'Saved my life': How an Austin team is bringing medical care to the homeless

Ashley Sharma takes the blood pressure of Denzil Wooten. She then tests his oxygen levels with a pulse oximeter on his finger. She documents it all and then asks him about his medication supplies, his blood pressure and any symptoms he might be experiencing.

"Your vitals all look good," she tells him.

Wooten, 58, has experienced homelessness for 15 years and has been a heroin addict and an alcoholic. On this day, he says, he has 69 days of sobriety.

Case manager Tony Nunez asks Wooten about the janitorial job he's about to start that afternoon and the housing they are trying to get him into after he leaves the respite where he's currently staying.

The trio stand underneath the roof overhang at a former Sonic restaurant in East Austin. It's a cold November day with a steady drizzle of chilly rain coming down.

Nunez and Sharma are part of the M3 Team, which stands for mobile medical and mental health. The team is a collaboration of the University of Texas' Dell Medical School; Integral Care, the Travis County community mental health provider; and CommUnityCare, the area's largest federally qualified health center, which provides medical care through its community clinics.

This kind of collaboration is an unusual approach, and the outcomes are being studied and will be shared in medical journals and conferences by researchers at Dell Medical School.

The people enrolled in the M3 Team program must have all four qualifying experiences: homelessness, chronic illness, a serious mental health diagnosis and a substance abuse problem. The program also prioritizes people who are African American because African Americans are estimated to make up about 32% of the people experiencing homelessness in Austin, while the total population is about 7.5% African American. The 2021 Ending Community Homelessness Organization point-in-time count estimated that Austin had 3,160 people who were considered homeless and 2,238 people who were unsheltered.

Since M3 began enrolling people in August 2019, it has enrolled 66 people, and 40 people are currently enrolled. They can handle at most 50 clients at a time. Ten people have graduated from the program, meaning they are housed and able to access care without assistance. Eight people have died, and eight have been lost to follow-up efforts — they simply can't be found.

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The collaborative has a five-year, $2.3 million federal grant from the Substance Abuse and Mental Health Services Administration for the M3 Team program. The three collaborators also make their employees available for the program.

The 12 members of the M3 Team are nurses, case managers, primary care physicians, psychiatric providers and peer support specialists with lived experience. Some of them are full-time with the M3 Team, while others serve these clients as part of their roles at CommUnityCare and Integral Care.

"We put the patient at the center and wrap around them a multidisciplinary team," said Dr. Tim Mercer, director of the M3 Team and a primary care physician for the Health Care for the Homeless program at CommUnityCare. He is also the leader of the global health program at Dell Medical School, as well as an assistant professor in population health and internal medicine.

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"If it's truly patient-centered, we will meet the patient wherever that might be," Mercer said. That means providing health care under the roof of an abandoned Sonic, or under a bridge, or in a patient's tent.

For Wooten, that means at least once a week members of the team see him to do a health check. They coordinate office visits with providers and make sure he can get to each appointment.

"I see them every week. ... Now I have a doctor, a psychiatrist; I have a case manager," Wooten said. "They do different things for me."

The biggest thing for him: "They talk to me."

The need for integrated care

The development of the M3 Team "grew out of a pain point I saw sitting in the clinic," Mercer said. "I'm an internal medicine doc trained and equipped to treat liver disease and heart disease."

Of the people experiencing homelessness he saw in the clinic, "the vast majority had substance use, mental illness; they all had social needs unmet. I felt like we were only addressing the small sliver of their problems and not in the ways that were important to them."

Being unhoused affects people's ability to care for themselves, including with chronic illnesses, mental health and substance abuse, Mercer said.

"We really needed care models that addressed those things together," he said. "There were agencies in town trying to address a piece of it, but it was all kind of happening disjointedly. That puts the burden on the patient to navigate all of that."

Mercer points to these statistics: People who are unhoused have a 10 times higher mortality rate. They have a life expectancy of 53 years, according to a study in the Journal of the American Medical Association.

A study in the Lancet medical journal found that people experiencing homelessness have double the rates of diabetes, high blood pressure and heart attacks of a person who is not homeless. They are 20 times more likely to have HIV, 36 times more likely to have hepatitis C, six times more likely to have depression and more than four times more likely to have substance use disorders.

