PPOH – Page 2 – Maria Yang, MD

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.

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.