Meet The Doctor Who Wants To Prescribe Housing
This is the second in a three-part series about housing and healthcare. Listen to parts one and three here.
I meet Dr. Josh Bamberger on the corner of Golden Gate and Leavenworth in the Tenderloin near the Kelly Cullen Community Housing.
“So this building is the largest permanent supportive housing facility in San Francisco — 172 units. It was built from the old YMCA, which was built to house people who lost their housing after the 1906 earthquake,” Dr. Bamberger says as we zig zag up Golden Gate, Eddie and Ellis streets.
He points out various clinics he worked at and started.
"Every building has these stories of different eras, and if you look at everything from a health lens, you’re like, 'Well like this had some things going on...'"
Things, he says, that show the history between city run housing and healthcare.
One of the first times the San Francisco public health system considered the importance of housing was in the late 80s and 90s. And that had a lot to do with the AIDS epidemic gripping the city. We walk toward the Windsor Hotel on Eddy Street, which has over 90 units. Bamberger says it was the first batch of permanent supportive housing that had a full time nurse on staff. He ran a clinic here in the basement 15 years ago.
“And we've been able to take care of some very sick people, very sick seniors successfully for many, many years now.”
He says when he was starting his medical career in the Tenderloin he wished he could offer something more to his sickest homeless patients.
“We would always be brokering housing or saying, ‘Oh, if we could only get this person housed’ as they cycled in and out of the emergency department, the streets, and shelter, and then back to the emergency department. We had no idea that that was even an option.”
He says it really took his patients to teach him how important housing as a treatment option could be. Bamberger points to a time during the 90s when he was caring for people with HIV experiencing homelessness.
“And yet even when people were taking their medicines, they weren't doing nearly as well as the people who are housed. And then you'd have the few people who get housed through hook or by crook, and it’s like, ‘Hey, they're doing great.’ AIDS becomes a chronic disease and they're living a full length of life. So, it was through those experiences that it became clear that if I didn't have a way to prescribe housing in addition to antiretrovirals, then people wouldn't get better.”
And then, a director with a similar vision was appointed to the department of public health. Dr. Bamberger says that between 1999 and 2013, the health department created 150 new units of housing a year through the healthcare system. And they’d refer it to patients they thought needed it.
“We would get referrals from social workers who are doing outreach, social workers within the hospitals, and they would send us a story,” then, he says, a nurse practitioner or a physician's assistant would visit, “And even listen to their lungs with a stethoscope to see how sick they were. And then, based on that assessment, we would prioritize them towards the limited number of vacancies that we had.”
It didn’t catch everyone, but Dr. Bamberger says the system was working. Still, in the last decade, housing moved out of the health department and eventually shifted to the Department of Homelessness and Supportive Housing.
But when COVID-19 hit, the pendulum swung back, for a year at least. Access to housing is still part of the homelessness department, but healthcare has been more of a priority. The city did major outreach to find the most medically at-risk, elderly folks and people with underlying conditions, and offer them housing in San Francisco’s shelter-in-place hotels.Thousands moved off of the streets and started getting regular medical check-ins.
“First of all, people didn’t die,” he says. “The mortality rate was almost two and a half times as high among the people who are on the streets. So, you know, you don't have to go to medical school to know that death is something you're trying to avoid in medicine. It's a fantastic argument why health care and housing need to be integrated.”
Doctors and nurses essentially did house calls to each room and got a sense of the health of the city’s most vulnerable unhoused population.
And through this big assessment, Dr. Bamberger says they found out something important: most seniors do fine when they’re given access to existing permanent supportive housing. But they also learned that a very small percentage — only about 140 people — need extra medical care that isn’t widespread outside of the city’s temporary shelter-in-place hotels.
“What we need to figure out is a way to catch those people on the street — or in shelters, or already housed — and have a way to move them to the next level of care, so that — as their dementia progresses, or their congestive heart failure progresses, and they can't even take a few steps without being short of breath — that we have somebody on site to assist them.”
If someone is unhoused and has a condition like dementia, or incontinence or another health problem that gets worse with age, there aren’t many options out there. Currently, someone could land a spot in senior housing and use Medical to pay for a support worker who could cook for them or bathe them.
But, Dr. Bamberger says, "If they have even less mobility or more dementia, you know, getting lost on the streets, the only option is to have them fail enough so that they end up cycling into the emergency department and then maybe be placed in a nursing home. Now, that's not where most people want to be.”
He tells me about one senior patient who would benefit from getting a spot in a board and care facility, housing with round the clock medical care. But, he’s living in an SRO with dementia that’s just getting worse.
“Actually, his SRO happened to have a fire about a month ago. So, he was disrupted from his regular routine and was quite lost. He's wandering the streets of San Francisco. He can't really find his way home. He's getting wounds on his legs.”
He’s really in bad shape and Dr. Bamberger says there’s nowhere to place him.
“He won't live very long, which I suppose is a comfort. But, that's not really how I want things to go.”
This small number of seniors who need extra care may only be a few hundred right now, but Dr. Bamberger expects that group will get bigger. The median age of San Francisco’s unhoused population is increasing. It was 37 back in the 90s, now it’s closer to 50. And more and more people are entering homelessness at an older age.
“If we can't figure out how to find this level of care for people who are too sick to live independently, but not sick enough to need a nursing home ... it is just going to be an inordinate amount of suffering among our seniors ... It's a relatively small number of people that we just have to figure out a way to do that. And not doing so is just a failure.”
The challenge, he says, is figuring out how to pay for it. Dr. Bamberger hopes a new mobile nursing team outlined in this year's city budget could be a first step.
Angela Johnston reported this series while participating in the USC Annenberg Center for Health Journalism‘s 2021 California Fellowship.