In treating the homeless, lessons for the health care system

Dr. Jim O’Connell was fresh off his residency when he took what he expected would be a six-month job at a Boston homeless shelter. He figured the staff would be thrilled to have someone with his training. He certainly wasn’t expecting what the nurses there gave him as his first assignment: Soaking clients’ feet.

It wasn’t punishment, O’Connell explained in Hartford Tuesday morning. It was a lesson: The only way to work with the homeless patients was to go slow, be present, and win their trust. And if you’re at someone’s feet, you’re not in his personal space the way you are when you listen to his heartbeat.

So he soaked feet. One of his regulars was a man O’Connell recognized from the Massachusetts General Hospital emergency department, where he’d trained. The man had been to the hospital hundreds of times. The chart listed him as paranoid schizophrenic and treatment resistant.

After three or four weeks of foot soakings, the man finally spoke to O’Connell.

I thought you were supposed to be a doctor, he said. What the hell are you doing soaking feet?

A few days later, the man had another question for O’Connell: Doc, he said, I’m having trouble sleeping. Can you give me something to help me sleep?

O’Connell prescribed a medication that helped. It was the start of the man taking medication for his illness. He’d been on the streets for 20 years, but soon after that encounter, he moved into a group home.  

Three decades after he began soaking feet, O’Connell is still working with people on the streets. He’s now president of Boston Health Care for the Homeless Program, which offers medical care to people under bridges, in coffee shops, shelters, clinics, hospital cafeterias and, increasingly, in supportive housing.

O’Connell was in Hartford Tuesday for a forum on homelessness, housing and health care, hosted by the Partnership for Strong Communities, and said the lessons he’s learned treating people on the streets have application for the rest of the health care system.

Almost invisible

Better serving people who are homeless can pay off for their health, and for the health care system as a whole, speakers at the forum said.

“Homeless people are high-cost utilizers of health care,” said Jill Benson, vice president of systems operation at Community Health Resources, which provides mental health and substance abuse services.

Many, like O’Connell’s early patient, are frequent visitors to emergency departments and rack up huge bills for inpatient or intensive care. Among homeless people covered by Connecticut’s Medicaid program, 500 had medical costs that topped $40,000 last year, and nearly 100 had costs of more than $100,000.

But in many ways, they’re still underserved — or at least, not served appropriately.

The mortality rate for people who are chronically homeless is four to nine times higher than for the general population — the highest of any subpopulation in the United States, O’Connell said.

“They’re almost invisible, despite the fact that they’re right outside our big institutions,” he said.

O’Connell’s organization tracked 119 homeless patients for 12 years. In one five-year period, they accounted for 18,384 emergency department visits. But by the end of the 12 years, half were dead.

The leading cause wasn’t exposure or hypothermia. It was cancer — something O’Connell said should have been prevented.  

“They’re coming to us in droves, and we’re doing a lousy job taking care of them,” he said. “If ever I saw an indictment of our medical system, this is it.”

Go to where they are

Over time, O’Connell’s team has learned what works. They treat downtown Boston as their office and hold morning rounds in a bagel shop. Psychiatrists see people at McDonald’s or coffee shops, because their patients don’t want to go to mental health facilities.

Medical and mental health professionals go to patients together. “It’s collocated,” O’Connell said, using a term more commonly meant to indicate medical and mental health providers working in the same or nearby offices, something experts have long advocated. “And we don’t lose people to referrals.”

O’Connell said he used to think of street medicine as episodic, offering first aid. But a nurse practitioner and physician assistant questioned why they couldn’t do more. So the organization now tries to offer continuity of care and to meet quality measures, such as giving all patients flu shots, even if it means administering them outside a public library.

A part of the answer, he said, is getting housing, a source of stability. Many of the organization’s clients now live in supportive housing, and for some, it’s been transformative. Initially, those running the program thought people getting housing would move into the mainstream medical system. But the group’s advisory board, the majority of which are patients, rejected that notion, saying they shouldn’t lose access to their longtime clinicians just because they get housing.

