Founded: 1970
Budget: $49.5 million
Patients served in 2020: 25,689
Patient visits in 2020: 133,418
Employees: 421 372 FTEs
Providers: 41 57 FTEs
Locations: 24

Homelessness afflicts growing numbers of Californians, all across the state. The economic downturn of the pandemic has caused thousands more who never imagined themselves without a place to live to be uprooted from their dwellings and forced out into the streets and parks. 

The homelessness crisis introduces special challenges to healthcare providers and service agencies. Populations of homeless people have distinct medical issues, not usually shared in the broader population, and they are notoriously hard to find and care for and follow up on. 

In San Diego a provider organization has adapted its model of care to specifically address the needs of the unhoused. La Maestra Community Health Centers goes out to the encampments, underpasses, and ravines where they congregate and gives them the kind of care they need. 

“We do a lot of wound care, cellulite, abscesses, and medication refills,” said Edith Elenes, a physician’s assistant who works directly with the homeless. “What is their past medical history? Do they need meds? Do they have scabies? It’s anything and everything.” 

A lot of patients use substances and alcohol, and they have falls after becoming intoxicated. The La Maestra Homeless Outreach Team (HOT) will clean them up and help them get back on their feet.  

For example: “I had a lady who said she sat on the grass and her pants had fallen lower than her butt, and it was a reaction to the grass,” Elenes said. However, her story didn’t add up with her medical problem. “She had a really bad infection, and we had to treat it with antibiotic. I have seen her many times, and I know she also uses, so I know there was more to it.”
 
For people who have been on the streets a long time, a major health issue is lack of basic hygiene, and inability to wash clothes or shower. They get infections from scrapes or bumps that could have been avoided if they’d had housing or access to a washroom. Minor problems morph into medical issues requiring intervention. 

And mental health has a great deal to do with the medical problems these patients face, said Javier Rodriguez, MD, medical director and chief medical officer at La Maestra. “Lack of insight, lack of judgment – the disease states in mental health are that much higher.” Elenes estimates that 90% of her patients also have some kind of mental health disorder. 

Middle class people would not suffer these kinds of issues. And in the context of a medical family practice, a PA like Elenes would not normally treat them. 

In family practice, she noted, “People will take care of their issues when they start, versus the homeless population, where they wait, or they don’t prioritize their health until they absolutely need to, or they do ER visits. Which is part of the reason we’re there, to keep them out of the ER.”

And at the moment, keeping them out of the ER has to be a top priority, said Cynthia Kaser, chief community programs development officer at La Maestra. “You don’t want non-critical needs going to the emergency room, because they are overflowing with Covid cases.”

La Maestra has two mobile units that it dispatches on a schedule to the locations where homeless people gather.  The clinic-on-wheels has a patient exam room and two dental chairs. A second unit offers mammograms. 

These mobile clinics take La Maestra’s providers out into the community, eliminating the need for homeless or other low-income patients to make their way to a brick-and-mortar clinic. “When we can bring two units together, we can perform clinical breast exams, pap smears, then they can walk into the other unit and get a mammogram,” Kaser said. “This has great impact for many women who never thought they would be able to have those services so easily accessible.” 

The barrier for many of these individuals is that their homeless encampment, in a tunnel or behind a bush, is effectively their home. “They carry their house with them,” Kaser said. The La Maestra care teams go out to these sites as a united force with other agencies who might help with food or addiction treatment or getting a driver’s license. “We can say, ‘We have a mobile medical clinic that can see you right now.’ Right now is the moment!”

When COVID-19 arrived, the city of San Diego turned its vast convention center into a shelter with services for the homeless. They sleep on cots six feet apart, and get showers, laundry, and three meals a day. For the duration of the pandemic, the mobile vans go to the convention center on Fridays and address the residents’ medical problems. Other days of the week, the mobile vans visit state prisons or accompany the San Diego Police Department’s homeless outreach team to different corners of the city. 

Founded in 1986, La Maestra didn’t start out as a health clinic but rather as an amnesty center for immigrants and refugees. The founders were teachers and immigration activists who gradually gained the trust of the people they served. The immigrant families asked La Maestra for help gaining access to healthcare services. 

“Local providers were not meeting their needs,” Rodriguez said. “They were not culturally sensitive or appropriate. There were linguistic issues, and distance is always an issue. Patients have a lot of fear and trauma in their lives coming from war-torn countries, making long journeys where they suffered along the way.”

From the very beginning, social determinants of health were integral to the program, said Zara Marselian, La Maestra’s CEO and guiding light. La Maestra became an FQHC in 1990 and has continued to add services under a holistic Circle of Care model that includes housing, legal advocacy, food security, addictions treatment, behavioral health, financial literacy, and a panorama of related offerings. The goal is to help individuals and families achieve self-sufficiency. 

“Many of their medical needs stem from these adverse social determinants,” Marselian said. The key to making the patients comfortable with the medical providers is to invest in building their trust. And the way you do that is through developing cross-cultural competency at every layer of the organization. The clinic staff must align with the patients they service, either through language or life experience or training. 

This cultural fluency helps sustain a two-way information flow in the clinic. Not just from the providers to the community, Marselian said, but “the patients sending back information that is very pertinent about the way they interpret the world. What are their beliefs? What are their preconceptions about certain treatments? Unless we know that, we can’t bring a message that makes any difference to them.” 

A recent example: La Maestra had some refugees who understood that the test for diabetes is what causes diabetes. “If we hadn’t gained that knowledge, we could not have known how to craft a message that would address those barriers. You can’t take the same message and give it to all the subgroups,” she said. “The same with the homeless. Unless we’re willing to address their biological, psychological, and social unmet needs, we are not going to get very far.” 

To make the connection, La Maestra hires from the Somali community, or the Sudanese, or the Iraqi – and of course the various Latino communities from Central and South America. Nineteen different languages are spoken in the clinics daily. La Maestra helps its employees identify their interests, and then invests in training and certifications to raise their skills. “Then you end up with a wonderful staff that these populations relate to,” Marselian said. “It’s kind of a no brainer.” 

For many years, Kaser said, the attitude was, “homeless go away, we don’t want you here.” Now there is a different approach: “Come over here, we want to see you, we want to take care of you”. 
 
“It’s critical we have hope for them,” she added. “Their clock may not ring today. But it might some other day, and hopefully take them off the streets.”