Healthcare in Action’s Street Medicine Teams Rely on HIE Data

In November 2023 I wrote an article about how the Los Angeles Network for Enhanced Services (LANES), a nonprofit, Qualified Health Information Organization (QHIO) network, was providing data in support of several street medicine programs. That work has become even more important during the current wildfire relief effort. During a recent webinar, leaders from LANES and street medicine program Healthcare in Action spoke about their collaboration. 

LANES Chief Medical Officer Ali Zadeh, M.D., said the organization has been working with the Los Angeles County Department of Public Health, on efforts to help people have been impacted by the wildfires. “LANES has been very much involved with evacuation center support,” he said. “We provided the public health nurses with access to patient information to assist them with ordering and re-filling prescriptions for folks who have been impacted and who have lost their livelihoods, their medications and other things as part of the wildfires. We've also been part of an analysis that's being conducted at DPH, currently evaluating the health impacts of the wildfires.”

LANES is supporting the effort of providing data on emergency department inpatient and outpatient visits that relate to asthma and cardiovascular conditions that would be impacted by this kind of wildfire activity, he explained.

Zadeh then introduced Sonali Saluja, M.D., M.P.H., the vice president of population health and medical director of Healthcare in Action, where she oversees clinical teams and leads research and evaluation efforts. She previously served as the direct of the Gehr Family Center for Health Systems Science and Innovation at USC’s Keck School of Medicine where she was an Assistant Professor of Clinical Medicine and Hospitalist at LAC+USC Medical Center. 

In her presentation, she stressed that Healthcare in Action is an almost entirely mobile organization that cares for homeless and unstably housed patients. Its mission is to improve the lives of people experiencing homelessness through high-quality and holistic care. Saluja said the organization meets its patients where they are both literally and figuratively to provide them with medical and social services. “When I say we literally meet our patients where they are, we will go to them whether they're in tents, RVs, under highway underpasses, you name it. When I say we meet them figuratively, what I'm talking about is really needing them to achieve shared goals about housing and health. That's really been such a positive experience for me as a physician working with patients. It's been truly a rewarding patient and provider dynamic.”

Healthcare in Action has 19 teams in six counties in California. From within each van, they can do medical care, care coordination and housing navigation. From the medical care side, they usually have one advanced practice provider, like a PA or an NP, as well as a medical assistant, RN or LVN. The care offered ranges from primary care and chronic disease management to OB/GYN, addiction/mental health care, even acute care for patients who would like to avoid going to the ED or urgent care. 

“It’s important to say that we really provide team-based care. We’re all in close communication with each other, and I think it really works well because we are a part of the same organization,” she said. 

“From a care coordination perspective, we have between three to five peer navigators per team, and this is really the muscle of our team,” Saluja said. “Many of them have lived experience themselves, either being homeless or having struggled with addiction in the past. They do everything from arranging transportation, going to appointments with patients, getting our patients food and clothing and hooking them up with all sorts of different services. And they really help to build trust with our patients. They do motivational interviewing to change health behaviors. So they're incredibly invaluable, and I would say the muscle and the heart of our team.”

The organization also has housing navigators, who can navigate the homeless management information system to get patients plugged into the right resources. They get funds through Cal-AIM for housing deposits and rent. In 2024 they improved the housing status of 949 patients and 279 of those, they were able to help support into permanent housing. 

Highlighting some results, Saluja said that Healthcare in Action diagnosed 715 patients with hypertension in the last six months, and 84% are receiving treatment, compared to a national average of only 63% When it comes to mental illness, they’ve diagnosed over 1,100 patients with mental illness, and 61% are on a prescribed treatment, compared to 47% of adults with mental illness who are receiving treatment nationally. 

“Our data doesn't include therapy, so it's probably an underestimate, and we're hoping to incorporate that in the future,” Saluja said. “And we have 106 patients who are on long-acting, injectable anti-psychotic medications, which we found to be really a stabilizing force for many of our patients with serious mental illness.” 

Saluja added that unhoused patients are much sicker, have poorer access to care, and the care that they do receive is highly fragmented. “That’s why having a tool like LANES is so critical and important for our ability to care for our patients.” The Cedars-Sinai-based medical record they use, called CS-Link, is integrated with LANES. 


For a recent patient encouter, Saluja described being able to quickly pull up this patient's medications and see that he was recently prescribed a bunch of medications, “which, to me, tells me this patient probably has heart failure and/or liver disease. They're also on a blood thinner. I'm very concerned about the fact that they have a lot of co-morbid conditions. I’m able to pull up their discharge summary, and very nicely, at the end of their discharge summary, it tells us about issues to address in the outpatient setting for this patient. 

“Without LANES, we would be starting from square one. We would probably have had to duplicate a lot of the exams and diagnostics that he already had, which would be expensive, it would lead to delays in care,” Saluja said. 

“Another thing that LANES is offering, especially with the integration into our EMR, is alerts about our patients admissions. This allows us to reach into hospitals and EDs to check on our patients. We can actually call the hospital and say, ‘Hey, before you discharge the patient, let us know. We can help to prepare.’ We can speak to our patients while they're in the hospital, even visit them there, which we do quite often. We also now are able to prepare for our patients’ discharge with medications, wound care, follow-up visits. It really has led to much smoother transitions of care.”

Saluja ended by sharing some of Healthcare in Action’s challenges and potential solutions it is exploring. “We have difficulty finding patients. We're exploring new types of tracking devices that patients are often very enthusiastic about accepting, but don't always work as well.” 

They also have challenges with low rates of medication adherence. “But we're working with pharmacies that now deliver directly to patients. We have limited access to technology in the field. Lanes has a mobile, friendly version that we've been using, and we are very excited for the upcoming LANES patient passport,” she said. “We have challenges with care continuity, but we're partnering with organizations across the patients' care continuum and other street medicine organizations. And lastly, we are looking for more sustainability and exploring things like street medicine payment rates to help us do that.”