Every year, dozens of homeless San Diegans die on the street.
Data from the county medical examiner’s office reveals 134 homeless San Diegans died on sidewalks and in shelters, hospitals or jails last year – a total that likely only offers a glimpse of the tragedy since county staffers only probe a small fraction of local deaths .
Though limited, county data also points to a growing problem.
In 2010, medical examiners reported they had identified 53 deceased people they believed were homeless. A decade later, as San Diego’s homelessness crisis has exploded , the number of reported deaths has more than doubled.
Now service providers and volunteers are resolving to do more to aid medically fragile homeless San Diegans. In the process, they are eyeing tacks that have worked elsewhere that San Diego’s been slow to implement despite having the nation’s fourth-largest homeless population.
“If not now, when?” said Fran Butler-Cohen, CEO of Family Health Centers of San Diego, which has health clinics across the county.
Father Joe’s Villages, Family Health Centers and a fledging organization known as the San Diego Street Medicine Alliance are ramping up initiatives to provide health care services on the streets, work that’s played out for years in other areas with large homeless populations.
Father Joe’s and Family Health Centers are also among a handful of agencies exploring either opening or expanding so-called recuperative care facilities meant to temporarily house homeless people released from the hospital. Today, there are only a few dozen of these beds  in the county, a reality that’s gotten more attention thanks to a new state law requiring hospitals to establish plans for discharging homeless patients.
Meanwhile, a San Diego Fire-Rescue Department program aimed at targeting frequent 911 callers – many of them homeless – that had gone mostly dormant  recently went back into service.
All efforts are aimed at making it easier for vulnerable San Diegans who may be reluctant or unable to seek non-emergency care to receive treatment and support.
Experts have long underlined the increased risks for homeless people whose health conditions can fester and escalate while they live on the street, leading to a greater risk of death at a younger age.
A UC San Francisco study of 350 homeless seniors in Oakland has revealed homeless adults in their late 50s often face health issues  similar to those in their 70s or 80s.
UCSF professor Margot Kushel, who led that research, emphasized that housing is the best medicine for homeless San Diegans.
“The treatment is housing,” Kushel said. “That is the treatment, but in a situation where we can’t do that the next best thing is to bring the treatment to where people are.”
Dr. Jeff Norris, medical director at Father Joe’s Villages, said he is determined to do just that.
Norris and others say a deadly hepatitis A outbreak that disproportionately battered homeless San Diegans underscored the vulnerability of the population. Fourteen of the 20 people who died were homeless. Norris, whose clinic is in the downtown area most densely populated with homeless San Diegans, said his team has also noticed more acute health issues and addiction among those living on the streets the past few years.
That inspired Father Joe’s to bring so-called street medicine practices they saw in communities such as San Francisco and Albuquerque to San Diego.
About a month ago, Father Joe’s began deploying a two-to-three person team to work with homeless patients on the street two half-days a week. The nonprofit is now seeking grant funding to support and expand its efforts.
Two weeks ago, Norris said, he looked on as a health worker spent an hour sitting on the sidewalk with a homeless man with a traumatic brain injury and a leg wound who was struggling with both mental illness and addiction.
“If they’re not gonna come to us, we need to go to them,” said Norris, whose agency is also exploring how to deliver substance use treatment to people living on the streets.
Family Health Centers is preparing to launch a similar street team ahead of the opening of its East Village housing navigation center  in late summer.
Butler-Cohen said her organization’s interviews with homeless people staying in the city’s shelter tents revealed that many lack primary care providers or have moderate to severe depression. She believes street-level medical outreach can address immediate health issues and encourage homeless San Diegans who feel defeated by their circumstances to seek other services.
“I think anything that one can do to build trust and alleviate suffering brings you one step closer to being able to work with an individual,” Butler-Cohen said.
Both organizations are also members of the San Diego Street Medicine Alliance, a recently created coalition of volunteers, nonprofits and county workers that are planning to organize events to provide medical care to homeless San Diegans.
County spokesman Tim McClain said county health workers have also increasingly hit the streets to provide vaccines and assess whether homeless San Diegans could be eligible for county programs and other services. Those street-level, wellness and vaccination-focused efforts ramped up during the hepatitis A  outbreak.
Experts with the National Health Care for the Homeless Council and others who have supported similar street-level medical efforts in other communities say they can make a significant impact.
Rachel Smith of Albuquerque Health Care for the Homeless, where workers have provided street-level care since the 1980s, said her city’s teams have delivered crucial preventative care to people who may not have sought it on their own.
Smith said doctors can often provide prescriptions and antibiotics on the spot and other workers may enroll homeless people they encounter in benefits, steps that can limit health issues that may escalate without aid.
“The sooner we can intervene on a health issue, the better,” Smith said.
For homeless people who have already been hospitalized and are preparing for release, Smith and other experts say the temporary recuperative care programs San Diego providers want to pursue could also help save lives.
Julia Dobbins, who coordinates the National Health Care for the Homeless Council’s work on recuperative care, said those programs can help homeless people recover in a safe place, reducing their chances of needing to return to a hospital and give providers a chance to connect them with other services, including housing.
Indeed, Yale New Haven Health System in Connecticut has reported  that system’s inpatient readmission rate for homeless patients fell from about 50 percent in 2012 to about 17 percent in 2016 for patients who had been discharged to recuperative care.
“It is a really good opportunity to catch people when they are sick or hurt,” said Dobbins, who said she’s recently fielded calls from officials in San Diego.
Norris, Butler-Cohen and Greg Anglea of Escondido-based Interfaith Community Services said their organizations are continuing to talk with potential funders and collaborators about how they might expand those services in San Diego County.
Meanwhile, a city program that often touches some of the most vulnerable homeless San Diegans has resumed after a hiatus.
Anne Jensen of the San Diego Fire-Rescue Department said the agency this month began again seeking out frequent 911 callers through its Resource Access Program, which aims to help address the issues spurring the repeat calls.
Nearly all on the current list of callers who dial 911 more than 50 times a year are homeless, Jensen said.
The program has shown success before.
NBC 7 San Diego reported in 2017 that the program had led to a 73 percent drop in calls  from the 911 system’s top 25 most frequent callers, a statistic that also speaks to improved health care outcomes.
“We accomplish that through connection to the right services,” Jensen said.
Norris, whose Father Joe’s team now meets monthly with Jensen’s group, said he is hopeful the bolstered focus on recuperative and street-level care for homeless San Diegans could save lives.
“We have to do better as a community,” Norris said.