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Health Care Services in Alameda
County: Homeless Individuals
Describe Their Experiences
2023-2024
For more information please visit: ALAMEDA COUNTY HEALTH CARE FOR THE
HOMELESS - Alameda County Health Care for the Homeless (achch.org)
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Table of Contents
Acknowledgements ....................................................................................................................................... 3
Project Leadership: ................................................................................................................................... 3
Project Supporters: ................................................................................................................................... 3
About Us ....................................................................................................................................................... 4
The Report .................................................................................................................................................... 4
Background: Homelessness in Alameda County ........................................................................................... 4
Homelessness & Health ................................................................................................................................ 5
Health Equity ................................................................................................................................................. 6
Focus Group Design ...................................................................................................................................... 6
Methods & Limitations ................................................................................................................................. 7
Who Did We Reach? ..................................................................................................................................... 9
Findings: Access, Bias and System Navigation ............................................................................................ 12
System Navigation and Access to Care ................................................................................................... 12
Consistency of Care ................................................................................................................................. 13
Bias, Discrimination and Safety............................................................................................................... 14
Lack of Trust in Service Providers ........................................................................................................... 14
Quality Issues/Inferior Services .............................................................................................................. 15
Experiences with Telehealth ................................................................................................................... 15
Barriers to Treatment ............................................................................................................................. 16
Missing Services ...................................................................................................................................... 16
Lacking Resources ................................................................................................................................... 17
Recommendations from People Experiencing Homelessness .................................................................... 18
Next Steps for Improving Health Care Services for People Experiencing Homelessness ........................... 18
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Acknowledgements
We would like to express gratitude to the individuals who took time to speak with us and
share their experiences. Their trust in us and belief that sharing their experiences will improve
care for themselves and others, is one that Alameda County Health Care (ACHCH) for the
Homeless is deeply committed to fulfilling.
Project Leadership:
Amy Garlin, AC Health, H&H, ACHCH
Andrea Zeppa, AC Health, H&H, ACHCH
David Modersbach, AC Health, H&H, ACHCH
Hanna Toda, AC Health, H&H, ACHCH
Liz Maker, AC Health, PHD, Community Assessment, Planning & Evaluation (CAPE)
Lucy Kasdin, AC Health, H&H, ACHCH
Luella Penserga, AC Health, H&H, ACHCH
Lynette Ward, AC Health, H&H, ACHCH
Phil Clark, AC Health, H&H, ACHCH
Project Supporters:
Abode Services
Bay Area Community Services (BACS)
Women’s Daytime Drop-in Center
Building Futures with Women and Children
CityServe of the Tri-Valley
Cornerstone Fellowship
Damon Francis, Alameda Health System, Homeless Health Center
East Oakland Community Project
First United Methodist Church
First Presbyterian Church Castro Valley
Homeless Action Center
Insight Housing
Multicultural Institute
Operation Dignity
South County Wellness Center
St. Vincent de Paul of Alameda County
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About Us
Alameda County Health Care for the Homeless (ACHCH) is a Federally Qualified Health Center
(FQHC) and division of Housing and Homelessness Services (H&H) within Alameda County
Health (AC Health). Since 1988, ACHCH has addressed the needs of Alameda County residents
experiencing homelessness by directly providing health care services and managing a
contracted network of providers to provide low-barrier, culturally responsive, and linguistically
relevant homeless health care services. ACHCH services include primary care, specialty care,
mobile health, shelter health, street health, substance use disorder services, drug overdose
prevention, dental and optometry care, medical respite, communicable disease response, and
environmental health.
The ACHCH mission is to improve the health of Alameda County residents experiencing
homelessness by ensuring access to culturally informed, whole-person health care and housing
services. One of our core strategies is to improve the health of people experiencing
homelessness (PEH) and mitigate the detrimental health impacts of displacement from housing.
The Report
In the spring of 2023, two Alameda County Health programs- Health Care for the Homeless
(ACHCH) and Public Health Community Assessment, Planning, and Evaluation (CAPE) leadership
collaborated on a project to better understand health care access and services provided to
People Experiencing Homelessness (PEH) in Alameda County. This report reflects the self-
reported experiences of individuals with prior and current lived experience of homelessness
across Alameda County.
Background: Homelessness in Alameda County
With an estimated population of just under 1.65 million, Alameda County contains the cities of
Alameda, Albany, Berkeley, Dublin, Emeryville, Fremont, Hayward, Livermore, Newark,
Oakland, Piedmont, Pleasanton, San Leandro, Union City and Unincorporated County (U.S.
Census Bureau, 2022).
According to the 2024 Alameda County Point-in-Time-Count (PITC, 2024) 9,450 people are
estimated to be experiencing visible homelessness on a single night, with 33% in shelter
projects (3,107) and 67% (6,343) in unsheltered settings. Additionally, there are thousands of
people in Alameda County who remain uncounted because they are doubled-up (i.e., couch-
surfing, sharing spaces with others but not on the lease), as these do not meet HUD’s (Housing
and Urban Development) definition of homeless.
Homelessness in Alameda County reflects racial inequities that disproportionately impact
people of color. For example, for participants in the Coordinated Entry System, Black/African
American people, who comprise just over 10% of the general population, represent more than
half, 53%, of the homeless population” (Alameda County, 2024).
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(Alameda County, 2023)
Homelessness & Health
Access to safe, affordable housing is a key social determinant of health. The impact of
homelessness on people’s health is profound; poor living conditions increase vulnerability to
illness and disease and decrease access to care, often compounding complex health problems.