Hospital investments

O’Connell’s program is a federally qualified health center, and receives most of its funding by billing Medicaid and Medicare for services. Some of its money comes from hospitals, which have come to see a benefit to investing in the program.

At Middlesex Hospital, Dr. Michael Saxe became convinced of the need to take a different approach to the patients routinely filling his emergency department. So many people would come with psychiatric needs that at times, the staff couldn’t safely watch all the patients who needed to be observed. On one chaotic night, a patient in the emergency department hanged herself.

“I realized that I could not simply sit back passively and run an emergency department and just take care of whatever came in from the community,” said Saxe, the hospital’s emergency medicine chairman. “I had to get involved somehow in trying to find a way to reduce the number of patients coming to our emergency department.”

The result was the creation of a team with representatives from the hospital and multiple community agencies that meets weekly to discuss the emergency department’s “frequent fliers,” focused on trying to figure out the best care and services for them.

Saxe said 30 percent of the patients are homeless. For some, the emergency department staff is as close as they come to family.

But they weren’t all familiar, like one young man with diabetes. The data showed that he’d come to the hospital 23 times in the past 24 months with a life-threatening diabetic emergency. He’d receive emergency care, be admitted to the critical care unit, and ultimately be discharged. And three weeks later, he’d be back. No one recognized the pattern, because there are dozens of emergency doctors and hospitalists at the hospital.

And no one realized he was homeless.

The team took the young man’s case and began addressing housing issues. “He now has housing,” Saxe said. “And no longer is cycling through our emergency department on a regular basis.”

In the first six months, Saxe said, the drop in emergency department visits and inpatient admissions among the 55 patients the team serves led to a 50 percent to 60 percent drop in money the hospital spends on their care.

“I come from the acute care side, but I found that we in the emergency department of the hospital need what you people are doing here in order to run our operation,” Saxe told the forum audience, which included many people working in social services and addressing homelessness.

Recovering without a home

Like the young man Saxe described, most homeless patients are never asked if they have housing when they’re at a hospital, Benson said.

But odds are, those patients will be back soon after getting out. In Connecticut, 30 percent of homeless patients who leave the hospital after an inpatient admission get admitted again within 30 days. And 70 percent end up back at the hospital in some capacity within 30 days.

A major problem, Benson said, is the lack of services for recuperation. Hospital stays have gotten dramatically shorter in the past two decades, and an increasing number of services — including many surgeries and chemotherapy — are routinely done on an outpatient basis, leaving patients to recover at home.

But what if you don’t have a home?

Boston Health Care for the Homeless Program, O’Connell’s organization, operates a 104-bed respite program that provides medical supervision and care and a place to stay for people who are too sick for the streets or shelters but not sick enough to be in a hospital. It’s named after Barbara McInnis, the nurse who taught O’Connell why soaking feet was important.

There’s work underway in Connecticut to develop pilot medical respite programs.

O’Connell showed a photograph of one woman who stayed at the respite program for months while waiting for a liver transplant.

On the streets, she kept her clothes smelly as a defense against anyone coming near her. She had hepatitis C and cirrhosis. She needed six months of residential stability and sobriety to qualify for the transplant.

One day, once she’d made it to the top of the transplant list, she called O’Connell to her room. She’d gotten dressed up, put on nail polish and lipstick, placed flowers in a Styrofoam cup on her nightstand and asked O’Connell to take her photograph.

The woman explained: She had two daughters whom she hadn’t seen in 24 years, since they were 4 and 6. She was about to undergo a major, risky surgery, and thought maybe they might be interested in finding out about her someday. She wanted to have a picture that would be presentable.

“This is the experience of illness and suffering when you’ve lost everything,” O’Connell said.

A few days later, when O’Connell returned to the Barbara McInnis House, 22 patients asked him to take their pictures. The walls are now covered in portraits.