Improving Health Care for People Experiencing Homelessness

This is an unedited transcript.

Hello, everyone. Thank you for joining today’s briefing, Improving Health Care for People Experiencing Homelessness.

I’m an Inquiry Health Policy at the Alliance for Health Policy.

For those who are not familiar with the Alliance, welcome.

We’re a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of how policy issues today’s briefing to you in partnership with the … Health Plan.

Before we get it begin, I’d like to remind everyone that you can join today’s conversation on Twitter, Using the hashtag All Health Life, and Join our Community at All Health Policy, Evolve on Facebook and LinkedIn. Now, I’d like to introduce doctor Sachin H. Jain, CEO of our partner organization for today’s event. Scan Health Plan, is going to kick off today’s event with some opening remarks.

Hi, everyone. My name is Sachin H. Jain, and I’m the President and CEO of Scan, Group and Health Plan.

I am thrilled to be with you here today, and scan is thrilled to be sponsoring this special session session on homelessness and healthcare.

I first became interested in this topic when I was an undergraduate student, volunteering at a homeless shelter and saw the intimate connection between health care issues and homelessness.

I saw that healthcare issues were oftentimes the reason that individuals became homeless or very often were the reasons that individuals were, were, often remained homeless or stayed without housing.

I believe that we have an opportunity in this country to reframe the issue of homelessness, which is oftentimes been characterized as a housing supply issue to be both a housing supply issue, as well as a health care issue.

I think we have tremendous opportunities, from a policy innovation perspective, to use both the Medicare and Medicaid programs to better serve the needs of people experiencing homelessness.

It actually re-allocate resources that are presently applied to addressing complications from homelessness and instead focus on both preventing homelessness as well as addressing the needs of people experiencing homelessness.

What do I mean by this?

I mean that our health care system is oftentimes very comfortable addressing gangrenous tau and sepsis in an ICU at a cost of hundreds of thousands of dollars in place of actually upstream preventative care to ensure that people are well and healthy and independent wherever they reside, whether it’s in their homes or on the streets.

Scan is investing very heavily in a new street based, street based medicine program that’s actually focused on applying the principles of managed care to really prevent up’s downstream complications of, of people experiencing homelessness.

An address.

There are behavioral and physical health needs on the streets.

Where people reside with the intent of trying to stabilize their health conditions. And hopefully getting them to a place where they may be sustainably housed, either through temporary housing, that leads to permanent housing, or through re-integration into their community and social safety nets.

This is, you know, one of our biggest problems.

And if you live in Southern California, you see people experiencing homelessness every day. And you see the suffering that they endure.

We want to be part of the solution.

And that is ultimately, what we’re here to discuss today is how we, as a society, can reframe the problem of homelessness, think differently about how to address it.

And, ultimately, drive sustainable solutions through existing policy instruments that can ultimately lead to real solutions for people who need it most.

So, I’m thrilled that we’re partnering today, with the Alliance for Health Policy. Thrilled that we have an amazing group of speakers, who are very skilled and knowledgeable about these topics.

And I’m hoping that we can start a dialog that will continue into the months ahead, about how we can actually take this problem, that I frankly, think, is an embarrassment to our society, and apply some real, sustainable solutions to address it.

Thank you very much.

Thank you, doctor Jain. Before we continue today’s conversation, I do have a few quick housekeeping note. I’d like to remind you that today’s panel has a question and answer session, and we want you all to be active participants. But please get your questions ready. You should see a dashboard on the right side of your web browser that has a speech bubble icon with a question mark. You can use that to beach bubble icon, to submit questions you have for our panelists at anytime.

We will collect these questions and address them during broadcast.

Throughout the webinar, you can also chat about any technical issues you may be experiencing, and someone will come to help you.

And now, I’m so pleased to introduce today’s moderator, as Ellen Lawton, Senior Fellow, at HealthBegins

I wanted to national expert in the integration of legal profession in health. And, excuse me, legal professionals, and the health care setting to address the social determinants of health.

She has found him at the National Center for Medical Legal Partnership at George Washington University. And an internationally recognized, internationally recognized for her leadership and developing the medical legal partnership model.

