Caring for Homeless Patients

Welcome to the Remedy, brought to you by NYC Health and Hospitals, innovating public health care to benefit all New Yorkers. Hey, it's Michael Shen. Every New Yorker deserves to live a healthy life, and access to great health care is closer than you might think. I'm really excited about today's episode because it's a topic that's near and dear to my heart. In fact, it's about the work that I myself and many other teams across the system are doing. Our topic today, Homeless Healthcare and the Path to Housing. So as you might know, I'm a primary care and street medicine doctor at Woodhall Hospital in Bedstuy, Brooklyn, where I work in a clinic that serves New Yorkers experiencing homelessness. In recent years, I've seen NYC Health and Hospitals expand the landscape of where we deliver care to unhoused patients. Since April 2021, our fleet of mobile vans have made more than 200,000 engagements, providing both street outreach and medical care to people living unsheltered. Our medical respite program served over 1,100 patients who needed a temporary place to stay. And beyond that, we also invest in the journey home. Our Housing for Health Initiative has connected over 600 patients to permanent housing. And so I want to introduce my two guests who are both my mentors in this work and who lead our system-wide efforts in this realm. Dr. Amanda Johnson, Assistant Vice President of Ambulatory Care and Population Health, and Leora Johntoff, Assistant Vice President of Housing and Real Estate at NYC Health and Hospitals. Amanda and Leora, welcome to the show. Thanks for having us, Michael. Deleted to be here, Michael. Amanda, you were my mentor when I was a clinical leadership fellow here in our system. And you're really the reason why I've entered into this realm of work, why I do the work that I do today. I want you to tell our audience a little bit about your role at NYC Health and Hospitals. Thank you, Michael. I still very fondly remember the day when you came and shadowed with us on one of the very earliest days of the show program. And so it's just a testament to how some of these really unique experiences can set a whole new career path for people. So what do I do at NYC Health and Hospitals? As you mentioned, I'm Assistant Vice President in the Office of Ambulatory Care and Population Health. I lead our care models team, our care models team, invests in, designs, implementing evaluates, enhance primary care models, care management programs and outreach programs for people who face structural barriers that impede their access to the traditional healthcare system. This means care for people experiencing homelessness and also for people returning to the community after jail or prison. I do that four days a week, four plus days a week, and I'm also a primary care doctor. So I see patients myself at one of our community health center sites based in Harlem. Thanks, Amanda. Leora, I go to you for all my housing policy questions. And of course, our teams work very closely to get patients housed. Can you tell our listeners a little bit about your role at NYC Health and Hospitals as well as the Housing for Health initiative that you run? Sure. I'm the Assistant Vice President for Housing and Real Estate and New York City Health and Hospitals. I come to this position with many years of experience around affordable housing and supportive housing, policy and finance. I feel very lucky to have worked at our Housing Agency City and Statewide. And here at each nature, we see our real estate portfolio, but it's been a lot of my time on leading our Housing for Health program, which really provides supports and housing opportunities for our patients experiencing homelessness. We do that a few different ways. One, we do use our real estate and land assets to facilitate the development of affordable and supportive housing, which is so important for the city as a whole. We oversee a medical respite program that you mentioned at the start of the episode. We also offer housing navigation supports for patients experiencing nobles lists so that they can navigate this complex system of finding an apartment in New York City. And we provide supplemental services in affordable housing projects for people who are medically complex who wouldn't otherwise qualify for supportive housing. So that's just a broad overview. It's a lot of work. Yes, thank you for this. Amanda, you were talking about all of your different hats and all of your different rules. And I wanted to point out some of them. You oversee our safety net clinics and I happen to work at one of them. You also oversee the street bans, which is called our street health outreach and wellness units or show units, which I also work in. Can you tell us a little bit about what those are and how that program began? Yeah, so the work precedes me and I really want to give so much credit to the physicians, nurses, care teams, social workers at our facilities who recognize that there was a need for patients experiencing both medical, behavioral, as well as social complexity. And their efforts to design a way of bringing them into first primary care that was different from the primary care they may have been used receiving elsewhere in New York City. And so this came to be known as the primary care safety net and the target population that often