Category: Homelessness

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Education Homelessness Lessons NYC PPOH

The Geriatric Adult Home.

During my time at PPOH, I spent one day a week working at a geriatric adult home.

An adult home is a residence that generally houses people with psychiatric conditions. They can be run by either public or private agencies. At best, they provide services and supports for the residents so they can live independently. At worst, they provide very little other than shelter; they just take people’s money. (The latter has resulted in a court order to shut down adult homes in New York.)

This particular adult home was small and housed people over the age of 60. My oldest patient was close to 100 years old. Before I started working there, I assumed that most of my patients would have cognitive impairment, such as mild to moderate dementia.

Well, I was wrong.

Certainly some of them had cognitive problems, but the majority of my patients had psychotic conditions, such as schizophrenia. Some of them had worked with numerous psychiatrists during their lifetimes, taken astounding amounts and types of psychiatric medication, and spent months to years in state psychiatric hospitals. A few of them reportedly underwent procedures like insulin shock therapy.

That they were still willing to talk to any psychiatrist humbled me.

Some of them had significant alcohol problems. Thankfully, most of them had stopped drinking by the time I met them. A few of them achieved sobriety after the age of 70.

Some of them had extensive homeless histories. Several had lived indoors for only a few years when I met them. Can you imagine people in their 60s and 70s who are homeless? plucking food from trash cans with their arthritic fingers? sleeping on disassembled cardboard boxes placed over heating grates?

This particular adult home was near a major New York City tourist attraction. People walked past it all the time without realizing what it was or who lived inside.

The residence itself featured a common area on the lower floor. There was a dining room that served three meals a day (8am, noon, and 5pm, with “tea time” at 3pm). Two clocks, one of which was broken, and an out of tune piano adorned the space. Chefs clattered around in the kitchen for 12 hours a day.

A large TV, a random collection of chairs, a pudgy sofa, and a leaning bookcase were in the living room. A computer over ten years old sat on an even older desk against the wall.

Halfway down the hallway—which had handrails every few feet—was the medication room. Against one wall were rows of shallow drawers, each labeled with the name and photo of a resident. The medication cart occupied one corner of the room. Underneath the large clamshell lid were circular slots that held small paper cups. Inside each cup were pills. A staff member would push the cart around during meals to administer medications.

If people did not attend meals, sometimes staff would go upstairs with the medication to the rooms of the residents. And sometimes the line between administering medication and coercion was blurred.

The rooms themselves resembled small hotel rooms. They each came furnished with a twin-sized bed and a pillow. Some of them also had a small writing desk and a chair. Residents were free to decorate and furnish their rooms as they wished. Almost all of them (who could afford it) bought televisions. Some hung framed art on the walls. Tchotchkes sat on nightstands. Others tacked photos of people—some they knew personally, some not—onto the worn walls.

Then there were residents—often those who had significant psychiatric symptoms—who did nothing to decorate their rooms. The walls were bare, the tiled floor was exposed, and when one sat in the solitary chair in the room, it looked like a scene from an institution.

They shared bathrooms, which were located out in the hall. There were no kitchens. If people could afford it, they put mini fridges and electric kettles in their rooms. The delivery guys from the local bodega routinely dropped off sodas, candy bars, meatballs, potato chips, and fruit.

Though a lot of people worked at the residence, there never seemed to be enough staff. Chefs cooked large quantities of food (that most of the residents did not like). Personal care staff performed thankless jobs: They helped residents shower, use the toilets, and dress themselves. Visiting nurses injected insulin and monitored blood pressures. Physical therapists encouraged people to walk more and taught them to walk safely, especially if they had walkers. Social workers helped coordinate appointments and offered informal counseling. An internist spent one day a week there.

The space I used for my office was literally the storage room for the recreational therapist. Amidst holiday decorations, arts and crafts supplies, and boxes of stuff, patients sat with me for 20 to 30 minutes. They would tell me about bedbug and cockroach infestations; deceased husbands; alcoholic mothers; instructions from God; “the one who got away”; the lack of fresh veggies and fruits with meals; the KGB officers in Times Square; constipation; bones in arms and legs dissolving overnight; talented children; the first time they were mentioned in the New York Times; the burden of using a walker; loneliness; the problems with liberals; the problems with conservatives; fears of death.

Though the internist and I worked there on different days, we worked together. He told me that I made his job easier. He definitely made my job easier. That experience alone strengthened my belief in the necessary collaboration between primary care and mental health (more on that later).

I am grateful that I had the chance to work with and learn from those patients. They taught me how to listen more and talk less. They demonstrated dignity in the midst of illness and aging. They showed me that people still want to learn and change, regardless of age. They reminded me not to take my youth and health for granted. They highlighted the value of laughter.