She’s recipient of the Innovations and Legal Services Award from the National Legal Aid and Defender Association as well. So, please leave a discussion in your expert hands, and I will turn it over to you. Thank you so much.

Great, thank you so much, Maddie, and thank you, doctor Jain, for your opening remarks. And I’d like to kick us off by introducing today’s panel of experts. I’m so pleased to be with them today. And first, we’re joined by doctor Barbara DiPietro, who’s the Senior Director of Policy at the National Health Care for the Homeless Council. And in this role, doctor DiPietro conducts policy analysis, provides educational materials and presents to a broad range of policymakers and other stakeholders. She also co-ordinates the councils policy priorities with international partners and organizes staff assistance to the policy committee.

Next up, is doctor, sorry, excuse me. Mister David Peery, who is the co-chair of the National Consumer Advisory Board at the National Healthcare for the Homeless Council.

Mister Piri is a passionate advocate seeking to end homelessness throughout Florida, while leveraging his legal training, advocating for homeless rights. When David experienced homelessness.

He was led to camillus health concern, where he became a member of a struggling consumer Advisory Board and really attempted to regain the consumer voice in governance, focusing on educating and empowering consumers to take control of their health care.

In his deep commitment to advocacy. David is a class representative in a Federal class action lawsuit that establishes the rights of people experiencing homelessness in Miami and works to combat the criminalization of homelessness.

Finally, I’m pleased to introduce doctor Jim O’Connell, founding physician and president of the Boston Healthcare for the Homeless Program, which serves over 11,000 homeless persons each year.

Dr.O’Connell established the nation’s first medical respite, program for homeless persons at the … Shelter, and he designed and implemented the nation’s first computerized medical record for our homeless program.

In addition to his role with PH, CHP, doctor O’Connell serves as an assistant professor of Medicine at Harvard Medical School and actively practices street medicine to deliver health care to people experiencing homelessness in the City of Boston. Welcome to our panelists.

We’re so glad that you can join us today, and I want to get right into it. So, I’m going to turn it over to our panelists to offer some opening remarks. Barbara, can we start with you?

Great, thank you so much, Ellen, Really appreciate being here and really appreciate so many of you joining for this topic. Just real quick note about the National Healthcare for the Homeless Council, where a membership organization comprised largely a federally qualified health centers that serve people experiencing homelessness, but also medical respite programs, consumers, researchers, and other advocates.

We’re looking to improve the health care system and end homelessness may provide training and technical assistance and research, policy analysis, and advocacy, and all the good things that, that we need in order to get our communities doing better health care for people experiencing homelessness.

Next slide, please.

Just wanted to level set a little bit about homelessness in the United States right now. So every year on the HUD the Housing and Urban Development Tasks communities with doing a point in time Count on a single night in January. Particularly in 20 21, there were a lot of issues with this Obviously code that has made things very hard. Counting people experiencing homelessness also comes with its own challenges.

But, over time, we’ve at least been able to get somewhat of a snapshot of what we see, again, on any given day, and what we see is not good. We have over 580,000 people who are able to be counted as homeless on a given night in January. And want to just spend a moment to look at what that demographic looks like, just again, as a snapshot.

So partly as to appreciate that homelessness looks lots of different ways. And everyone has a different story. So this idea of brandishing with one brush this as being a behavioral health issue and addiction issue.

Something like this is not really appropriate ARMA because, again, while those may be factors that are present, they don’t characterize the whole largely. It’s really important for us to center this entire discussion of a lack of affordable housing in the United States.

And so that’s what’s driving homelessness.

However, when we look at who’s experiencing homelessness, we’re seeing a lot of people on their own, but we also see a lot of people and families.

one of the things that we can tell you, and Tim and David certainly can also add to this, is what happens to families experiencing homelessness over time?

They tend to separate and so, you see a lot of individuals who are experiencing homelessness did come from families, but when we don’t intervene quick enough, particularly before someone loses a job or loses the ability to pay rent, that’s all we’ve sent to family enterprises.

It’s also important to see that about 40% of people who are homeless are unsheltered.