met that definition of medical, behavioral, and social complexity, often where people are experiencing homelessness. On the care team, we have a primary care doctor. So nothing new there. We have somebody who is capable of treating people with complex intersecting, interacting medical conditions. But they're able to meet more of the patient's needs in one place, in one encounter, because of the support they have through the other care team members. And so this involves nursing, social work, as well as an explicit emphasis on how we can either co-locate or integrate our behavioral health colleagues. So as we've evolved and scaled the primary care safety net model, it started at Bellevue now over five years ago and has come to Wood Hall and is now an Elmhurst Lincoln. We've been able to bring in a psychiatric provider, either a psychiatrist or a psych and P so that people who receive care at the safety net practices, but needs specialty mental health care don't have to make what can be a really long walk upstairs or down the hall. They can have their needs met in one place by a care team who knows them as a person. I think the other reality of experiencing homelessness is a loss of control and not really being able to command your life, command your day in a way that people who have more resources are able to do. And so when you have time, when you have transportation, when you have other things in your life taking care of and you're like, today is a day that I want to seek medical care, today is a day that I want to connect with the care team. We have to make that connection as easy as possible and that's where thinking about how we structure our schedules and how we manage time becomes important. So one of the things that stands out with primary care safety nets is an approach to scheduling that includes longer appointment times because people who have experienced trauma, who have cognitive impairment, who have mobility issues, just need more time to start to build that relationship, to start to share their story, to start to embark on a diagnosis in management journey with their care team. It also means that we have to be ready for walk-ins. We have to be ready to accept people when they're ready to seek care. And so if we tell somebody that they have an appointment in two weeks for a month, if you're planning horizon is two weeks for a month, that's great. If you only have certainty over what your day might look like this afternoon or maybe tomorrow, then we have to be ready to meet you today when you're ready to receive care and plan for the future, figure out how it is that we're going to be able to connect to continue making progress because neither primary care nor the housing journey can be addressed in one session. And we also meet people elsewhere outside of the Four walls hospital. Can you tell us how the show van program began? Absolutely, Michael. So dating back to April of 2021 when New York City Health and Hospitals was really in the midst of meeting the demands of the pandemic, stepping up to the crisis that we were facing at that time, our efforts to address COVID didn't stop at the doors for hospitals. So very early on, there was experimentation with doing mobile outreach, mobile testing, eventually mobile vaccinations. And I was offered the challenge of trying to understand how we could do this for people who are experiencing homelessness. And my answer was it can't just be about COVID. It's important as it was and as much as people want testing vaccination and treatment, people have so many tasks to manage in a day, especially when they're experiencing homelessness, that we have to take that same approach of being able to provide multi-service delivery in the community setting. So in the park, in the street corner, at the bus stop, we're have you. So this meant having again a multi-disciplinary team. So we are able to provide medical services, COVID or otherwise, and some of the common other medical complaints can range from things like wound care and rashes to hypertension or blood sugar, diabetes, those types of issues. But people are also coming to us with concerns about the behavioral health. We have a social worker who is on our team who is fundamental to actually pioneering our roving model. So not just having a van where people can come and get services. That's position in the community and highly visible. But also being able to strap on the backpack and go and rove in kind of a half mile to a mile radius around the van, to like you said, literally meet people where they are with their possessions in a space that seems comfortable to them. With the help of the social worker, we're able to do additional things, like make new connections to or reconnect people to behavioral health providers. We're also able to offer treatment for substance use disorder, connecting people to treatment when they're ready for treatment. And having the medical provider who is willing and able to prescribe eaprenorphine, being able to connect people to more intensive forms of treatment for substance use disorders is another incredible way that the show programs have been able to meet people's holistic health needs. Our social workers and community health workers who were with us are also really important for connecting people to social services, be it a place to get a hot meal that day, or