– Michelle Cook thought the dark blotches in the wound on her leg were just scabs until nurses from Mercy San Juan Medical Center told her, no, it was infected.

Cook, a lifelong resident of the Sacramento suburb of Carmichael, met the nurses after seeking shelter for a night at Carmichael’s Christ Community Church. Homeless since Jan. 1, Cook said she’s looking into programs that offer transitional housing.

“I can’t stay on the streets. I’m 53 years old, and I just can’t do it. It tears me up,” she said. “It’s embarrassing to be out there, the way people look at you and treat you. I didn’t choose this, but they still stereotype. It’s hurtful.”

A number of churches in this unincorporated area of Sacramento County take turns helping Cook and other locals experiencing homelessness as part of a nine-week shelter program known as Winter Sanctuary. Each church offers meals, showers and a night’s lodging for the coldest months.

Yet one of the greatest challenges facing people who are homeless is accessing primary medical care and following the medical instructions they’re given, said Scott Young. He’s president of Carmichael’s Homeless Assistance Resource Team (HART), one of the groups running a Winter Sanctuary program. That’s why he wanted Mercy San Juan nurses on hand three years ago when the cots began unfolding at Carmichael churches.

“We see a lot of skin infections, and so it’s really a blessing to have Mercy nurses here to attend to their needs,” Young said. “They can wrap wounds. They can also give referrals if somebody is in need of something beyond what they are able to do on a Thursday night. They can refer them to a doctor or tell them to go to an emergency room.”

It’s challenging for people in the midst of homelessness to manage their medical care, Young said. They have no way to keep wounds clean. They can’t afford medications or, if they can get them, have nowhere to store them, especially things such as insulin that require refrigeration. They can’t follow doctor’s orders to stay off their feet or to take it easy. Extreme temperature changes aggravate their medical conditions.

During medical interventions with Bay Area residents who were homeless, case managers found that the number of emergency room visits dropped by 34 percent for those who found permanent lodging, vs. 12 percent for their peers who had no shelter. The costs of care for those with homes dropped 32 percent, compared with a 2 percent decline for those who didn’t.

Young gets that housing is a key part of solving health challenges, so while the Mercy nurses work to maintain or improve the health of guests at Winter Sanctuary, he and other volunteer advocates are helping to find lodging for individuals who indicate they’re ready to make the transition.

“Last year, we had a total of 78 different people in Winter Sanctuary over the course of the eight weeks,” Young said. “Out of those 78 people, 14 found housing either during Winter Sanctuary or in the months immediately after it.”

Young said that Carmichael HART plans to start a transitional housing program this year and also is working with homeless students and families in the school district. Many of the Winter Sanctuary guests grew up in, or have ties to, those communities, Young said; although they might find more services in Sacramento, they feel threatened by the idea of living on unfamiliar downtown streets.

Until everyone finds a permanent home, Young said, Mercy nurses volunteer once a week to offer minor care. They started their work in Carmichael, he said, but have now added nearby Citrus Heights.

The nurses said they clean wounds, look for telltale signs of uncontrolled diabetes or hypertension and offer over-the-counter medications. They listen — and they learn.

Margaret Cherrix, a registered nurse who manages preoperative services at Mercy San Juan, recalled how they initially brought bottles of medications to hand out to those who needed them. But she and other nurses said they quickly realized no one was going to take a whole bottle.

“We had all these supplies and we were trying to encourage people to take more, take more, and they were like, ‘We can only take what we can put in our pocket or in our little pouches,’ ” Cherrix said. “One year, we gave out little fanny packs because people steal from them if they leave things unattended.”

After talking to people who are vulnerable, you realize you are probably one coping skill away from being in the same situation, said Marcy Phipps, a registered nurse who directs five intensive care units at Mercy San Juan. Many of the people who come to Winter Sanctuary don’t have the resources to manage chronic conditions such as diabetes, she said, and others have a mental illness or disability that prevents them from doing so.

Longtime advocate for the homeless Noel Kammermann, executive director of Sacramento Loaves & Fishes, said HART’s effort to provide basic medical care where people are gathering makes a lot of sense. It can be really difficult for the homeless to make medical appointments for several reasons, he said.

The batteries on cellphones or other timekeeping devices may die, he said, or they can’t afford transportation. In addition, he said, some homeless people are trying to maintain their jobs or get jobs, and they don’t want to miss opportunities or get in trouble for missed work.

Homeless service providers have been studying what happens when homeless people overcome such obstacles. From April 2011 to May 2013, Los Angeles groups identified dozens of homeless patients whose medical expenses were among the 10 percent highest at regional hospitals, and then they began to look for people in that group who indicated they were ready for housing, according to a 2013 report from the Corporation for Supportive Housing.

After patients began to find housing, each person’s public and hospital costs declined on average to $16,913 over a year’s time, compared with an average total of $63,808 before the transition.

Kammermann said: “We have to be mindful that having a safe place for someone to stay and be and exist on a day-to-day basis makes an incredible positive impact on all of us.”

After talking with nurses at Winter Sanctuary, for example, Cook said she made the decision to go see a doctor about her wound. She’s also applying to get into a transitional housing program that helps unemployed people get back into the workforce.

Young said he and other HART volunteers like being able to consult the Mercy nurses about people they feel may have larger health problems.

“They can tell us, ‘Yes, this is something that you need to worry about,’ or ‘No, this person should be fine,’ ” he said. “We’re not medical professionals who are doing this. We are a group of volunteers, but our goal is to keep this a safe place for our guests and our volunteers.”