I learned that people, regardless of age, are just people. No one thinks that they will be 75 years old. Then, one day, you are.

Categories
Education Funding Homelessness NYC Policy PPOH

Project for Psychiatric Outreach to the Homeless.

In New York, I worked for an organization called Project for Psychiatric Outreach to the Homeless (PPOH). It has a humble history: Over 20 years ago, a group of psychiatrists were sitting around and discussing the need for psychiatric services for the homeless. They decided to volunteer their time and skills to this population.

The organization grew and, for both administrative and financial reasons, eventually became part of another social service organization, CUCS. At this point, PPOH serves more formerly homeless individuals than people who are currently homeless.

PPOH is not a big outfit. By the time I left, there were about 12 full-time psychiatrists, several part-time and per diem psychiatrists, and a handful of psychiatric residents. As a group, we worked at nearly 60 sites in three boroughs of New York City.

The job is atypical in many ways. PPOH psychiatrists are paired with different social service agencies to provide psychiatric services. The rationale is that social service agencies often don’t have the resources to employ psychiatrists. Furthermore, these agencies often do not know how to provide the support and supervision to psychiatrists. What they do have, however, are patients who would benefit from psychiatric services, but the patients either cannot or will not visit a psychiatrist in a clinic or other typical setting.

Thus, PPOH brings psychiatrists to the patients.

Funding for PPOH differs from funding for “mainstream” psychiatric services. PPOH receives funding from state and city agencies (government money), grants (from organizations like Robin Hood and van Ameringen), and fees from the social service agencies themselves. These fees are usually lower than what it would cost to hire a per diem psychiatrist directly.

Because PPOH did not receive money from Medicaid, it did not have to follow Medicaid rules and regulations. (PPOH would not be able to fulfill its mission if it did accept Medicaid funds, as Medicaid has requirements that physicians see patients in a physical locations designated as clinics. This contradicts the organization’s mission. While at PPOH, I often saw patients on sidewalks under scaffolding, in their apartments, etc.)

I was one of the few psychiatrists in the group who worked with an agency who worked with Medicaid, though because of the nature of the program (an Assertive Community Treatment program; more on that later), the regulations had little effect on my actual clinical work. It did influence the documentation I had to provide.

PPOH does not have any contracts with insurance companies (as the target population often did not have traditional insurance), which also means that there were no negotiations about reimbursement rates or discussions about concessions to have access to the patients on an insurance panel.

Thus, I essentially had a job outside of the US healthcare system, which, in many ways, was appropriate: The population I worked with was also generally outside of the US healthcare system. Despite this, we often viewed ourselves as “hot spotters“, as a few of our patients often crossed into the US health care system through ERs and hospitals.

Because of this funding structure, I worked as a salaried employee. There were no productivity expectations or bonuses. While this arrangement can result in people slacking off, my boss chose his employees carefully to prevent this problem.

Psychiatrists who choose to work at PPOH, however, do not work there for the money. The median salary for a psychiatrist in New York is apparently $228,815. During my time at PPOH, over 90% of psychiatrists in New York earned more money than me.

(Yes, the specter of student loans continues to haunt me and, of course, it would be nice to make more money, but let’s be honest: I was earning enough money to live comfortably in New York. Not everyone who lives there can say that.)

In exchange, I had the time and opportunity to work with those who often do not receive care. Many of these individuals had significant psychiatric conditions that contributed to their lack of employment, homelessness, and poverty. I had more control over how often and how long I got to see patients. Patients had easier access to me and I had the flexibility in my schedule for urgent appointments.

The idealist in me finds the fiscal realities of health care demoralizing. I don’t like thinking about how economics affects the relationships I have with patients. I didn’t go into medicine to think about that stuff. However, I do firmly believe that physicians should have a basic understanding of their clinic or department budgets. Form follows function. And form follows funds.

Next: What my job at PPOH actually looked like.

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Homelessness Seattle

Three Years.

My stomach lurched when I saw him.

He was leaning against a brick building, his fingertips gripping the walls as if they alone were holding him upright. His head swiveled back and forth in animated conversation.

He was standing alone.

He looked exactly the same as he did before I left Seattle for New York: Matted hair, unwashed skin, lopsided smile.

During my last year of residency, I spent one day a week working at a shelter. He unexpectedly appeared there one afternoon. Staff told me that he was an occasional visitor for the past fifteen years. When winter descended upon the city, they saw him more often. He disappeared during the dryer months.

Wary of psychiatrists—he had spoken to several in his lifetime—he kept our first meeting short.

“Would you be willing to come back next week so we can talk again?”

He shrugged.