if somebody wants to come inside, which is one of our goals, it's an important step on the path to housing. Being able to connect them to a bed or an environment that's going to meet their needs, that they're going to feel safe and comfortable in. And then kind of the last component is being able to provision material goods. So if it's had outside and you need water or a cap, if it's cold outside and you need gloves or a hat, a sandwich, condoms, menstrual products, hygiene kits, we want to be able to give you those things, because we know the time you spend with us is time that you would otherwise spend trying to collect funds or find these things to meet your daily needs. I agree. All of those things we give out all day and it really, really helps us meet people's needs directly instead of having to go a convoluted route to get there. So just to say that our program is really thriving under your leadership and we feel really great about it. I can speak for our team at our Woodhall Street Band. Thank you so much, Michael. I will also say that this program, SafeGenet Show, the other things I'm embarking on in terms of, emergency department engagement and navigation, as well as inpatient consult, the only reason that these programs are successful is because of the commitment and the integrity and the authenticity of the care teams who are actually delivering the services. I think there's a chasm of trust that we have to bridge when we're trying to do this care and the reason that people keep on coming back, why on like day two of your show program, you had people waiting at the van for you because you were able to connect with them and you kept your promise. You said we'd be here tomorrow and you were there tomorrow and that's the first step in all of this. Yeah, it's aptly named because it's all about showing up. You both have a very unique view of homeless health care from a system level and given your unique backgrounds, you know, Amanda, you're a primary care doctor, doing large-scale programming, Leora, you're coming from housing and real estate background working in a public hospital. I'm curious to hear your perspectives on this. What are the greatest challenges of serving unhoused people in New York City right now, Leora? I think we live in a very complicated city with a housing crisis. The report just came out two weeks ago that the housing vacancy rate in New York City is 1.4%. That means there just isn't enough housing. So the biggest challenges are there isn't enough housing for those who need it. There isn't enough affordable housing. Access to housing is a challenge for the entire city. And in particular, in this population, it's difficult to navigate the system. The system is complex. It's complicated if you are housed, if you're not housed and you have to collect income documents and IDs and birth certificates and you have to show bank statements to apply for an apartment. That's very difficult. And I think we're all lucky that we have supports in our life when we had to get our first apartment or we branch out on our own. But if people have lost that connection to their community, their family, their friends, or they have nowhere to go, you have just sort of rebuilt that process. And it becomes very ministerial. And everyone needs a good concierge service. They can call housing for help. And that's what we try to help with. It's just sort of to navigate that system. So housing supply, access, navigating the system. It's really a challenge. It's really frustrating. And hopefully we can provide supports for that. And I'll tell you, even in my work, I had to kind of also learn a little bit about the system. And it is beyond complex. Yeah, I would say that there's just a lot of also different models of housing that are available. Even though there's generally not enough housing, our patients need different kinds of housing. And those resources even become further limited. So whether it's supportive housing or they could live in a apartment with some minimal supports, or they have a rental subsidy. It's just a really difficult to navigate. But also you want to make sure people are in the housing that best suits their needs so they can thrive. So it's tough out there. And we're really grateful. I think we should be grateful at H&H that we have good partnerships with our colleagues at other city agencies. We are a safety and hospital system. And it is a benefit that we can speak to our colleagues at other agencies, doing really the hard work of financing housing, developing housing, running shelters, creating supportive housing so that we can all work together to solve this crisis and also house those who are most vulnerable. It really does take a village. We couldn't do it alone. And we need our government partners, CBOs. We need the teams at the facility. So it's kind of a team effort. Yeah. And Amanda, I think you touched on a lot of these challenges when you were speaking about our programs here. But what are some of the other challenges that you see facing on house New Yorkers? Yeah. So to bring it back a little bit to the clinical perspective, I would say that one of the first things that can get in the way of trying to improve the healthcare experience for somebody experiencing homelessness is that we don't talk about homelessness. I think that there can be such a stigma