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Laura Seitz, Deseret News
Audiology technologist Anne Lobdell checks Robert Caldwell's ears at the Fourth Street Clinic in Salt Lake City on Wednesday, Oct. 12, 2016.

SALT LAKE CITY — At Fourth Street Clinic on Wednesday, Robert Caldwell, a professed lover of rock ’n’ roll music, got his hearing tested.

Down the hall, a caregiver placed a splint on 9-year-old Gustavo Valdez's finger, which had been jammed by a basketball.

Shannon Walch, meanwhile, was in the downtown clinic that serves people experiencing homelessness for a diabetes checkup.

Presently, Walch and her partner, Diana Toohey, live at the Road Home.

"I hate it, but things happen," she said. "So life goes on."

Although each of them is homeless, Fourth Street Clinic is their medical home.

As Salt Lake City, Salt Lake County, the state and other partners are engaged in reform of the system of homeless services, the future of health care services is playing a key role in that discussion, said Alan Pruhs, executive director of the Association for Utah Community Health, the federally recognized primary care organization for Utah.

Plans call for Fourth Street Clinic to remain a major provider of comprehensive health care services to people experiencing homelessness.

But as the city prepares to select sites for four homeless resource centers, the parties agree it is not financially feasible to set up clinics at each location, said Pruhs, addressing participants of the 13th annual Utah Homeless Summit on Wednesday at the Sheraton Hotel.

One alternative is a mobile clinic that would visit each center on a rotating basis.

"When we're talking about mobile medical, we're talking about a clinic on wheels. It has a lab in it. It has private exam rooms. This is really your doctor's office on wheels. These are not inexpensive units to purchase and operate, but it would be the best way to have dignified health care, privacy and comprehensive services," Pruhs said.

Another option on the table is establishing a second homeless health care center in Salt Lake City.

"We want to locate it in an area with housing with some type of density, also in a location that would work with other individuals who are experiencing homelessness in the Salt Lake County area," Pruhs said.

One site under consideration is the permanent supportive housing complex Palmer Court, which is owned and operated by the Road Home. The facility, which has 201 units, is located at 999 S. Main.

"We felt it was a great site to start exploring an option for a second homeless clinic in the downtown Salt Lake City area," Pruhs said.

While it is generally accepted that access to health care is profoundly important for people experiencing homelessness, it is also a critical issue for formerly homeless people who are in housing, he said.

Sixteen people who lived in permanent supportive housing at Grace Mary Manor died in fiscal year 2015. The 84-unit complex houses people who have experienced chronic homelessness and have a disabling condition. The facility is owned and managed by the Housing Authority of the County of Salt Lake.

"That hit us hard — 16 deaths among 84 people," Pruhs said.

In a meeting among community health center chief executives and housing authority directors, Pruhs said he learned that on-site managers at Grace Mary Manor were calling emergency medical services "every 2.3 days."

"It just blew me away. I thought, 'Wait a minute. We got them off the street. We got them into permanent supportive housing, beautiful complex, great services,'" he said. "Something was missing, and they said, 'We're missing health care. They're not able to access health care, and we're not medical experts.'"

The conversation was a springboard for more extensive planning to address proposed changes to the system of homeless services as envisioned through Salt Lake County's collective impact process but also to manage costs.

An emergency room visit for a primary care issue costs about $1,600 in the Salt Lake Valley, Pruhs said. Treatment at a community health center for the same ailment or minor injury costs $140 to $220. But people who lack access to a primary care provider often have no other access point than emergency departments.

Barbara DiPietro, director of policy and advocacy for the National Health Care for the Homeless Council, said it is important to remember that homeless people who qualify for housing through voucher programs or rapid rehousing are highly vulnerable in many ways, including poor health.

"What does that really mean? It means people going into housing are typically one step closer to death," DiPietro said.

Placement in supportive housing can present new challenges to health such as loneliness, isolation and "housing guilt," feeling guilty about being provided housing while other homeless people do without, she said. Some also fear relapsing in substance abuse treatment and worry that the housing placement won't be successful.

"When we house somebody, that’s not the end of the story. That’s the beginning of a new story," DiPietro said.