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In Austin, the Ending Community Homelessness Organization said in a September 2017 report that when people experiencing homelessness have a medical need, 40% have been taken to a hospital by ambulance in the past six months, 64% have gone to an emergency room and 34% have been admitted to a hospital. For mental health, 21% don't go anywhere, 40% go to a hospital, 28% go to a clinic and 10% go to a Veterans Affairs location.

"We wait for sick people to come to us," Mercer said. "There was a subset of the population we were not serving well."

A different kind of care

The M3 Team approach is intensive. Most patients get two touch points a week, which could be a visit with a primary care doctor, a call from a case manager or a visit to psychiatric services, as well as the mobile team visiting them where they live or where they want to be seen.

"We are caring for what I would argue is one of the most vulnerable and complex patient populations in our community," Mercer said. "It is going to take resources. They deserve it."

The team follows the clients even after they become housed.

"The work doesn't stop once people get housed," Mercer said. Housing "is not a cure-all. It can be a bumpy transition period."

The conversations the team members have with the clients tend to change as clients make the transition into housing.

From the beginning, Mercer said, the team took a "no wrong door approach. There's nothing that's not our problem. If it's our patient's problem, it's our problem."

That means if patients need help getting their identification, such as a birth certificate or Social Security card, the team helps them. If they need access to food or transportation, the team helps with that.

"Patients aren't used to that," Mercer said. Instead, they are used to being told they need to go to a different organization for each need, he said.

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The M3 Team's caseworkers access different organizations to address these needs. Since the team enrolled its first patients in August 2019:

  • 100% have been enrolled in health care insurance, through Medicaid, Medicare or Central Health's Medical Access Program, which provides health care in Travis County to people living at or below 200% of the federal poverty level.

  • 66% have been enrolled in Social Security disability.

  • 84% have received Supplemental Nutrition Assistance Program benefits for food.

  • 40% now receive transportation assistance from Capital Metro.

  • 55% have gotten into housing, and 82% of those have maintained housing after six months.

All of this is "reflective of dogged case management," Mercer said.

Nunez said often his job is helping clients fill out forms and understand what the forms are asking in each question. "One of the things we try in earnest to do is break down barriers," Nunez said.

The team has also seen health improvements:

  • 29% reduction in depression scores.

  • 64% reduction in emergency room visits for mental health in six months and 56% reduction in 12 months.

  • 54% reduction in ER visits for medical needs in six months, 52% in 12 months.

  • 31% reduction in substance abuse in six months, 45% in 12 months.

None of this happens without the patient's buy-in. The patients get to decide what they want to work on. "If it's addressing their addiction or not, then we will do that or we won't do that," Mercer said.

Eventually, what Mercer and the team see is that trust gets built.

"We understand," Nunez said. "We meet people where they are at."

"We're not going to force people into services," he said, but "they have to be ready to address something."

What they address, "they get to choose," Sharma said. "It's like a choice you are making."

That could mean focusing first on health, or it could be substance use, housing or mental health, or something not even on that list.

"They always consider what do I need," Wooten said. "What do I want to do? ... It's amazing to me how much love and compassion they have. I'm not going to let them down."

Finding Denzil Wooten

When the M3 Team found Wooten, he was in the hospital. He had high blood pressure and scarring in his lungs. He had overdosed seven times. He was down to 112 pounds, and he is 6 feet tall.

"I was near death," he said.

Wooten's world fell apart 15 years ago when his mother died.

"I fell off the deep end," he said. "I was devastated. My mother was my world."

He became homeless and slept under awnings of businesses.

"I slept on concrete in rain, sleet and snow, in cold and hot," Wooten said.

He made his living by panhandling. "I would dance for them and salute and make people happy," he said.

The M3 Team is his surrogate family, he said. "I'm going to make you proud," he tells Sharma and Nunez.

Wooten has struggled. It has not been a direct line to recovery and wellness. Recently, when he fell back into his addiction and became homeless again after being housed, his peer support specialist John Ridenour came and found him, got him into a respite center and helped him get back to sobriety.

Ridenour is five years into recovery for alcohol use and said he ignored his own mental health issues for years while drinking. Being part of the M3 Team is an opportunity for Ridenour to give back and pay it forward, he said. "I received a lot of help in my life. I want to alleviate some suffering," he said.

Wooten said that because of the M3 Team, "I don't get as angry. I don't get as depressed. ... My behavior and my attitude are totally different."

He now takes his medication every day, he said, and Sharma makes sure he is getting his refills.