Self-reported health and disabling conditions from the 2022 Point-In-Time Count demonstrate
the complex needs of an underserved population, who face multiple barriers accessing care,
and often distrust a medical system that has caused and compounded traumatic harm
(Alameda County, 2022).
Health, health care, and housing are interwoven. PEH have worse health outcomes than
individuals who are stably housed. For all causes of death, mortality rates are many times
higher for people experiencing homelessness than the general population (Alameda County,
2022). According to the 2022 Alameda County Homeless Mortality Report, the age-adjusted
mortality rate for people experiencing homelessness in Alameda County was 5.4 times that of
the general population of Alameda County.
People experiencing homelessness have unique health needs and benefit from innovative care
delivery models such as street health programs and flexible, drop-in clinic hours-which
minimize barriers and increase access. Most importantly, services provided through a health-
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equity and trauma-informed lens are key components to foster trust and relationship building.
Health care for people experiencing homelessness also requires improved data sharing and
collaboration to facilitate continuity of care and increased access.
Health Equity
ACHCH envisions a just society, in which all persons have meaningful access to quality health
care and housing. This belief of health equity is the foundation of our mission - to improve the
health of persons in Alameda who are homeless or at-risk of homelessness by ensuring access
to culturally informed whole-person health care and housing services. To achieve this, we must
first and foremost acknowledge the health inequities that impact our communities. The key
drivers of these inequities are often referred to as the social determinants of health, which are
the conditions in which people are born, grow, work, pray and age - all of which are shaped by
distribution of money, power and resources at global, national and local levels are influenced
by policies and regulations (WHO, 2018).
The impact is pervasive and deeply embedded in our society. Out of those who are impacted, it
is particularly communities of color who are at greatest risk of poor health outcomes. A growing
body of research shows that centuries of medical racism in this country has had a profound and
negative health impact on communities of color. On their Minority Health page, the Center for
Disease Control (CDC) writes the following:
The data show that throughout the United States, racial and ethnic minority groups
experience higher rates of illness and death across a wide range of health conditions,
including diabetes, hypertension, obesity, asthma, and heart disease, when compared to
their White counterparts. Additionally, the life expectancy of non-Hispanic/Black
Americans is four years lower than that of White Americans (para. 3).
According to a 2013 study completed by Alameda County Public Health, many low-income
residents and communities of color in Alameda County face barriers to good health, such as
poor air quality, dilapidated housing, limited access to healthy food and parks, underfunded
schools, and few economic opportunities. These community conditions are linked to higher
rates of asthma attacks, obesity, diabetes, heart disease, and mortality. For instance, an African
American born in West Oakland can expect to die almost 15 years earlier than a white child
born in the Oakland Hills area (Carlson, 2014).
Focus Group Design
Between May 2023 and March 2024, ACHCH Homeless Services Regional Coordinators
facilitated focus groups and one-on-one interviews in collaboration with partnering community-
based organizations. These meetings took place in multiple settings, including homeless
encampments, emergency shelters and drop-in centers, with an objective to engage with a
representative sample of people experiencing homelessness in Alameda County. They spoke
with 157 participants at 16 different sites (Appendix A) to learn about their experiences of
accessing and utilizing health care services.
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Focus group participants were asked about their experience receiving health care in various
settings: check-ups and routine care, emergency care, dental care, specialist care, mental
health and substance use services. We wanted to learn: What health care services do patients
use the most? What have patients’ experiences been using the health care system? What
challenges have patients experienced in accessing and utilizing health care? Where are there
gaps or unmet needs? How can Health Care for the Homeless work with other health and
service providers to improve health care for PEH?
For more details on the main themes of the focus groups and interviews and quotes, see
Appendix E.
Data collection methods included an Alameda County researcher who took notes, made
recordings, and reviewed findings. See Appendix B for more information about methods and
limitations.
The questions asked in the focus group are as follows:
1. What types of health care services have you used in the past two years?
2. Where have you gotten these services? If not, what were the barriers?
3. Do you have a regular place where you receive health care from a doctor or a nurse?
4. What kinds of resources or support make it easier for you to get the health care that
you need?
5. Have you had trouble getting any of the health care services that you needed?
6. Have you had any concerns about your safety when getting health care services?
7. Are there any other resources or services that you need, but have been unable to get?
8. Has a doctor, nurse or other health care provider given you referrals or linkages to other
health care services or resources?
9. Have you met with a doctor, nurse, counselor or other provider by telephone or online
in the past year?
Methods & Limitations
Methods
Under the direction of an evaluation consultant, four ACHCH Homeless Services Regional
Coordinators worked with partner agencies serving PEH to conduct 13 focus groups and 4
sessions of key informant interviews (KII) at 16 different sites throughout Alameda County,
reaching 157 participants.
Regional Coordinators worked with partners to select host sites serving a diverse range of PEH –
sheltered and unsheltered. They also chose sites with a wide range of patients, by location,
housing situation, race/ethnicity, gender, and age.
To guide development of focus group questions and methods, ACHCH convened discussions
with the Alameda County Health Care for the Homeless Commission, ACHCH Community
Advisory Board (CAB), and a core group consisting of ACHCH staff, Regional Coordinators, and
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the Evaluation Consultant from CAPE. They identified top concerns and worked together to
write and edit focus group questions (See Appendix D for the Focus Group Protocol which
provides the main topics and specific focus group questions).