This is really speaking not just to the lack of affordable housing, but to the lack of dignified alternatives. So our shelter system is stretched to capacity. And particularly during coven, where we did social distancing. And a lot of other provisions in shelters, we weren’t able to serve as many people. Many communities opted into a hotel or motel programs so that we could get people off the street, particularly those that were increased risk of infection.

But still, we’re seeing a very large segment of unsheltered population. And then, within the shelters, we’re seeing a lot of families and kids.

So, I just want to appreciate kind of the different demographics that come with a larger population.

Next slide, please.

So I think, in the context of healthcare, and again, we want to route this, in the lack of affordable housing. So when we say housing is health care, that’s where we’re coming from.

Is that nothing that we do with healthcare providers works as well?

If someone goes back to the shelter or under the bridge or to the encampment, stable, housing is important for stable health.

When we look at, for example, the disparities in illness and in the conditions that we’re treating in the health care system, and you’re experiencing homelessness, you’re gonna be experiencing diabetes, and hypertension, and other chronic illnesses are higher rates than the general public.

And this is true for chronic medical conditions, as well as behavioral health and mental health and substance use disorders.

one of the things that I’m sure Tim’s certainly in doing this work for decades can say, that, back in the 19 eighties, the Institute of Medicine, as it was, and now the National Academies of Sciences. They put out a study in the mid eighties about homelessness and the rise of the synthetic issue in the United States.

And they found three things.

one, is that poor health causes homelessness, Whether that’s medical debt, whether that’s an illness or an injury, that just gotten worse to the point where someone lost housing and couldn’t afford care.

It also found that homelessness exacerbates existing health conditions, but also creates new one because homelessness is a very difficult traumatic event.

Then because homelessness is traumatic, it also makes it hard to engage in health care when you are homeless.

There’s a lot of other things going on to ensure your survival and managing your diabetes or your chronic health condition may not be at the top of the list when you’re struggling to find food and a safe place to put your head.

So all of these things combine where homelessness creates significant healthcare struggles for individuals, and then as a result, that creates significant struggles for the health care system serving them.

Want to also mention that we can’t have this discussion without talking about structural racism, and I don’t think it’s an accident not public policy that African Americans and black and brown populations are overrepresented in the homeless population compared to the general public.

So when we think about the public policies that create homelessness faster than we can end it, we think about the public policies that have pushed more people who are black and brown into poverty and into homelessness.

Those are the honest conversations that we’re hoping to have here today.

With that, I’m going to turn it over to my colleague, David …, who can talk with you more about what all this looks like from a personal perspective that he brings to this conversation.

So David, I’ll turn it over to you.

OK, thank you, Barbara.

So yes. My name is David Perry and co-chair of the NASA Consumer Advisory Board, which is a network within the NASA healthcare for the Homeless Council.

And I’d like to present a perspective from the streets perspective of individuals who are un sheltered and talk about some of the barriers or perhaps conversely, access points that may be available, either prohibit or may be available to folks I’m seeking health care.

And many of those barriers are set out onto the slide here onto the bullet points of the slide.

one point, I just want to make that this on this slide.

That’s the overall point. Here is how intensely traumatizing homelessness is.

And, in fact, I think, unless you’ve actually experienced it, you have no idea how it affects, quite literally every aspect of your thought pattern, everything that you possibly would think of throughout the day. You’re simply in survival mode. And you’re also in a protective mode to protect yourself against your own vulnerabilities. So, I just wanted to just make that very clear as an umbrella concept that homelessness is intensely traumatizing, which leads to the remedy.

or at least the approach that we need to take a trauma informed approach, which I’ll talk about in just a moment.

But this first bullet point here is extremely important.

And in my home state, such as Florida, and the other dozen or so states that have failed to expand Medicaid, that the failure to expand Medicaid is not only a moral failure. I would contend, but also a public health failure.

That Medicaid is obviously the access point that people have who are entrenched in poverty to accessing health care.

And we can see the effects, the concrete effects that manifest themselves every day.

Here, in our non medicaid Expansion States, such as Florida, that individuals who lack access to primary care, let ready access to be a rural health services, obviously, have to wait until some type of health condition reaches a crisis point that they get admitted to a emergency room to the ED.