associated with being in a shelter or unsheltered. And people don't always want to volunteer that with their healthcare team because they don't know how it's going to be received. But I think once you start to make that part of your clinical practice and one way of doing it is normalizing it, part of my annual exam. If we're going to do an annual exam, we're going to get something good out of it. I ask people about their housing situation. Who do you live with these days? Where are you staying? If I'm not experiencing a ton of resistance and I want a little bit more specificity, are you staying in a house these days? An apartment to shelter something else? And trying to open up the door to being able to talk about housing, either that day or in the future if somebody's housing situation starts to be a little less stable. So I think breaking down stigma and being able to talk about somebody's housing as a really important driver of their health is the first step. And one of the reasons why we look at the data in broad strokes and wonder why we have this disparity. But then don't know how to attack it, how to address it when we're in the exam room or, you know, in the park with the patient. I think another couple of items that I'll mention that are in a little bit of the structural and interpersonal realm have to do with perspective taking as well. So you've uncovered that somebody is living in a shelter. So what did that actually mean? What do you actually know as a physician, for example, about what your day looks like when you were in a shelter? And so you have to perhaps put your prescribed agenda aside and talk to somebody about their daily routine because you'll clearly be humbled about the pearls of wisdoms you're about to offer about medication management. Oh, you can set up your pills on your nightstand or you can put them out in your bathroom so that you see them by your toothbrush and you quickly realize that that's not this patient's lived reality. And you need to engage them as a problem solver once they've identified what their goals might be. I think you also have to acknowledge that their goal might not be on day one of your visit, getting their blood pressure under control. There could be so many other things that are going on ranging from pain to hunger, to withdrawal. So much that is weighing on them that might make it hard for them to have a conversation about what you as a medical provider might see reasonably as a significant risk to their longevity. And then lastly, to the point about someone's lived reality, so many of the things that we would be coaching around in terms of healthy eating and physical activity and stress management and getting good sleep are very hard to plan for when you are living in a dormitory cell setting. And those are the things that I look to housing for health, look to Lyora's team to address. And so on that point, Lyora, you mentioned the housing crisis in New York City, your team, as part of the housing for health program, does a lot to connect people experiencing homelessness to permanent housing. Can you tell me why I've kind of wondered this myself? Why the nation's largest public hospital system is directly investing in this path to housing? When I think you and Amanda have sort of articulated that already, right? Why it's so important to help patients address their immediate needs, right? And if housing is at the top of the list because they don't have a bedside table, they don't have a kitchen to cook their meals. They're sleep deprived. They have a lot of stress because they don't know where they're going to put their head down tonight, they're hungry. If we get someone house first, we can start slowly addressing all the issues that have compounded over the years. And if someone is happy and healthy, the other piece of a puzzle will be in place. Meaning if someone has housed, we can start addressing their happiness and their health. And I think being on a house, I could only imagine is a very stressful situation. So first thing to address is really, in my mind, and I'm not a clinician, you could speak to it more, but it feels like for many patients, the first thing they want to address is housing because it's too hard to address all the other things because it's so dependent on their living arrangements. And there's a whole city system around that. I think our job here at Health and Hospitals is to break down government silos, to serve patients, to serve our colleagues on the front line, who also are frustrated by the process and try to take some of that pressure off. And hopefully we do that the best we can, as we said earlier, is not an easy system to navigate. Speaking about the landscape of housing and the path to housing, there's also gaps between where people live and the hospital where sometimes there's somebody who may not be sick enough to be in the hospital, but they're a little bit too sick to be in shelter or living outside. And we have a program for that. And that's called medical respite. Can you tell us a little bit about that? Sure. We're very proud of our medical respite program. And it also started right as I started at each and age a few weeks before COVID. And it's a program that allows patients who are experiencing homelessness who are medically cleared from their longer than usual inpatient stay. I've learned, as