They are working on getting him back into housing.

"This team saved my (expletive). They saved my life," Wooten said. "I'm eternally grateful and humble."

Finding Mondray Maye

Mondray Maye, 58, would sit on the corner in his wheelchair in the Rundberg Lane and North Lamar Boulevard area off U.S. 183.

"They found me," Maye said of the M3 Team. "I was drunk, sitting in a wheelchair at Lamar and Rundberg."

Maye had a 105-degree temperature and blood clots in his lungs.

"I was a walking dead man," he said.

He was enrolled in the M3 Team program in August 2020.

"I finally found people I could talk to," he said. "They always sit there and listen to me."

Maye began drinking when he was 10.

"It just escalated," he said.

When his mother and wife both died in 1986, he hopped on a freight train and began riding the rails. He saw 42 states that way, including Alaska.

When people would ask him how he got to Texas, he would say, "I don't know. I was drunk."

He thinks he's been in Austin for about eight years.

This year, he is two years sober. He now drinks coffee instead of the eight 25-ounce cans of beer he would drink in a day before.

"I tried to medicate myself," he said of his drinking. "I had no one to talk to."

He has been housed for a year, and he now is receiving disability payments. He's taking computer classes, and he's adopted a puppy named Chantal.

This Thanksgiving and Christmas, Maye cooked for some of his neighbors in the senior living apartments where he lives. He's reconnected with some of his family members, who had no idea where he was for years.

"They go from survival mode to living mode," Sharma said of the people she's watched get housed.

For years, Maye never got a solid night's sleep, he said. Now he has a bed.

"I'm still weird about it," he said. He thinks someone might come through the apartment door at any time.

The team has helped him with mental health and his diabetes, which is improving, as well as his mental health. He recently discovered that he probably broke his foot while drinking, and the team is helping him address that old injury.

"They ask me what I need. If I need something I go to them," Maye said. "This is my family."

Maye said he couldn't get sober until he dealt with the psychology behind it.

The M3 Team is now working on what it would look like for Maye to graduate from the program. There is no set time period, and everyone is different.

"It's about sustainability and long-term," Sharma said. "We want to make sure they can do it on their own."

"We never want to provide services that people have to depend on," Nunez said. "We're trying to empower people.

"He's such a beautiful example of that," Nunez said of Maye.

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Finding Renate Roberts

Renate Roberts, 33, had been on and off the streets since she was 17. Her illnesses include avascular necrosis, neuropathy, gout, heart failure, diabetes, thyroid problems and mental health issues. She has had seizures, which have affected her short-term memory. She was addicted to meth for four years.

In 2019, when the team met her, she was living in her car, which wasn't running. She also had lived in a tent in an approved camp site for people experiencing homelessness. That summer she had had heart surgery, and she had almost been raped when she was on the street. She went into psychiatric emergency services.

Roberts said if she hadn't met the M3 Team, "I would be really sick right now or possibly dead. My health was in such a bad state."

"I would be in and out of the hospital," she said.

Now the team has helped her get her diabetes under control from an A1c (a marker of blood sugar levels) of 16 to 7 (below 5.7 would be normal). She's lost 60 pounds.

"I feel a lot better," she said. "I used to be a slug. I have a lot of energy now."

The team helped her qualify for Section 8 housing and found her a place to live, where she has been since January 2021. The team is helping her apply for Social Security disability benefits.

The team makes sure she has medication refills, and it coordinates doctors' appointments and rides to get there.

"I get overwhelmed," Roberts said of all the forms that need to be filled out and her health care needs. With the M3 Team's help, "I don't get mixed up."

Nunez and Ridenour said Roberts is a good example of the collaboration that clients experience.

"While she has had different obstacles in her way, there was always this willingness to join with us, to collaborate with us," Nunez said. "She's one of the most resilient people we've met."

Roberts isn't quite ready to be graduated from services yet.

"I still feel like I have a ways to go physically and mentally," she said. "When I do graduate, I want to become a peer counselor."

She would give the M3 Team a five-star rating, she said.

"If someone needs help, they are going to get them the help one way or another," Roberts said.

The program has 40 people waiting for services and plans to add another nurse this year. It will apply for additional funding this year to continue the work as well as publish papers about its successes.

This article originally appeared on Austin American-Statesman: Austin M3 Team team brings health care to the homeless