or often EMS will bring them to the clinic instead of the emergency room.
Central Health's 2024 demographics study, which came out in March, includes statistics on the unhoused population it serves, as well as populations based on U.S. Census tracts. That report collected data from July 2022 through June 2023, before Travis County and Integral Care formally created the diversion program and before Central Health started the Bridge Clinic. The data shows a huge gap between being admitted to the hospital and having a safe place afterward, said Jessie Patton Levine, the analytics quality manager with Central Health, during a March board meeting in which the demographics study was presented.
In that study, behavioral health, cardiovascular disease, high blood pressure and substance use disorders were the most common chronic conditions treated in people experiencing homelessness. They had two to four times higher rates of behavioral health, substance use disorder and kidney failure compared with all enrollees in Central Health's Medical Assistance Program, which is similar to an insurance program through the hospital district. Chronic respiratory illnesses such as asthma and chronic obstructive pulmonary disease also were higher.
The unhoused population also had a high reliance on going to the emergency room for their care vs. going to a primary or specialty care clinic. Trips to Dell Seton Medical Center, the safety net emergency department for Travis County, were twice as much as any of the other clinics or hospitals for these Central Health patients.
The patients who are unhoused also had lower rates of cancer and diabetes care than other Central Health populations, which doesn't mean they didn't have those conditions. It just means they were not being diagnosed with them as often, in part because of a lack of continual care from a primary care doctor.
The report states: "The data underscore persistent disparities, particularly among racial and ethnic groups, as well as the increased medical complexity of the unhoused population."
The Bridge Clinic focuses on making it easy and less stressful to get medical help. Patients don't have to have an appointment or be an established patient with the clinic. They can come anytime from 8 a.m. to 5 p.m. Monday through Friday. There is a side entrance to avoid a traditional waiting room, which is another obstacle to seeking care.
"We are meeting patients' needs without asking them to conform to traditional medical models or a traditional primary care model where they have to show up on time and there's a wait period and there are all these barriers," said Dr. Pheba Thomas, the physician lead for the clinic.
Sometimes patients are exhausted by the time they arrive at the clinic, said Dr. Audrey Kuang, Central Health's co-director of high-risk populations and founder of the Bridge Program. It makes a difference that they can come to the clinic, take a rest and then see the doctor, she said.
If the team comes at the patient right away about fixing their blood pressure, "we're not gonna accomplish anything and that patient's going to leave being like, 'I just got berated at this office and nobody's helpful,' versus if you say, 'take your time, have a snack, soak your feet, do what you need to do first, and then we'll talk about everything else later," said Dr. Jennifer Nunes, a physician at the clinic.
The clinic has four patient rooms but is housed in the same building as the specialty care clinic, which means the clinic's doctors can consult with gastroenterology, hepatology, infectious disease, a dietician and palliative care, as well as having a pharmacy and an ultrasound available down the hall. CommUnity Care also has a substance abuse clinic in the same building.
One of the things that makes Bridge Clinic doctors most happy is the over-the-counter medications and supplies they keep to give to patients. These include pain relievers, fungal cream, iron pills and antacids.
"What's hard for us, it's not being able to give things to our patients we know they need. ... Knowing our patient needs it, deserves it, it would make them feel better, it's part of their treatment plan." Kuang said. "I think that's why we get so giddy with this."
Once they have created a connection with patients, Kuang says they are seeing them return for follow-up visits or the next time that they have a health concern. The clinic can arrange rides for patients to get to the clinic if they know what area of town the patient will be in at what time.
"There are so many people lost in the system," she said. "I feel like we're one family looking out for our neighbors and our community," she said.
While patients can come to the physical Bridge Clinic any Monday through Friday, on certain days the clinic staff also brings care to the community: the Integral Care respite center on Mondays and the city of Austin's Eighth Street Shelter for Women on Wednesdays.
A nurse and medical assistant pack up all the supplies they will need from the Central Health offices at 1400 N. Interstate 35, the site of the old Austin Children's Hospital, and drive it to the location. Then a doctor helps them unload and set up the clinic for the day, including a secure internet service for logging patient records.
At the Integral Care respite center, one room becomes where patients arrive and get their vitals checked, as well as talk to the nurse and the medical assistant about any services they might need. Another room is the doctor's office.
On a Monday in March, Jalen Reasonover, a medical assistant, is taking Perez' blood pressure and blood oxygen level, as well as taking some blood for basic lab work. Perez asks if there is any way they could get him some eyeglasses. Nurse Lana Sherrill tells him they will have a voucher for an eye checkup and a pair of glasses when they come back next Monday.
Inside the doctor's office, Dr. Tim Mercer, Central Health's co-director of high-risk populations and an associate professor of Population Health at Dell Medical School, examines Perez with a stethoscope and feels Perez's ankles for any swelling. They talk about Perez's improved blood pressure and run through the other things Mercer has been working on with Perez: pain in his back, difficulty using one of his hands and wrist, and a boil from a stab wound in his knee that doesn't seem to want to go down.
Mercer then looks at the boil, which will need an ultrasound and a follow-up appointment with a surgeon. The clinic will schedule those for Perez.
Mercer also sends a prescription for a year's supply of blood pressure medicine as well as Narcan, should Perez choose to use opioids again, and talks to him about using fentanyl test strips and not using drugs alone. He advises against using Xanex on the street because most likely it has been laced with Fentanyl.
Mercer talks without any judgement, making Perez feel more open to not hide his past drug use.
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Perez's goal when he leaves the respite center is to work in construction, after he gets new copies of his Social Security card and his driver's license, which he lost.
The clinic has its own social worker to help patients get what they need and connected to programs and resources they might want. This includes making sure they have medical care through either Medicaid or Central Health's MAP program.
Housing is one of the biggest wants. In Kuang's ideal world, the Bridge Clinic staff would have housing vouchers they could hand out. Perez has been on wait lists for housing, he says, since 2022.
Mercer's big picture goal is for Central Health to have the agencies providing the care work in partnership and continue to break down barriers to health care.
"We have a lot of work to do," he said.
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This article originally appeared on Austin American-Statesman: Central Health establishes Bridge Clinic for homeless patients