I'm a houseer, that people experiencing homelessness have a longer inpatient stays in the hospital than you and I. And if they're in the hospital for 23 days, that's too long. And then hopefully they can be discharged from the hospital. Go to medical respite. And that's a program where people can live for 30, 90 days, get access to OTRPT, medically tailored meals, some nursing services. They can stabilize, convalesce, heal, which they wouldn't be able to do. Act shelter, you can't have all those services. Those services we could have at her home, but these patients don't have a home. And so we could offer this service. But I think what's particularly unique about our respite program also is that we offer in tens of thousands of case management. We really, really want to get everyone housed after their stay. And so sometimes we have slightly longer respite stays because we really want to navigate that system and bridge from hospital to respite to housing. Going from hospital to respite back to the hospital or back to shelter isn't the ideal path. Sometimes it happens. I mean, we don't want to be housed. And most people want housing and we do everything we can to get them to that next step, which sometimes takes a little longer. Yeah. And out of the hundreds of people that we have moved into permanent housing, are there any that stick out in your mind that you remember well? I mean, I'm not on the front line, Michael. I think you know that. But I think we had a lovely interaction when we were walking around Woodhall where we feel very lucky to partner with a nonprofit to develop two supportive housing buildings on that campus. And those supportive housing units are available to our patients who qualify. And we ran into one of your patients. And that, for me, was a highlight. He was very happy. And he seemed to be very excited to introduce us, himself to us, to me. And he was extremely excited to see you, Michael. So maybe you want to say, how happy is now? And how he's doing? Yeah. He's a very, very pleasant guy. We love saying him when he comes into clinic. And we've been working with him for almost two years now. And I think that it is very heartwarming to see somebody that you've been working with consistently over that period of time achieve their goal. I think that is always something that keeps me motivated and inspires me to go to work every day. And I remember when he walked out, I was like, Oh, that's my guy. I know him. And we said hi. And he said hi to your whole team. And it was great. Everybody's smiling. That was a great experience. Do you think he's still going back to the clinic, given that it's such like close proximity to the housing? Oh, yeah. He comes in all the time. Okay. He still engages with us in primary care. And we have lots of medical goals that we want to work on together. So the journey continues. And I just did a home visit for him. My community health worker and I went over to visit him. And we saw how he set up his place. And yeah, it was, you know, the heaters are very warm there. So that might be one note. But I would say I've been to a couple of apartments. Yeah. And sometimes I don't always meet every patient at house. Of course, it's a large volume. And there's so many great people on the team. But it is really heartwarming to go to apartments that are so set up to meet with such detail and care, whether someone's stereo system or their interest or their artwork. And it does feel very personalized and that they're excited to have their own space and cook their own meals. I think your patient also talked about cooking his own meals. And I think it's just fun to see and very rewarding. And I think everything we do, it feels extra like cherry on top. Like, oh my god, I'm so glad we could do it. It's on our campus. It's down the street for Michael's clinic. That's great. Like how can we do more? And I think that's why we're really focused on using our land for more housing, more supportive housing and supporting patients through that process. Yeah, the proximity to the clinic is definitely such a plus for us. And Amanda, I want to also turn to you. I know that we have so many street bands across our system. And I was wondering if you had any stories from any of those experiences from the teams out there that you had to share. I think one of the great things about the show program and the show care teams is that they're not just in the community. They're not just doing the street medicine, but they are in the safety net. They are in our inpatient wards and they're able to provide, like we already said, that concierge experience, like you have a doctor who is going to be with you every step of the way and making sure that your needs are met, because that's what it's going to take for you to feel like you can engage with the health care system. Those are the successes. And these are not small issues. I mean, these are really severe wounds that could render someone at risk of a life-limiting infection. And being able to get someone to the point where they can receive that pivotal care is really important. That actually brings to mind somebody that we had recently been working very closely with since last summer. And he was somebody who also had a lot of wounds on his legs and was living outside and had been for many years. And the street bands allowed us to