Richardson Bay, a shallow arm of San Francisco Bay, lies just north and east of the Golden Gate Bridge, off Sausalito, California. The estuary is home to beautiful vistas and some of the nation’s most expensive real estate; its marina is dotted with yachts and sailboats. Many of the owners are likely looking forward to a series of America’s Cup events, beginning in August 2012. But just north of the comfort and safety of the marina, another group of boats is anchored. These boats serve as home for a diverse group of individuals known as “anchor-outs.”

Life as an anchor-out is a no-frills proposition. There is no sanitation service, no running water or electricity, although some individuals run generators. Anyone who needs to get to shore – to obtain drinking water, for example – does so in a dinghy, most likely by rowing. The Marin County Department of Health and Human Services (MCHHS) estimates that upwards of 40 percent of the approximately 130 anchor-outs live on very low incomes. While some have chosen this lifestyle, others remain on the often run-down boats out of necessity.

Anchoring-out can be dangerous. An estimated three to four people die on the water each winter. Fire is a significant hazard, as propane is often used for cooking and heating. During storms, boats can break away from their anchors and drift, occasionally crashing into docks and other structures that line the bay.

And many anchor-outs have unmet health needs. It is this last challenge that brought a group of UCSF nursing students to Richardson Bay on two afternoons last fall.

Collaboration Fosters an Idea, Builds Trust

Adam Leonard, Kate Murray and Carrie Shaffer are in the Master’s Entry Program in Nursing (MEPN) at UCSF School of Nursing. In fall 2011, they did a 10-week rotation in MCHHS’s Division of Aging and Adult Services. At the time, the MCHHS had already begun discussions with the Sausalito Police Department about how to approach the anchor-out community – not to issue citations or find infractions, but to discover what their needs were and how public safety officials could help.

Nevertheless, the anchor-out community’s general wariness of the police and the town posed an obstacle. Nurses, especially student nurses, seemed the ideal way to make the initial contact and overcome the wariness. The students and their mentors at MCHHS decided that this also would be an opportunity to do health assessments as part of a collaborative outreach effort.

“The anchor-outs are relatively isolated out there,” says Shaffer. “You aren’t going to reach them with the normal kinds of outreach like free screenings at community markets or visits to homeless shelters. It really has to come to them.”

That’s why in November, the police ferried the students, along with public health nurse Jan Zaslav, to the anchor-outs, where the nurses did basic health assessments, provided flu vaccinations and emergency kits, and talked with the anchor-outs to understand their concerns.

“We were a little surprised to find that some of their biggest requests were for very basic supplies,” says Leonard. “Life vests, flashlights and fire extinguishers were at the top of the list.”

“That’s a little different from what we typically find when we work with homeless and precariously housed individuals,” says Zaslav. “But living on the water presents unique challenges, which requires a different approach to providing services.”

Laying a Foundation for Ongoing Help

The nurses saw 20 people that first afternoon. When word spread among the anchor-outs that there were nurses and other public service workers offering no-strings assistance, two individuals opted to come off the water and into transitional housing, and three more requested help for potentially moving onshore. While the goal isn’t to take those who are aging safely in place out of their homes, says Zaslav, some of the anchor-outs are clearly at risk living on the water.

The students, MCHHS and the Sausalito Police Department subsequently partnered with other community organizations and nursing schools, this time inviting the anchor-outs on shore to a local park, where they were offered further health assessments, flu vaccinations and the items that anchor-outs had said they needed most. In addition, thanks to an effort by the students to solicit donations, the community organizations provided vouchers for eye exams, blankets and socks, information from the local Humane Society (some of the anchor-outs have pets in need of veterinary care) and extensive information on the network of local services that provide help for the homeless and precariously housed.

In fact, one of the goals of the event, says Rita Widergren, the supervising public health nurse for MCHHS, was to make sure the anchor-outs knew about available services that can help address ongoing concerns about their isolation.

For example, Sean Stephens, the county’s Veteran’s Services officer and one of the originators of the outreach idea, was pleased that he was able to connect directly with five veterans. “Now we know who the veterans are out there,” he says. “We’ll be working with them to get benefits – including health care and access to housing – that they didn’t even know they were eligible for.”

Still More to Do

The events also spurred discussion of how the public health community could best continue to serve the anchor-outs. Under the supervision of Sheila Proctor, assistant clinical professor in UCSF School of Nursing’s Department of Community Health Systems, Leonard, Murray and Shaffer have drafted a grant proposal to add two staff to MCHHS specifically to address the health and safety needs of unique communities like the Richardson Bay anchor-outs and other potentially “hidden” communities that exist in Marin County’s vast coastal areas.

The grant proposal is an excellent way to cap off an intense learning experience, says Proctor. Working on it helped the students direct their enthusiasm for community health into activities that can positively affect the future of these communities.

The MEPN students are hopeful that the outreach will continue to grow, especially if it can give the anchor-outs a voice. “People are isolated not only from the community, but from each other,” Leonard says. “Nursing is partly about relationship building. We advocate for our patients, but we can also help bring people together so they can advocate for themselves.”