Although the original goal was to do focus groups, site staff felt strongly that some participants
could not be reached via a group, due to factors such as street noise at encampments and
differing schedules. At four of the sites, the core group decided to switch tactics to do KII with
PEH. After reviewing the first group, they worked with the Evaluation Consultant to streamline
multi-part questions to make the KII less cumbersome for participants.
Staff from host sites assisted with logistics and participant recruitment. They identified
convenient times and places to convene and provided outreach to their clients. To increase
chances of successful recruitment, the core group created colorful flyers. To facilitate
recruitment and to thank participants for their time and valued input, ACHCH provided $50
supermarket gift cards to each participant and brought refreshments.
At each of the 16 sites, an average of 7-10 PEH participated, with the smallest group comprised
of 6 people, the largest of 16. Regional Coordinators facilitated all the groups in pairs, with the
exception of the Spanish-language KII at the Multicultural Institute, which were facilitated by
fluent Spanish-speaking staff from ACHCH. At focus groups, participants filled out a brief
demographic questionnaire which asked for their age, gender identity, race/ethnic identity and
living situation during the past 30 days. Either Regional Coordinators or the Evaluation
Consultant took extensive notes during groups and were able to tape records and transcribe 12
of out of the 16.
The evaluation consultant entered notes and transcriptions into a qualitative software analysis
program (Dedoose) and conducted a thematic analysis. Code words and phrases for identifying
and calling up common themes were created “a priori” based on the topic areas and “in vitro,”
emerging from the text.
On review and analysis of focus group reported data, staff realized that we were not able to
organize/stratify focus group data and patient input by race of individual respondents. We
realized that in future focus groups, we must take steps to systematically develop our data
collection by race to be able to effectively review the input of people most marginalized and
impacted by homelessness and in homeless services.
The Evaluation Consultant presented preliminary results to the core group and garnered
feedback on the accuracy and relevance of themes generated during the analysis. The core
group crafted the response to the findings, including next steps for ACHCH. As the findings are
written up and presented to different audiences, particularly participants and other PEH, they
will be revised to better reflect the intended meaning.
Limitations
The focus groups and Key Informant Interviews (KII) provided rich information, but they were
labor intensive. Even with 16 sites and 157 participants, we did not have a fully representative
sample of PEH by race/ethnicity, immigration status, age, length of time homeless, whether
people have children or parents living with them and other factors. When compared with
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demographic data from larger samples of PEH, we reached fewer unsheltered people. To
ensure their input would not be underrepresented, we provided some separate analysis for
groups that had a majority unsheltered participants.
We were unable to recruit the desired number of unsheltered participants due to the logistics
associated with encampment settings, including the ability to create a space that accounted for
distractions, privacy, and noise, resulting in more focus groups but with fewer individuals
participating in each. See Appendix C for charts describing who we spoke with in more detail.
We were able to note different views for women, Black, indigenous or people of color (BIPOC),
seniors, people experiencing disabilities and unsheltered people. While we were able to stratify
data by sex and housing status of focus group participants, a striking limitation of the focus
group data was that we were not able to stratify patient data by race of people responding. As
Black persons -- especially men -- are a disproportionate near-majority of people living in
homelessness we must acknowledge this limitation and build in efforts in future focus groups to
center the needs and words of people most marginalized and impacted by homelessness.
The staff and advisory groups who devised the questions wanted to know as much as they
could but ended up with ten multi-part questions that were sometimes difficult for participants
to understand. Written prompts, such as listing some potential things that could make
accessing care easier, were especially helpful in explaining the meaning of the questions.
According to the Spanish-speaking facilitators, some concepts did not translate well, and they
suggested streamlining the questions for all PEH going forward.
Focus groups do not work for all people. Some people do not want to share personal
information in groups, or with people they do not know well. KII were a better way to gather
the opinions of some PEH, but they lack the advantage of the group setting, which helps
participants understand and articulate their own opinions after they hear from their peers.
In the future, ACHCH will consider more participant-friendly ways to hear from PEH, including
training PEH to conduct the focus groups and KII.
We raised expectations for host agencies and participants to take action steps to address the
issues raised in focus groups and are committed to providing results in a user-friendly written
form, through presentations, or other methods.
The 2024 PIT Count accounted for 9,450 people experiencing homelessness in Alameda County
on a single night. Due to the challenges of timeline and staffing, this project’s sample size is
small when considering the scale of homelessness across Alameda County
Who Did We Reach?
One hundred fifty-seven (157) PEH at 16 sites throughout Alameda County participated. Brief,
written demographic questionnaires, collected for 151/157 participants, demonstrate that we
spoke to people who were similar in age and gender to the wider population of PEH. However,
it is important to acknowledge the limitation that we spoke to a lower proportion of
unsheltered PEH (41%) than were reported unsheltered in the 2024 PITC (67%i).
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See Appendix C for charts describing who we spoke with in more detail.
Gender Identity: 60% of participants identified as Male, 38% as Female, and 2% as
Transgender/2-spirit, and 2% unreported.
Race/Ethnicity: 30% of participants identified as Black/African American, 24% White,
17% Hispanic/Latino,14% Multi-Race, 7% Asian, 2% Other, 2% Native Hawaiian/Pacific
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Islander, 1% American Indian (1/151) and 3% preferred not to state.
Figure 1 shows participant living situations in the prior 30 days in the following categories:
• 39% Unsheltered- living outside, in cars/RVs, tents and other areas not suited for habitation.
• 33% Sheltered – living in their homes/apartments, in a homeless shelter, in transitional
housing or a drug/alcohol rehabilitation program.
• 2% Doubled Up – living in the homes of friends or family.