To my surprise, he appeared the next week. And the week after. And the week after that.

He told me about his immigrant parents. He told me that he was an avid reader. He often had a copy of the local paper or a library book tucked under his arm when he came to the shelter. His vision was poor, so I’d often see his face inches from the pages. He squinted. He told me about the wooded grove he slept in, though would never tell me its exact location. He showed me the toiletries he kept in his duffel bag, including the razors he used to shave his face without any water or cream.

He never told me what happened that made him homeless. He never told me who he spoke to when he was alone.

Several months before my departure, I told him that I was moving to New York City. The lopsided smile blossomed on his face.

“I used to live there,” he said. The smile withered and his expression darkened. “Be careful. There are a lot of people there. It’s not a safe place. Especially the subway platforms. Make sure you always hold onto the columns in the subway stations.”

To demonstrate, he stood up and dug his fingertips into the walls of the office as if they alone were holding him upright.

Three years have passed and I have returned to Seattle. Three years have passed and he remains homeless with limited to no options for supportive housing. Three years have passed and the only things he can hold onto are the walls along the city streets.

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Education Homelessness NYC

How Long Do People Stay Here?

Let’s visit a homeless shelter in New York City.

There’s no sign on the building. On the sidewalk outside of the unmarked entrance are several men. Three of them are chatting with each other. Two others are leaning against the wall, taking drags from their cigarettes. After you pass, one of them coughs up a wad of phlegm and spits it out. A man sitting on the sidewalk asks, “Spare some change?” He shakes a tattered coffee cup at you. The few coins inside jangle.

You try to pull the door open. It’s locked. Through the glass you see a few people looking out at you. They’re not smiling. Finding the doorbell, you press the white button. A few seconds pass. A harsh, steady buzz suddenly fills the air, informing you that you may now enter.

“Sign in!” a man barks at you. Behind the splintered desk is a man in a security uniform. He’s pointing at a log book, the page nearly filled with names in blue ink.

As you write in your information, he asks, “Who are you? Where you from?”

“Empty your pockets.”

“Open your bag.”

Satisfied with your answers and confident that you don’t have weapons, drugs, or alcohol, he steps out from behind the desk with a metal detector wand. After he waves it over your body, he says, “Go. You’re fine.”

Before you see the thick, plastic chairs in the main room, you smell the odor of fetid sweat. Seated in the chairs are men wearing unwashed jeans, oversized shirts, baggy jackets, and generic baseball caps. Some of them are reading newspapers and books. A few older women are sleeping upright, their chins nearly resting on their chests. One of them is wearing sandals; her toenails are discolored and misshapen from fungus. Her ankles look like eggplants. A young man seated in a wheelchair tries to drink his coffee, but his tremulous hand cannot keep the cup steady. Next to him is a man wearing a porkpie hat, red lipstick, two winter coats, board shorts over torn tuxedo pants, and yellow sandals. Three women are shouting at each other; one of them reaches for the neck of another and screams, “I’M GONNA KILL YOU, YOU—”

“How long do people stay here?” you ask, realizing that the room is filled with people. You can’t imagine living like this; you’d get out of here as soon as you could.

They feel the exact same way.

But you ask an excellent question. What is the average length of stay in a homeless shelter?

Some caveats: Data on homelessness is almost always incomplete and inaccurate:

  1. Researchers can only collect data that is available. People who stay in homeless shelters are available. People who live in cars, abandoned lots, and in transit stations—away from researchers—are generally unavailable.
  2. Researchers often must rely on the information homeless individuals share (“self report”). For a variety of reasons, people who are homeless may not share much about themselves… if they consent to interviews at all.

That being said, available evidence suggests that people stay in homeless shelters anywhere from two [1. “The average length of stay in emergency shelter was 69 days for single men, 51 days for single women, and 70 days for families.”] to seven months. [2. “In a survey of 24 cities, people remain homeless an average of seven months…”] (I read a paper within the last year that I now cannot find—of course—that demonstrated that the majority of people who experience homelessness are homeless for less than six months. Furthermore, of those people, most of them are homeless for only one day!)

This suggests that the majority of people in shelters do not experience chronic homelessness. Emergency shelters, then, are arguably used just for that: emergencies. Those who enter shelters obtain the help and resources (either within or outside of the shelter) to get them back on their feet. They exit the shelter system in less than a year—sometimes within a few months—and never use the system again.

However, there are individuals in shelters who meet the definition of “chronically homeless”. Some researchers have “identified that approximately 10 percent of users account[ed] for 50 percent of the annual nights of shelter provided”. [3. See page 1-10 of this document for the statistic that 10% of shelter users account for 50% of annual nights of shelter provided.] These numbers should sound familiar to those of you who follow health care policy discussions, where “5% of patients use 50% of all health care spending dollars”. [4. More about “A Small Proportion of the Total Population Accounts for Half of All U.S. Medical Spending” here.]

