Common Ground at Venice Family Clinic

Venice Family Clinic (VFC) is a federally qualified health center (FQHC) and University of California – Los Angeles-affiliated community health system based in the Venice neighborhood of Los Angeles. In addition to their Venice offices, VFC maintains more than a dozen FQHC locations around the greater LA area. Programming includes outreach with people experiencing homelessness and health services including primary and specialty care, dental care, behavioral health care and SUD treatment, health education, health insurance enrollment, and early childhood development programs. In 2013, the AIDS services organization called Common Ground, which included a syringe services program, merged with VFC and continued operating under their auspices. Prior to participating in the patient navigation project, care navigation and case management were available through other VFC programs but not the Common Ground SSP—the project presented an opportunity to expand these programs to include people who use drugs, improve follow-up care within the VFC system for SSP participants, and strengthen referral relationships with external providers, including, most urgently, housing systems and service providers.

With significant organizational experience working with populations inadequately served by mainstream health care, including people experiencing homelessness and immigrant communities, VFC came into the project with deep understanding of the value and impact of trauma-informed approaches in patient engagement and care provision. Motivational interviewing was one of VFC’s key methods for determining participants’ goals for navigation and identifying priority external providers and referral networks. These approaches, in combination with harm reduction values and centering the stages of behavior change model, were vital for developing trust and creating buy-in with participants. Most people engaged through patient navigation had previously interacted with, and often, been disappointed by, medical and social service providers. VFC was able to work more effectively with participants because of the many strengths of being an SSP – utilizing a harm reduction approach, nonjudgmental staff who could build trusting relationships, and tailoring navigation strategies to the needs of each participant. Another crucial factor was the flexibilities of patient navigation funding. Flexibility in allowable uses of project funding was key in being able to offer navigation that was most responsive to participants’ needs. For example, VFC covered the costs associated with receiving a state identification card or birth certificate, which would often open the door to accessing other services.

One longtime participant, whose parents are also connected with the program, had been visiting the SSP for years. In the first few weeks of project implementation, he came in for supplies and expressed that he wanted to go into inpatient SUD treatment. Previously, SSP staff might have offered him the phone number or address of a local provider, but this time the navigator was able to arrange a place for him the same day and call a rideshare to take him to the treatment facility. In this case, co-locating patient navigation within the SSP allowed VFC to use years of familiarity and rapport with this participant to quickly respond to his request. In another case, an SSP participant’s health had severely deteriorated during 2020 and 2021. He was hospitalized multiple times per month and often showed wounds from frequent assaults. He was open and friendly with staff but presented with psychosis, and it took time and effort for the patient navigator to be able to gauge interest or discuss care needs with him. After several weeks of dedicated engagement, the patient navigator was able to take the participant to the VFC clinic to make a medical appointment—for him, a major success.

VFC’s main challenge was a lack of accountability and follow-through among external providers, resulting in missed opportunities to support participants and additional effort for the navigator. When external partners “drop the ball,” participants come back frustrated and disappointed. This contributed to burnout among staff and disillusionment among participants—in addition to the harms to their health and safety from having service and resource requests go unfulfilled. The patient navigator was therefore working at multiple levels, building relationships with participants while reinforcing accountability with external providers. Development of memoranda of understanding (MOUs) had been a recommended first step of the project, but as the scope of navigation services grew over time in the midst of a pandemic, staff had limited capacity for administrative work of that kind and cooperation was based primarily on personal relationships between VFC staff and partner organizations. While relationships are immensely valuable in facilitating handoffs between service providers and building comprehensive networks of care, formal understanding between organizations that clearly delineates roles and expectations can support sustainability and flexibility, especially during times of high staff turnover.

During the project period, VFC enrolled 93 people in navigation. Of those enrolled, VFC reported 20 connections to MAT, 156 connections to HIV and HCV testing and/or care, 38 individuals supported to establish long-term primary health care, and 22 connections to long-term mental health care. A significant number of referrals were for survival services, including clothing (93), housing (68), vital records (43), food and nutrition assistance (24), driver’s licenses and identification cards (22), and unemployment benefits (12). VFC made an additional 22 referrals to detox services and 8 other SUD treatment referrals.