meet him there every week, sometimes multiple days in a week. And in doing so, this person who had previously been very stigmatized whenever he went into an emergency room was able to get our attention a little bit. We were able to work with him on wound care consistently. We eventually worked with our partners at DHS, the department of pharmaceutical services to get him into a shelter of a very specific kind. And he's been doing very well. His wounds are closing in. They're getting smaller, rather. And we still see him every week. And he's been improving a lot in his goals as well. He wants to get to a certain place and we're helping him get there. I have one last question. The issues of housing, especially as they interact with health and well-being, they seem particularly overwhelming to New Yorkers in the current moment. So my question to you is, what advice would you give to New Yorkers who want to know how they can help? Leora, I'll start with you. I think it's a good question. Michael, we live in a city of 8 million plus. It's a density. We feel it now that it's come back to life. We have a supply and demand issue. We have high demand for housing, for affordable housing, from our housing that meets people's needs, working class, New Yorkers, low-income New Yorkers, and we just don't have a supply. And I think at a local level, when housing comes up in our neighborhood as a development, you should publicly support it. Because more housing means less homelessness in general, and not all development is bad. And I think if we adopt that approach, we can get more housing built and we can solve or attempt to solve the homelessness crisis because homelessness is a housing problem. There just isn't enough of it. And locally, we could publicly support projects that come up in our own neighborhoods and support them and say, yes, I wanted in my neighborhood. It's OK. We could have more housing here. There are still buildings to be built. And I think that's the one thing that I would recommend for people who are like, what can I do? I think that is a very tangible thing to do locally. So go to a community board meeting. Indeed. Be out there and say that all development is bad and that it's a good thing to increase the housing stock. And as I mentioned earlier, HPD released a housing vacancy survey. There are only 1.4% faking units in the city. It is just not enough to meet the needs. That's the lowest it's been. It's the lowest it's been. It's down from two years ago, which was 4.5%. It really is a supply demand issue. People can say a lot of other things, but I really believe the more housing stock that's built, the more options there are for everyone. Rooking the workers, we do class, we refer to government employees, people experiencing homelessness. And many of our patients, many new workers are rent burden, but if you increase supply, you can try to alleviate that pressure. And I think that's local in the city, but if our podcast gets out to the birds, that's the whole neighborhood. I think transit oriented development is really important. And we should expand that graph outside of the five boroughs. The more housing that's built, the more we can unlock the potential. Thank you. Amanda. I think Leora summed it up quite well. I think anything I could say is going to pay all in comparison to the importance of expanding the housing supply. I think the one other step on this journey that can help us be more fierce and ardent advocates for this issue is fortifying the workforce that is part of the helping professions. We've talked about having multidisciplinary care teams. We've talked about how many people it takes to help somebody get housed because of how Byzantine and complex this process is and we are experience a workforce shortage. So if you are so inclined or you know someone who is inclined or you're in a position to make sure that people who are in the helping professions can afford to live in New York City themselves, that's a critical component of the puzzle and the beauty of doing this work. And one of the reasons I'm so lucky to be a primary care doctor is that I get a view into people's lives and the opportunity to understand who people are outside of some of these labels including homelessness are insheltered. And it reminds people of our shared humanity. It reminds us that this is a situation that so many of us could find ourselves in. And so therefore we all have responsibility to ensure that the fabric of our community provides for everybody because we don't know what's going to happen from one paycheck to the next. So challenge the stigma. Go to a community board meeting and if you're looking for work come to New York City Health and Hospitals. We're hiring. So that's our discussion for today. Leora Amanda, it's been a pleasure. Thanks Michael. Thank you Michael. Thanks Leora. A big thank you to Leora, John Tiff and Dr. Amanda Johnson for joining us on the show today and discussing our efforts to care for those who are experiencing homelessness in New York, as well as house them. Thanks as well to you for listening. Please remember to leave a review and subscribe. I'm Dr. Michael Shen and this has been The Remedy, brought to you by NYC Health and Hospitals. See you next time. This podcast was produced by amazed media labs. 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