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Sacramento Street Medicine Health Research Initiative
1.
Date of outreach
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Hour
Time
:
Minutes
AM/PM
-
AM
PM
2.
Are you a patient of Sacramento Street Medicine
Yes
No
3.
If yes, full name or patient number
4.
If yes to the question above, how many times have you had a consult with an SSM provider this year?
1-2
3-4
5-6
7-8
9+
5.
If yes, to your knowledge, has SSM decreased hospital visits
Yes
No
Unsure
6.
Age
Under 18
18-24
25-34
35-44
45-54
55-64
65+
7.
Race
White
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Another race
8.
Gender
Female
Male
Non-binary
Other
9.
Camp Location
Gold
Blue
Purple
Green
Silver
Orange
10.
If patient: Chief complaint today
11.
Do you have insurance?
Yes
No
Unsure
12.
If yes, who is your insurance carrier
Kaiser
Molina
Anthem
Healthnet
Unknown
Other (please specify)
13.
Do you have a primary care provider?
Yes
No
Unknown
14.
If yes, how many times did you see your PCP this year?
1
2
3
4
5
More than 5
15.
Who is your PCP/Medical home
Elica Health Center
Wellspace
OneCommunity
Kaiser
SNAC
Unknown
Other (please specify)
16.
For non-patients: how many times have you had a consult with an SSM provider this year?
0
1
3
4
5+
17.
How many Emergency Department visits in the past year
0
1-2
3-4
5-6
7-8
9+
18.
Number of hospitalizations in the last year
0
1
2
3
4
5+
19.
Reason for hospitalization
CHF
COPD
Wound care
Trauma/Assault
Substance us
Mental Health
Illness
Other (please specify)
20.
What hospital was used
Kaiser
Mercy General
Sutter General
Methodist hospital
UC Davis Emergency Department
Mercy San Juan
Other (please specify)
21.
Do you have a Case Worker
Yes
No
22.
Do you have a history of any of following chronic conditions
Hypertension (high blood pressure)
Congestive heart failure
Psychiatric disorders (such as bipolar disorder or schizophrenia)
COPD and/or Asthma
Depression
Other (please specify)
None of the above
23.
Internal note (do not ask) :Resources used for Medical and/or Basic Outreach
Wound care provided
wound care supplies provided
Point of care glucose test
STD testing
Vitals
Pregnancy test
COVID-19 Rapid Antigen Test
Medication Dispensed
Prescription
HbA1C
Urinanlysis
Lab draw
Referral for diagnostic imaging
Other (please specify)
None of the above
24.
What are your thoughts on Street Medicine compared to traditional clinics or hospitals?
25.
For patients: document blood pressure reads