• 17% Combo – Living in a combination of unsheltered, sheltered and doubled up situations.
• 7% Not Homeless – Living in their own home or apartment
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Findings: Access, Bias and System Navigation
During the focus groups and interviews, participants discussed at length the structural barriers
they faced when trying to access care including primary care, specialty care, substance use
services and behavioral health. A common theme among the responses were discrimination
based on homeless status in health care settings, inferior services, and distrust in health care
providers. When able to access care, they spoke about the poor quality of the care they
received.
System Navigation and Access to Care
Participants cited denial of care access due to lack of health insurance, necessary paperwork,
the technology needed to apply for medical insurance, and access, skill and understanding of
computerized application and scheduling systems. Many of the respondents reported confusion
about their health insurance status, and medical care options, particularly those who have
Medi-Cal and Medicare.
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Participants experienced the consequences of what they perceived as a lack of communication
and coordination among their providers in coordinating specialty care. As patients, they were
asked to repeat the same information to multiple providers, and received conflicting referrals,
including conflicting instructions/advice from consultants, care team members and other
agencies or specialists they were referred to for care. Respondents reported “getting the
runaround” and being sent to multiple providers and agencies for care.
Consistency of Care
About one-third to half of the participants in each group reported having a medical home. The
most common types of health care facilities used were community health centers, hospitals and
hospital-based emergency departments (most often at Wilma Chan Highland Hospital in
Oakland) and mobile health care services. People who qualified for supplemental or more
complete health coverage, such as pregnant women, veterans and seniors were most likely to
have a medical home.
Those who reported having a medical home or having used medical care stated similar
challenges as what is typically reported among the housed population. This included
participants who knew their medical home and had established care – participants reported
experiencing challenges seeing their doctor regularly as well as long wait times to secure an
appointment with a primary care provider. Most people said that they were not able see the
same provider, due to provider turnover and lack of availability.
“We get cut off from one signature being missed.”
“Seeing a new person when in pain is very scary. Not the opportune time. There is a human bias –
people give better care to people they know and care about.”
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Bias, Discrimination and Safety
Participants described experiencing racism and bias related to homeless status, which at times
resulted in denial of access to care. Some noted the assumption by staff and providers that they
were using and/or seeking drugs. In nearly all the groups, participants expressed suspicion
about the motives of health care providers and viewed health care as a profit-seeking system
that is unwilling to provide them necessary care.
Participants who identified as women spoke about the discrimination that they experienced
due to their gender, especially when combined with race, particularly women who identified as
black, indigenous or pacific islander (BIPOC). In one focus group, a black woman described her
lack of trust in health care providers:
Seniors and people experiencing disabilities reported greater issues with safety at health
provider sites and more difficulty accessing technology.
Lack of Trust in Service Providers
Other reported systemic issues that diminished trust in service providers included:
• Inconsistent primary care provider /Provider turnover
• Need to establish care with multiple providers
• Miscommunication and conflicting instructions/advice about their care
• Repeating the same information to multiple providers
• Inconsistency in treatments
“...Maybe the next doc will be racist or people practicing on us as lab rats.”
“We have people traumatized by the medical system.”
“Whenever they deem it’s an owie or a trivial issue, they’ll kick you out of the hospital and if you have
any objections, their security is on you.”
“I was assaulted getting into an elevator in a garage at [health center]. Safety concerns are constant
for slow walkers”
“My fear of doctors is part of the reason I have not had children. [There are] horror stories of how they
treat black women.”
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Quality Issues/Inferior Services
In most groups, participants shared stories about receiving inferior and even dangerous care in
the past, citing medication errors, and being discharged before a serious health problem was
adequately addressed. Several participants interpreted a question originally meant to ask
about their sense of safety at health care locations as a question about whether they felt the
health care that they received was safe.
Additional issues reported were the belief that health care provided to homeless individuals
was inferior and harmful, lack of follow-up care, long wait times to see a provider, penalization
for missed appointments, and a lack of understanding from providers and systems regarding
the challenges faced by people experiencing homelessness.
Experiences with Telehealth
Participants were asked whether they had used or would be willing to try telehealth. The most
common method by which they had used telehealth was by telephone calls, followed by video
calls on smartphones, tablets or computers. Participants recognized that telehealth is becoming
more prevalent and may even involve AI (artificial intelligence).
Participants described several advantages and disadvantages to telehealth, including bypassing
the need for transportation, and usually shorter wait-times between time of scheduling and the
appointment than in-person. To discuss some difficult subjects, some participants expressed
that it may be more comfortable to use telehealth. Participants suggested that telehealth is
most suitable for mental health appointments.
The most frequent challenges described by participants about telehealth were technical. Some
people were confused or overwhelmed by computers and software. Others did not have access
to a suitable device or a private location in which to conduct an audio or video call. Having an
unreliable telephone or source of electricity posed another technological challenge. For some
conditions, people preferred face-to-face contact, and did not feel that an audio or video call
was sufficient to understand their health needs.
“…I hear about like, people who have access to private health care who are wealthier. We are getting
like maybe similar care, but we're not getting treated with the same type [of] sensitivity.”
“I liked that I did not have to jump up and run around...Saves time and money, anxiety and stress.”
“I’m an eye contact person. Don’t trust it, and I’m digitally challenged with all the technology.”
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Participants identified preferences and recommendations for telehealth. Several people
reported that they preferred telephones to computers or tablets, particularly if they needed to
download software.
Barriers to Treatment
Participants shared perceptions that providers and systems did not understand their situations
and the challenges they faced accessing health care and associated services.