So what’s going on with these individuals who experience chronic homelessness? Are there risk factors for chronic homelessness? If so, what do you think they are?

Categories
Education Homelessness

What Does “Homeless” Mean?

So you’ve thought about the definition of the word “homeless”. Question: Which of the following people would you consider “homeless”?

Ms. Alfa was living in a one-bedroom apartment until the entire building burned down in a fire. She’s been “couch surfing”—spending a few nights at a friend’s apartment, then a few nights at her sister’s house, etc.—for the past two weeks.

Mr. Bravo works in the pizzeria around the corner. He’s the guy tossing the pizza dough in the window. For the past year, he’s had an agreement with his boss: He closes the restaurant every night at midnight and cleans up the shop. He can then sleep on some cardboard in the pantry until seven o’ clock in the morning.

Ms. Charlie is in jail. She was renting a room, but still has another six months left in her sentence. She has been evicted from the room because of unpaid rent. She lost her job due to her incarceration and has no other sources of income.

Mr. Delta lost his job as a construction worker after his left leg was amputated. A man pushed him onto the subway tracks when a train was approaching. While he was in a physical rehabilitation center, his landlord evicted him on false allegations. Mr. Delta was discharged from the rehab center to a men’s shelter, where he now shares an efficiency apartment with a roommate.

So? Who’s homeless?

The United Nations has offered a definition of homelessness [1. I can only find the United Nations definition of homelessness on Wikipedia]. Everyone described above would meet that definition.

The United States Code, however, has its own definition of homelessness. Here it is:

For purposes of this chapter, the term “homeless” or “homeless individual or homeless person” includes—

(1) an individual who lacks a fixed, regular, and adequate nighttime residence; and

(2) an individual who has a primary nighttime residence that is —

A. a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill);

B. an institution that provides a temporary residence for individuals intended to be institutionalized; or

C. a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.

Ms. Alfa would NOT be considered homeless. Though she is “couch surfing”, which implies no fixed or regular housing, she is not spending her nights in a shelter, an institution, or a place “not designed for, or ordinarily used as, a regular sleeping accommodation for human beings”.

Mr. Bravo would likely be considered homeless. The pizzeria is “fixed” and “regular”, though not necessarily “adequate”. The pizzeria meets criteria 2C. Individuals who live in cars, subway stations, and abandoned buildings would also be considered homeless for the same reasons.

Ms. Charlie would NOT be considered homeless, though this is not evident from the definition provided above (see 2B). In practice, it doesn’t matter if someone loses her housing while incarcerated: If she had housing prior to jail, she is not considered homeless, even though she has no place to go upon release. The same applies to hospitalizations. [2. This is often a significant problem. Those who may need housing the most are often deemed ineligible.]

Mr. Delta would be considered homeless (see 2A).

Next: Who would you consider “chronically” homeless?

Does someone have to homeless for at least six months? one year? two years?

Would he have to be homeless for 365 consecutive days? What if he crashed at a friend’s house one week out of every month? What if he rented a hotel room when he had the money to do so?

The federal government has a definition for “chronic homelessness”, too: [3. Chronic homelessness is defined on page 3 of this document. I curiously can’t find it in the United States Code directly.]

… either (1) an unaccompanied homeless individual with a disabling condition who has been continuously homeless for a year or more, OR (2) an unaccompanied individual with a disabling condition who has had at least four episodes of homelessness in the past three years.

Compare this definition to that for “homeless” only. What’s different?

The definition for “homeless” says nothing about duration, nor does it say anything descriptive about the individual. For the definition of “chronic homelessness”, the individual must have been homeless for certain periods of time. Additionally, the person must have a “disabling condition”. [4. I’m not sure what to make of the qualifier “unaccompanied homeless individual”. Does this mean that children with a parent are not considered “chronically homeless”? That doesn’t seem right.]

The government has a definition for “disabling condition”, too: [5. “Disabling condition” is defined on page 4 of this document. I also can’t this in the United States Code.]

… a diagnosable substance abuse disorder, a serious mental illness, developmental disability, or chronic physical illness or disability, including the co-occurrence of two or more of these conditions…. [ In addition,] … a disabling condition limits an individual’s ability to work or perform one or more activities of daily living.

And that is how medicine, including psychiatry, has a role in the care of the homeless.

If you’re thinking that the definition of “chronic homelessness” suggests the medicalization of social issues, you’re not alone. If you’re thinking that medical and social issues are obviously intertwined, you’re also not alone. More on this to follow.