The Street-Based Care Imperative: Psychiatric Support and Clinical Integrity for the Unsheltered

As the prevalence of unsheltered homelessness continues to rise, so does the urgent need for effective psychiatric care tailored to this vulnerable population. Street psychiatry and its broader counterpart, street medicine, involve field-based services delivered directly to individuals where they live, whether in encampments, under overpasses, or on sidewalks. This model has emerged as a promising solution to the “access gap,” yet its success hinges on sustainable funding and a profound shift in clinical philosophy.

Meeting Patients Where They Live

Research indicates that older unsheltered adults are the fastest-growing segment of the unhoused population, often experiencing accelerated aging and a high burden of chronic and psychiatric conditions. For these individuals, the traditional healthcare system is not just inaccessible; it is often perceived as hostile or ill-equipped to handle the realities of street life.

Why It Matters

The intersection of homelessness and mental health is a critical public health issue. Individuals experiencing unsheltered homelessness suffer from high rates of psychiatric conditions while facing significant barriers to traditional care. Street psychiatry aims to mitigate these challenges by bringing support directly to those in need, fostering a more inclusive approach to care.

The Reality of Accelerated Aging

Older adults on the street often have the health profiles of individuals 10 to 20 years their senior. Chronic physical illnesses such as cardiovascular disease and diabetes frequently co-occur with severe mental illness (SMI) and substance use disorders. This complexity requires a specialized form of “street-based geriatrics” and psychiatry that recognizes the cognitive and physical decline occurring in real-time on the pavement.

Breaking the Cycle of Emergency Dependence

Despite the potential benefits of street psychiatry, many initiatives remain underfunded. Current financing relies heavily on precarious grants that lack long-term sustainability. Without these services, the default care for this population remains the emergency department or the criminal justice system, both of which are incredibly costly and ineffective for managing chronic psychiatric conditions. Addressing funding concerns is about more than just access; it is about systemic efficiency. Effective street-based care can reduce emergency expenditures and create the stability necessary for eventual housing.

Who It Affects

The challenges of homelessness and mental health ripple through every layer of the community, causing a wide spectrum of vulnerability. Unsheltered homelessness is defined as ‘living in a place not designated for human habitation, including streets, vehicles, and parks.’ Additionally, the number of adults over age 50 experiencing unsheltered homelessness is expected to double by 2030. In response to these growing numbers among people experiencing unsheltered homelessness, street medicine was developed as an alternative healthcare delivery model. This alternative model of care was developed to better account for the circumstances of this unique patient population and better meet their healthcare needs. Instead of the traditional outpatient and inpatient medical settings or mobile clinics, street medicine providers go directly to a patient’s encampment and reduce several barriers to care that are commonly experienced by those experiencing unsheltered homelessness. Examples of barriers that street medicine bypasses include lack of transportation, concerns regarding leaving personal items unattended for long periods of time, as well as fear of discrimination and stigmatization.

Patients

Primarily, it is the unsheltered individuals, including an increasing number of older adults, who face the immediate consequences of inadequate care. A recurring theme among these patients is the fear of dying on the street, often alone and without dignity. Patients express a deep desire for consistency and humanness in their care. Both are important elements frequently missing from high-volume clinical settings. For someone struggling with schizophrenia or severe depression, the stability of a street medicine team that visits them weekly is a life-saving tether.

Clinicians

Clinicians, including psychiatrists and street medicine teams, are the frontline witnesses to the systemic failures of the healthcare system. They often experience moral injury, which is defined as the distress of knowing what a patient needs (such as housing or specialized psychiatric facilities) but being unable to provide it due to structural barriers. These practitioners emphasize that street-based care requires more than just medical kits. Street medicine requires the time and effort to build trust and radical humility.

Policymakers & Health Systems

Policymakers must balance the immediate need for street services with the long-term goal of permanent supportive housing. In 2023, the Centers for Medicare and Medicaid Services (CMS) initiated reimbursement for clinicians who provide care to unsheltered individuals in a “non-permanent location on the street or found environment, not described by any other POS code, where health professionals provide preventive, screening, diagnostic, and/or treatment services to unsheltered homeless individuals.” This move to reimburse clinicians for their efforts to care for the unsheltered patient population makes it clear that the important nature of this work is apparent to policymakers.

Furthermore, health economists highlight that while street medicine is an interim solution, it is a necessary one for those who are currently falling through the cracks of every other safety net.

Data Collection

A recent study was conducted in various geographic areas in Los Angeles, California, where an interprofessional team provided comprehensive, full-spectrum primary care and social services delivered directly to people experiencing unsheltered homelessness in their own environment. The interprofessional care team was comprised of a prescriber (eg, physician, physician assistant, or nurse practitioner), a registered nurse, a social worker, and a community health worker with lived homeless experience. During the program’s first year (2023-2024), the program provided care to approximately 2000 unique patients (40% aged 50 +) and conducted over 11,000 patient visits.

Key Themes in Street-Based Psychiatric Care**

Based on qualitative data from practitioners and patients, three core themes emerge as essential for effective care:

What Changes

The evolution of street psychiatry represents a critical shift in our society’s commitment to its most vulnerable members. It is a recognition that mental health care is not a privilege reserved for those with an address, but a fundamental human right.

A Right to Care

The stories of patients like those in the Los Angeles study, individuals who simply want to die with a sense of “belonging” and a “roof over their head,” remind us that clinical care is about more than just science and innovation. It is about restoring dignity. By establishing sustainable pathways for street-based care, we are not just fixing a healthcare gap; we are affirming the value of every human life, regardless of where that life is lived.

The future of street psychiatry depends on a collaborative commitment from clinicians, policymakers, and the public to ensure that “dying on the street” is no longer the inevitable conclusion for our aging and mentally ill unhoused neighbors.

Fundamental Changes

To move beyond the current grant-to-grant existence of street-based programs, several fundamental changes are required to develop strategic reforms for sustainability:

• Diversified and Institutionalized Funding – Funding should not exclusively depend on philanthropy. State and federal Medicaid programs must adopt billing codes that specifically recognize “place-of-service: street”. This would allow street medicine teams to bill for the complex, time-consuming care they provide, ensuring long-term resilience for these programs.

• Specialized Training and Support – Healthcare systems must invest in training specifically for the “unsheltered geriatric” and “street psychiatric” populations. This includes training on trauma-informed care, de-escalation in field settings, and the management of accelerated aging. Additionally, clinicians need robust psychological support to prevent burnout from the intense emotional labor of street work.

• Integrated Social and Clinical Frameworks – Mental health cannot be treated in a vacuum. Psychiatric support must be integrated with housing navigation, legal aid, and palliative care. A “team-based” approach—where a psychiatrist, a social worker, and a housing specialist work together—is the most effective way to transition individuals from the street into stable environments.

• Research and Real-World Evidence (RWE) – Increased investment in research is needed to document the long-term outcomes of street psychiatry. By quantifying the reduction in hospitalizations and the increase in housing placements, advocates can make a stronger “business case” for these services to insurance companies and government agencies.

References

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC12508372/
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC5881727/
3. https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-sets