Housing Instability: One notable barrier is medical respite. Medical respite care is acute and
post-acute care for persons experiencing homelessness who are too ill or frail to recover from a
physical illness or injury on the streets but are not ill enough to be in a hospital. It is a short-
term residential care that allows individuals experiencing homelessness the opportunity to rest
in a safe environment while accessing medical care and other supportive services (National
Health Care for the Homeless Council, n.d.). One participant reported that their provider was
not able to perform orthopedic surgery on them because they lacked a consistent and safe
home in which to recuperate. If the provider was aware of the respite resource, they would
have been able to receive the needed surgery.
Lack of Transportation: Participants discussed the challenges of traveling long distances within
Alameda County which presented a barrier in getting to medical and social service
appointments challenging.
Technological Challenges: Participants also reported missing appointments due to common
circumstances of PEH such a lacking a phone on which to receive reminders, resulting in
communication gaps and long wait times to be rescheduled.
Missing Services
Participants identified specific health needs that remained unmet even after seeking care
(Table D5). In order of frequency, the most common unmet health care needs were:
• Behavioral health/psychiatric care
• Dental health beyond basic, such as specialty care or restoration as opposed to
extraction
• Affordable and easily accessible medications, especially for blood pressure, psychiatric
conditions, and Attention Deficit/Hyperactivity Disorder (ADHD)
• Primary care, particularly preventive services
• Adjunct and alternative care, such as chiropractic, acupuncture, and herbal medicine.
* Psychiatric care and dental health were of particular concern for unsheltered groups.
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Lacking Resources
All participants, particularly unsheltered, identified a wide range of practical resources that are
needed in order to travel to access medical care or social services including housing service
providers (Table D6). These resources include the following:
• Car repair
• Childcare
• Electricity to charge devices
• Clothing
• Phones
• Food
• Showers
Participants described services that made it easier to get health care (Table E7). Transportation
to appointments or having health care come to them via a mobile van, helped all people,
particularly unsheltered. Participants described greater motivation to come to health care
appointments when they could get other needs met at the same time and location, such as
food and access to computers, and when staff were friendly and helpful. Participants described
the importance of having health insurance that covered a wide range of services. Another
resource that was reported as helpful was a care coordinator or resource navigator, provided
that the coordinator or navigator knew about local services and could maintain a consistent
relationship.
For more details on reported barriers and experiences, see the following tables:
• System Navigation and Denial of access to health care (Table D1)
• Discrimination and lack of trust (Table D2)
• Quality issues/inferior services (Table D3)
• Lack of communication and coordination from providers (ED4)
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Recommendations from People Experiencing Homelessness
To improve health care for people experiencing homelessness (PEH), participants
recommended:
• Improve access to medical homes, for both new and existing patients so that PEH can
develop trust with providers.
• Foster a welcoming, judgement-free environment with friendly and helpful staff
• Create targeted medical services for PEH
• Offer flexible hours at medical clinics
• Outreach to PEH where they live to provide and inform of available services
• Create a “one-stop-shop” for health and resource needs
• Provide care coordinators or resource navigators to work one-one one with patients
• Simplify paperwork for social services and health insurance
• Transportation to medical and social service appointments
For more details on participant recommendations, please see Table D8.
Next Steps for Improving Health Care Services for People Experiencing
Homelessness
The findings reinforce the urgency in successfully achieving the goals in the ACHCH 2024-2027 Strategic
Plan.
Key Recommendations:
• Continuous quality improvement in health care services and delivery must include
ongoing, substantive input from PEH.
• Patient experience, future focus group data and patient input must be stratified by race,
to be able to effectively review the input of people most marginalized and impacted by
homelessness and in homeless services.
• Earning and deserving the trust of PEH should be a central aim and organizational goal
of health care providers like ACHCH.
• We must work to identify and reduce systemic complexities that create barriers for
people who seek immediate help with basic human needs, including health care.
• We must prioritize relationships, including longitudinal, one-on-one relationships with
care coordinators and peer navigators, both to provide support and surmount barriers
created by systemic complexities.
• Bring services to people in a way that invites engagement, shares information, and
provides care in the community.
• To address stigma, exclusion and racism, require unconscious bias training for all new
hires and adopt hiring practices that are fair and equitable.
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Appendix A: Where We Spoke to PEH
Locations, Dates and Participation
12 Focus Groups and 4 Rounds of Key Informant Interviews (KII)
Partner Agency Location Date Participants
First Presbyterian Shelter Castro Valley May 1, 2023 12
East Oakland Community Project (EOCP) Oakland May 15, 2023 11
Women’s Daytime Drop-in Center Berkeley May 19, 2023 7
CityServe Pleasanton May 24, 2023 6
Cornerstone Fellowship Livermore May 26, 2023 6
Insight Housing Berkeley May 30, 2023 7
Sunrise Village Fremont May 31, 2023 14
Bay Area Community Services (BACS)
South County Wellness Center Fremont Jun 9, 2023 12
First United Methodist Church Hayward Jun 27, 2023 9
Building Futures for Women and Children– Davis
Street San Leandro Jun 29, 2023 7
71st Street RV Parking Site Oakland Aug 29, 2023 10
St. Vincent de Paul Oakland Sept 7, 2023 10
Multicultural Institute (KII) Oakland Oct 2, 2023 10
East 12th Median (KII) Oakland Jan 23, 2024 18
Mosswood Park (KII) Oakland Feb 8, 2024 8
Peralta Park Oakland Mar 2, 2024 10
Total # of Participants 157
Majority unsheltered focus groups are shaded light blue
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Appendix B: More Information About Participants
Definitions: In the 30 days prior to the focus group or interview, participant was:
• Unsheltered- living outside, in cars/RVs, tents and other areas not suited for habitation.
