COEUR d'ALENE - When Ryan Smith handed the signed sheet of paper over to Shari Griffin, she grinned.

And it was a big grin.

"It's life-changing for me, I can tell you," Griffin said as she sat in the Dirne Community Health Center's mobile medical center.

The paperwork, signed by Smith, was exactly what the Coeur d'Alene woman needed to allow her 5-year-old dog, Louie, to be considered a companion animal so it could live with her.

"I can't part with my animal and I can't get a place to live without the paperwork," Griffin said on Wednesday just outside the St. Vincent de Paul HELP Center. "But I can't do without him. I'd rather be in a jail cell than be in a truck without my dog."

It's been rough for Griffin of late. Her truck barely runs, she was evicted from her home, and work, well, it's tough to find. It has been, she admits, a bit depressing.

"I bit the dust, actually, couldn't keep my head above water," she said.

But she's not giving up.

Which also brought a smile to Smith, a Dirne physician assistant.

It's why he's taking medical care to those who need it, but can't afford it.

It's why he was glad he could provide assistance for Griffin.

"It's that extra little hope, that extra reassurance," Smith said. "Things are OK today, maybe not tomorrow, maybe not the next day, but at least they're good today."

Griffin, for now, is stabilized. It starts with a place to live, then perhaps landing a job, then getting her truck fixed. It is the first of many small steps.

"Now you have the ability to feel a little bit of comfort and make those next steps," he said. "That's what it's all about."

Smith, for the past two years, has been seeking out those who need medical assistance but can't afford it, don't know where to look or where to go. They get into what he called that "dark spot."

He wants to point them in the right direction to regain control over their lives.

"That's why we're here," he said. "We're here to help."

Until about two months ago, Smith and a nurse made their rounds in his car. He filled a few fishing tackle-type boxes with medical supplies, filled out the paperwork by hand and went where he was needed - or where he thought he might be needed.

His efforts to treat the homeless have been noticed, both locally and nationally.

"Ryan and his team have made a huge impact," said Jeff Conroy, St. Vincent de Paul executive director. "There are times when people won't seek services because they're focused on a medical issue. By Ryan serving the people we are able to provide more services, to more people."

The National Health Service Corps also featured Smith, a 1999 Lakeland High School graduate, for his work in healthcare at Dirne.

The NHSC is a federal project to help locate medical professionals in areas with high underserved populations with the use of school loans or loan repayment systems which attract more providers than may otherwise establish in an area.

"It's great to see Ryan get this national recognition," said Mike Baker, Dirne CEO. "The spike we've seen for access to healthcare in these last few years has been demanding. We need more medical providers like Ryan to grow the medical services this community needs."

Dirne CHC recently added pediatric services in Post Falls with Kootenai Kids. This addition is the first in several steps to build capacity to provide access throughout Kootenai County.

"We have a desperate need for a couple more physicians to help us prepare for the future," said Baker. "Mid-level providers - nurse practitioners and physicians assistants - are coming to help Idaho, but we need those physicians to join us to provide that professional mentoring."

But some say it really is Ryan who turned around the Dirne Community Health Center's approach to helping the city's homeless population.

Dirne had a walk-in clinic that catered to homeless populations, but it didn't receive much traffic.

And when he set up shop at the St. Vincent's HELP Center or Fresh Start in Coeur d'Alene, there were privacy and safety issues. Some folks weren't really sure about talking to Smith for fear it might at some point cost them money.

"Sometimes someone would stop in, and others, no one. I was kind of feeling like it was a waste of time," he said.

Two years ago, Baker asked Smith to improve the program.

Smith was sent to the National Healthcare for the Homeless Conference in San Francisco where Smith said he learned the key to success with this population was this: Go to them.

"When I got back, I talked to the CEO and said, 'Why are we sitting in here waiting for them to come to us? Let's go to them,'" Smith said.

With that conversation, "street medicine," was born.

"What we wanted to do was make it a little bit more private, a little more conducive to actual health care," he said.

Smith would load two fishing tackle boxes full of medical supplies into his car and drive around with a nurse and outreach worker to churches, soup kitchen, encampments and parking lots to see patients - wherever they were.

"Before we would get some people coming into the clinic, but it was really hard to get them to trust us - and trust is huge with this population. When we started getting out to where they were, it created that trust, which also vastly improved follow-up care."

Word got around the community about Smith's work. A presentation to the Coeur d'Alene Rotary Club resulted in a $15,000 donation to buy a motor home for mobile operations.

Smith's parents pitched in with renovations and electrical work.

The Dirne Mobile Medical Clinic provides more privacy and also the ability to complete a more focused examination. It is equipped with a computer to utilize electronic health records and the ability to print off patient education materials for their various issues.

There's a relaxed, open lounge area for Smith to initially meet patients, and a private exam room.

It's parked outside the St. Vincent's HELP Center on Harrison on Wednesday mornings, and Fresh Start at 16th and Sherman on Thursday mornings.

Afternoons, it travels to where needed.

On any given day, Smith might find himself treating someone with diabetes, another with a broken bone, or one feeling suicidal.

He estimates he's treated around 100 patients through the mobile clinic and expects to see even more in the winter.

"It's sad. People are in desperation," he said.

A common denominator is they have little or no money and nowhere to go.

In some cases, quick access to health care is critical.

"It's part of the reason we go out to try to find them. They don't have to wait for an appointment," Smith said. "Giving them access is a much easier, much better way. It's so safe for them. It allows them to feel trusted, to feel they're part of society a little bit."

Ryan Smith grew up in Coeur d'Alene. He is the first in his family to go to college. He went into medicine and graduated from Idaho State University's physician assistant school because he wanted to be able to answer health question from his friends and family.

Smith didn't know as a teen the "desperate situation" Idaho would be in now. With Idaho's lowest number of doctors per capita in the nation, his choice to stay in Kootenai County benefits his hometown.

"This is where I wanted to be," Smith said.

He credits the NHSC with allowing him to do what he does.

"I wouldn't be able to support myself without NHSC Loan Repayment, but more than me, the NHSC allows community health centers all over the country to do what they do - which is to try to make a difference," he said.

Navigating the health care system is difficult, Smith said. But perhaps what the Dirne mobile medical center provides more than anything, he said, is hope.

"That's probably the biggest reason. People are in desperate need," he said.

"You see that passion in their eyes and that ability to change - someone actually cares about them."

Most PAs, he said, don't get the sort of opportunities he's had. Doctors would usually run such programs.

Smith said it feels great to make a difference.

"We practice hope and reassurance first and medicine second," he said. "It's the hope and reassurance that allows our patients to get through the day and come back to see us the next day. This program means so much to the people it serves, and I am just thankful to be part of it."