Venice Family Clinic Patient Navigation Encounters (March 2020 – February 2022)

Total Patient Navigation Enrollment – 93

In February 2021, the VFC navigator engaged with a 25-year-old man who had been accessing supplies at the Common Ground SSP for approximately two years. He was originally from Texas and had no family in Los Angeles. In addition to supplies, the participant was seeking assistance in finding housing after two years of homelessness. The participant was also interested in returning home to Texas. After a fentanyl overdose that resulted in hospitalization, he began asking for MAT—then changed his mind because he did not believe he could complete an outpatient treatment program while living outdoors. The navigator focused his efforts on addressing the participant’s housing needs and finding an inpatient treatment program with available space. When appropriate referrals were identified, it was challenging to follow up in a timely way with the participant because he did not have a cell phone.

In mid-March 2021, the participant requested linkage to a detox program, and the navigator was able to find a bed and provide transportation. When following up a few days later, VFC found that the participant had checked out of detox. With no other way to reach him, the navigator began to look for the participant while on outreach around Venice. When the participant returned to VFC in April, the navigator contacted the LA County Department of Mental Health to connect him to Transition Age Youth (TAY) housing. The participant completed an assessment and was placed into an emergency shelter bed that day. At that time, he was able to see VFC’s MAT provider and began receiving medication to treat his opioid dependence. Once housed through TAY services, the participant’s health and wellbeing improved markedly, and with stable housing he was able to follow up on medical referrals, pursue outpatient treatment, participate in therapy at the Common Ground SSP, and continue to see the VFC MAT provider.

However, due to barriers in the LA County Department of Mental Health system, the participant would not be able to complete the necessary assessments to receive long-term services before his 26^th birthday, when he officially aged out of TAY program eligibility. The patient navigator worked with another housing agency to place the participant on a waitlist for interim adult emergency housing, and the participant and navigator worked together to get the participant’s birth certificate, ID, and a cell phone in preparation. He received a place in a temporary adult housing shelter but disengaged from VFC and the patient navigator after he lost his TAY housing in July. As of August 2021, the participant was still unhoused but had reengaged with the patient navigation program. He was participating in an outpatient treatment program while living outdoors and again requested to enter inpatient treatment. However, VFC struggled to find him a bed, and there were no interim housing services available due to his age.

This case study exemplifies the need for an adaptable approach to navigation to a range of services. Addressing the participant’s early goal of SUD treatment required navigation through services for emergency and long-term housing, vital records, personal identification, cell phone access, supervised detox, inpatient treatment, outpatient treatment, and MAT prescribing and maintenance, in addition to regular access to harm reduction supplies. In each case, the navigator followed the participant’s priorities. The participant and the navigator were also able to maintain and reestablish engagement over nearly a year. Investing long term, dependable resources in SSPs means they have the ability to maintain program staff and provide sufficient compensation and support, which facilitates continuity of care and makes it easier for participants to reengage at their own pace.

Participating in this project allowed VFC to draw on existing patient navigation approaches and organizational capacity to extend services to SSP participants and other PWUD. The navigation team’s harm reduction training, motivational interviewing skills, trauma-informed approach, and lived experience were essential for building strong, trusting, and accountable relationships with participants. Despite direct access to many co-located services through the FQHC, VFC’s participants and navigation team dealt with near-constant frustration and lack of follow-through when seeking services from or engaging with external providers. For the navigators, efforts to work with external systems of care contributed to feelings of hopelessness, burnout, and a perception that other providers would not address their own barriers to care if they could assume that the SSP staff would be available to provide navigation. SSPs and other programs implementing navigation services for PWUD should prioritize opportunities to build accountable partnerships with the most in-demand external services, finding agencies that are responsive to feedback and willing to improve their engagement of PWUD.