• Sheltered – living in their homes/apartments, in a homeless shelter, in transitional housing or a
drug/alcohol rehabilitation program.
• Doubled Up – living in the homes of friends or family.
• Combo – Living in a combination of unsheltered, sheltered and doubled up situations.
• Not Homeless – Living in their own home or apartment
• Missing – Participant did not fill out a demographic survey or skipped the question about their living
situation.
Figure 1: Living Situation by FG
Unsheltered
Only
Sheltered
Only
Sheltered &
Unsheltered
Doubled Up Missing
Info
Not
Homeless
CityServe
Pleasanton
50% 50%
Cornerstone
Fellowship
17% 50% 33%
Mosswood Park 75% 25%
Women’s Daytime
Drop-In Center
29% 43% 14% 14%
BFWC-Davis St. 14% 43% 43%
Insight Housing 86% 14%
Saint Vincent de
Paul 60% 10% 30%
First United
Methodist
45% 33% 22%
Peralta Park 70% 20% 10%
71st St .RV Parking 90% 10%
Multicultural
Institute 30% 70%
EOCP 18% 73% 9%
BACS South County
Wellness Center
67% 25% 8%
First Presbyterian
Shelter
8% 75% 17%
Sunrise Village 86% 14%
E. 12th Median 94% 6%
21
22
23
24
Appendix C: ACHCH Client Focus Group on Health Care Protocol
I. Background, Introductions and Settling in (15 mins)
1. Thanking Participants
2. Purpose of the Focus Group
• We invited you here today to share your experiences getting health care in Alameda County.
3. Who we are (HCHP & CAPE, relationship to host site)
• We work for the Alameda County health Care Services Agency. Lynette and Andrea are
Regional Coordinators for the Health Care for the Homeless Program. Liz works on data and
research projects and is helping to guide the focus group process.
• The HCHP program is speaking with about 10 different groups of people who have
experienced homelessness to learn more about how we can increase health care access and
improve services.
4. Housekeeping
• This focus group will be about one hour long.
• Location of bathrooms
• At the end of the focus group, please see Hanna to sign for your gift card.
5. Informed Consent
• This focus group is confidential. Your name, or information that identifies you will not be
written down or shared with anyone outside of this group.
• This group is voluntary – you do not have to participate.
• You can stop participating at any time or skip questions.
• Is it OK if we use this tape recorder to help us remember your answers? We will erase the
recording once we are finished with all of the focus groups.
6. Ground Rules
• Before we get into our discussion, I have a few reminders and requests.
o There are no right or wrong answers
o All responses are valued.
o It is okay to have different opinions. We do not all have to agree.
o Speak one at a time.
o Do not repeat what you hear to others outside of the group. What is said in here should
stay in here.
o Does anyone have anything to add?
Topic II.A. General Questions for Patients (45 Minutes)
1. Types of services
that they use
• We are interested in hearing about your experiences of getting and
using health services such as doctors, nurses, mental health and
SUD treatment services? (Can edit list of services for each group)
• What types of health care services have you used in the past two
years?
2. Where they get
services
• Where have you gotten these services? (Prompt: Street health,
mobile clinic, “brick and mortar) If not, where are the barriers?
25
Topic II.A. General Questions for Patients (45 Minutes)
3. Medical home/
Continuity of care
• Do you have a regular place where you receive health care from a
doctor or a nurse? By regular, we mean a place where you return
more than once for the same services, such as routine checkups or
care for a specific condition?
• If yes, where do you get your regular health care? (Prompt: Street
health, mobile clinic, “brick and mortar” building?)
• Are you able to visit your nurses or doctors as often as you would
like?
• Are you able to see the same nurses and doctors each time you
visit?
• How do you think this has affected your health care? (Prompt:
Having to tell your story to new people each time; having to make
new relationships; getting past “triage” to the services you need).
4. Facilitators/what
makes it easier?
• What kinds of resources or support make it easier for you to get the
health care that you need? For example, varied clinic hours, friendly
staff, Health Care Navigators.
5. Challenges and
barriers
• Have you had trouble getting any of the health care services that
you needed? Which services?
• What kinds of challenges or barriers did you face?
• How did you get around those barriers?
6. Safety • Have you had any concerns about your safety when getting health
care services? Please describe.
7. Capacity, gaps and
needs
• Are there any other resources or services that you need, but have
been unable to get? Which ones?
Topic II.B. More Specific Questions for Patients (20 Minutes)
8. Referrals and
linkages
• Has a doctor, nurse or other health care provider given you referrals
or linkages to other health care services or resources? Which ones?
• Were you able to access those services or resources? Why or why
not?
9. Experiences with
telehealth
• Have you met with a doctor, nurse, counselor or other provider by
telephone or online in the past year? (This is sometimes called
“telehealth”)?
If yes to
telehealth
• How did you connect? (Prompt: dial-in phone call, Smartphone, tablet
(iPad) with Wi-Fi, computer with Wi-Fi)
• What did you like about using telehealth?
• Were there any downsides or barriers you had?
If no to
telehealth
• Would you be interested in meeting with a doctor or nurse by
telephone or online? (this is sometimes called “telehealth”)
• Why or why not?
26
Topic II.C. Other Comments
10. Other • Is there anything else that you want to tell us about your health care?
II. Wrap-Up (5 Minutes + extra to pick up gift cards)
1. Thank you
2. Instructions for Getting Gift Cards
3. Report will be finished in Fall of 2023
27
Appendix D: Findings by Focus Group Theme
• Note: Within each table, themes are listed in order of frequency they were discussed during focus
groups and key informant interviews.
• Themes of particular concern for unsheltered populations are starred (discussed at 3 or more of the
5 majority unsheltered focus groups or key informant interview sites).
Table D1: Barriers to Care – System Navigation and Denial of Access to Health Care
Theme Sample Quotes
*PEH are denied care
due to lack of health
insurance
• “I was denied GA, Medi-Cal and no referrals from SSA. I was
overwhelmed by the GRID (list of services in Hayward).” (First
united Methodist)
• “I went to Kaiser, and the second they found out that I don’t have
the coverage, they didn’t come out to take the IV out of my arm.”
(E 12th Median)
* PEH are denied health
care due to lack of access
to required technology or
skills to use it
• “Cuss them out, cry sometimes, give up. Sometimes I’ll turn it
around and ask them for a .pdf, so it already has the info, all I
have to do is DocuSign and send it back. I don’t even know what a
.pdf is.” (Cornerstone Fellowship)
• “I went and applied for GA I did everything that they required me
to do. And then it came down to Scantron thing, for
unemployment, but you had to, to call a particular number and
then it tells you the website.” (Oakland RV Parking)
PEH are denied care due
to lack of paperwork
• “We get cut off from one signature being missed.” (Building
futures – Davis St)
28
Table D2: Barriers to Care - Perceived Discrimination (Bias) and Lack of Trust
Theme Sample Quotes
PEH do not trust the
health care system or
providers
• “People want to perpetuate the problem to perpetuate their
employment. As long as there’s a homeless problem, good job, I
can be working on it. That’s why we get the runaround. Entities
compete over money. Don’t let it get to folks.” (Women's
Daytime Drop-in Center)
• “Doctors and pharmacies are in a conspiracy.” (Berkeley Drop-in
Center)
* PEH are labelled and
accused of drug use or
crime
• “So many stereotypes – no drugs or criminal record… Unhealthy
for mind and body.” (First Presbyterian)
• “Providers ask what are you here for drugs? I don’t need pain
medication – I tell them right away. I’ve been on it for more than
20 years. Always trying not to take it”. (Women’s Daytime Drop-
in Center)
PEH experience racism
from health care
providers and systems
• “Not having a steady doctor that I go to and see every other
month or so. Figure out what to do. Maybe the next doc will be
racist or people practicing on us as lab rats. (Seems to have
general agreement based on head nods.” (First Presbyterian)
• Note that racism plays a role in many other themes, such as poor-
quality health care, communication problems and trust with
providers.
29
Table D3: Barriers to Care-PEH Reported that They Receive Inferior Services
Theme Sample Quotes
* Health care given to
PEH is inferior and even
harmful
• “I think they’re gonna kill us every time. They give me the wrong
medications sometimes. (E 12th St. Median)
• “Whenever they deem it's an “Owie” or a trivial issue, they’ll kick
you out of the hospital and if you have any objections, their
security is on you” (Mosswood Park)
• “We have people traumatized by the medical system.” (Women's
Daytime Drop-in Center)
• “Like where I hear about like, people who have access to private
health care who are wealthier. We are getting like maybe similar
care, but we're not getting treated with the same-type sensitivity
and compassion in the process.” (Women's Daytime Drop-in
Center)
Providers and systems do
not follow up with
patients
• “I got a referral for orthopedic surgeon. They never called me
back. They never even ordered me. But now I still have to wait
another two weeks before I can call them. And then I never got a
call back, so I said screw it. My hand still hurts.” (South County
Wellness) Patients Have Long Wait
Times to See a Provider;
Penalized for Missed
Appointments
• “I get better help from AHS or la Clinica. Hard to get on because
of long wait times (South County wellness)
• “Hard to make it to appointments. If you miss out more than 2 or
3 times, maybe they just kind of write you off.” (Cornerstone
Fellowship)
•
* Providers and systems
do not understand
challenges faced by PEH
• “I also think that a lot of health care professionals in general are
not necessarily sensitive to their patients’ individual situations or
mental states or just the categories they fit in.” (South County
Wellness)
• I need surgery on my shoulder, but they won’t give me because I
am homeless. I can lie to them. Said if not staying in a house,
can’t get the surgery that I want. Place to shower, clean the
wound. (CityServe Pleasanton)
30
Table D4: Barriers to Care- Lack of Communication and Coordination from Providers
Theme Sample Quotes
Providers and
organizations do not
provide adequate
information to PEH
• “Communication can be a barrier. Can cause misconceptions or
false directions.” (First Presbyterian)
• “Give you food stamps and don’t tell you have them. How are you
supposed to spend them?” (Building Futures with Women and
Children – Davis Street)
* “Getting the
Runaround”
Patients Were Sent to
Multiple Providers and
Agencies for care
• “Getting referrals is hard- trying to get primary care, and I’m
going in circles even trying to find the office and even think about
taking an application. I thought I signed up for Medi-Cal and it’s
been circles. I’ve had Med-Cal for 2 years and I don’t have a PCP.”
(E. 12th Median)
* Patients need to give
the same information to
multiple providers
• “Sometimes when you call to make an appointment, they ask for
all of your information. Every time that I call, I have to give them
all the info. I just tell 'em I already gave it to you. Look it up.”
(Cornerstone Fellowship)
Providers do not
communicate with each
other about the patient
• “Give you referrals, (the providers) Don’t get together about it.
Ain’t nobody know nothing.” (East Oakland Community Project)
• “You get one doc saying don’t worry about it, it’s nothing, and the
other tells you it is serious. Conflicting messages.” (South County
Wellness)
31
Table D5: Top Unmet Health Care Needs Mentioned
Theme Additional Information
* Behavioral
health/psychiatric care
• Hard to find therapists for patients and children.
• Limited # of visits.
* Dental care beyond
basic
• Needs specialty dental care. Can have teeth extracted, but not
saved.
Pharmacy/medications • Most common medications mentioned: Blood pressure, cardiac,
psychiatric, ADHD.
• High costs, not covered by medical insurance.
• No way to get to pharmacy.
Primary care/medical
home
• Described more in Medical Home Section. “Revolving Door” of
providers. Lack of preventive Care.
Adjunct & alternative
care
• Chiropractic, acupuncture, herbal medicine, homeopathy.
• Sometimes trusted more than “Western Medicine.”
• Patients used it for “self-treatment” to bypass medical system
Other unmet health care
needs
• Asthma or COPD, high blood pressure, cardiac, care
coordination/navigation (if knowledgeable), dermatology,
diabetes management, diagnostics - XRAY, MRI, blood work, drug
treatment programs, ENT/hearing, injury, mobile van/street
outreach, orthopedic care, other specialty, pain, physical therapy,
surgery, urgent care
32
Table D6: Top Unmet Needs for Resources
Theme Additional Information
Housing • Described evictions, difficulty with eligibility requirements.
Described wanting “stable housing,” and a “place of my own.”
• “Social worker was supposed to help with housing, and they
never got back to me. I have always addressed with them that I
was unhoused. It is affecting my mental, physical health and
Blood Pressure.” (Women’s Drop-in Center)
Transportation • “One big barrier is transportation to appointments much anxiety
around how to get to places you need, distances.”
* Other practical
supports, often need
more than one at the
same time
• Car repair, childcare, clothing, computer or technical assistance,
education. electricity to charge device, food, legal representation
(especially for citizenship), phones, shower and personal hygiene,
help or replacement for stolen or lost items
33
Table D7: What Makes it Easier to Get Health Care?
Theme Additional Information and Quotes
*Resources and Supports
Provided Along with Health care
• Housing, transportation, food (See unmet resource
needs)
Having adequate health
insurance
• Able to access their health plan and get coverage for
needed services.
Effective care coordination and
systems navigation
• Care is consistent and builds relationships over time
• Effective resource navigators are available
Friendly and helpful staff • “Being pleasant when folks come in” (Operation Dignity)
Having a medical home with a
regular primary care provider
• Consistent place for health care
• Able to see same provider
• “It makes it easier to ask for help when you have rapport
with the doctor/RN.” (Mosswood Park)
* Mobile van and street
outreach where PEH are
• “They (mobile van) knew they were dealing with
homeless and poor people. Had an interest in helping.
Makes a difference.” (South County Wellness Center)
34
Table D8: Recommendations from Participants
Theme Additional Information and Quotes
* Provide services via a
mobile van
• Alameda Health Care Bus –would like regular visits @ encampment
(E 12th Median)
•
Design health services
around the needs of
PEH
• “A general practitioner who can only take care of the homeless
community. Whenever we need something, they go straight there.
Can make the referrals. It’s a link. Easy to go and be heard. Use
same specialists. Almost like a family doctor.” (South County
Wellness Center)
• “Need a ‘one-stop-shop.’” (First Presbyterian)
• “Flea market for doctors” (Sunrise Village)
• “Have wealth of knowledge, wealth of experience in this group and
all those groups. Let them tell their story and try to figure out
where we can do a little bit more, where we can change it.”
(Oakland RV Parking)
Make changes that
increase access for PEH
• Increase health insurance coverage for PEH
• Reduce waiting times to get primary and specialty care
• Provide health care during more flexible times
• Provide transportation to health care appointments
• Provide some services by telephone
Communicate with PEH
in ways that they
understand and trust
• Employ staff who speak the language, and who share culture and
lived experience with PEH.
• Hire more staff who are women and people of color
• “The problem is, if somebody misses an appointment or gives
generic responses, that counselors should reach out to somebody
who is an advocate…. And somebody more in their level of
communication rather than a doctor or therapist or somebody, you
would feel threatening them”. (Oakland RV Parking)
Provide effective care
coordination/navigation
• “Like an advocate. I am old school; I would rather speak to them
than go on a website. Creates more jobs having advocates.”
(Sunrise Village)
• Provide assistance with technology to fill out forms and access
medical care.
Provide targeted
outreach to PEH
• Outreach to PEH where they are:
• For People Experiencing Homelessness in tents. Put plastic flyers
on poles where they can see it. (Sunrise Village)
• Need outreach specific to homeless community. Health care is
confusing for people in general, even more so for the homeless. It
seems unattainable (copays, paperwork if you don’t have someone
guiding you). (South County Wellness Center)
35
Table D8: Recommendations from Participants
Simplify processes and
paperwork
• “The communicating this point that it's gotten so overwhelming for
the people that are trying to take care of us. Our frustration is
getting so intense. It's, you know, we're, there's gotta be
simplicity.” (Women’s Daytime Drop-In Center)
• “I mean, how do you guys don't just use like, just one database
where your, that's where your file is stored. So whenever you go to
this doctor over here who, who might not even be in the same
network.” (South County Wellness Center)
36
References
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