And I don’t think it needs explanation to anybody on this call here that obviously, once it reaches that point, it’s going to be obviously much more costly and much more difficult to treat. And that’s going to have much worse outcomes.

So, says, I would simply add says first, bullet point of emphasis that experience to expand Medicaid is not only moral, but it does have significant public health consequences to individuals who really have Medicaid as the primary point of access to health care or who are, who would have it. If it was available to them.

The second issue and that actually folds into this second issue of the broader issue, the lack of access to primary care, behavioral health, and supportive services, And that affects really, the poor people emersed in poverty in general, as as well as the people who are specifically living on the streets.

We do have access to the wonderful system of community health centers, of which, the health center that I’m affiliated with, Camillus Health Concern, here in Miami, Florida.

Many do have access to primary care, behavioral health and support services within the network of FQHCs, fairly qualified Health Centers.

Unfortunately, that network is not extensive enough to be available to everyone on the streets.

So, again, you know, even when you are in states that, apparently have expanded Medicaid.

So, folks that are, living on the streets, unsheltered, entrenched within poverty on the streets, don’t always have access as primary care services.

And that manifests itself and very significant effects and adverse effects on their health.

What we have here is summed up the huge problem here in Florida and Miami, in particular.

In the third bullet point, the problem of hospitals discharging people onto the streets.

That is, major, that is significant.

We do know that there are federal regulations laws, if you will, that advise hospitals not to do so, Perhaps even prohibit hospitals are penalized hospitals with discharging people who are … onto the streets. Who are not sick enough to fit within DRG is not sick enough to be maintained within the short term acute care setting.

But are way too sick to take care of themselves on the streets.

And so there’s this new industry, I think, that popped up in a few years, that recognizes this called transitional care.

However, huge, we have documented many instances here in Miami. In fact, these instances happen, quite literally, on an every day basis.

Where are the local hospitals have no place else to discharge individuals where the case managers at the discharge planners are working overtime and, quite literally, are at a dead end in terms of being able to place individuals in any type of transitional care setting.

And that has had devastating consequences. We have what’s known as an MSF Medical Street. Excuse me, a street medicine team here in Miami. This actually documented specific instances of individuals, not only having adverse health effects, but actually dying across the street from the hospital, and I’ll repeat that.

We have documented instances in which an individual who was discharged onto the street has died several instances as a matter of fact.

Quite literally, just either across the street, or right down the block from the hospital.

So this has devastating horrific effects, and we are many of the public health professionals here locally are looking to see what we can do to establish medical respite care programs, which I think were pioneered by, but by Jim Dicarlo, one of the other speakers on this panel.

This next bullet point here: Lack of effective outreach is a big problem for many people on the streets are because of the vulnerabilities, because they’ve been.

So we’ve been so traumatized and abused by folks that we think, would ordinarily be protectors, like the police that often turn out to be predators in terms of criminalizing homelessness or simply a lack of sense of trust.

Among many unsalted people on the streets, when it comes to connecting individuals to health care services, many of the individuals, unfortunately, who conduct street outreach, are not effective because they tend to look down or they have what’s known as maybe a judgemental attitude towards folks. So, it’s extremely important to use a trauma informed approach.

Not so much, to ask people what is wrong with them.

But more to ask people, what happened to you, to get you to, to the spot to where you’re at.

Stop looking at the know, purported moral or character failures of individuals. And look at the systemic issues that cause people to be on the streets.

And when you start to ask those questions, not the systemic structural issues.

When you take a trauma informed approach, when you reach people where they are at, instead of trying to coerce them into a different level, that’s when you start to build that trust and you get effective outreach.

What we’ve found is that the most effective outreach are individuals who have surmounted those challenges themselves.

Peer support specialists, for instance, on peer support is excellent, effective way to reach people which leads a segue into this next bullet point here as a need for peer supports, community health workers, and trauma informed approaches that use a harm reduction philosophy along those same lines.

We have found here in Miami that we have a pioneering syringe exchange program that has proven itself to be very effective in getting people with in that continuum to allow them to receive them health care services.

So folks that would go into the syringe program injectors and the like, would then get care, for instance, for wound care services or for hepatitis or things like that.

And then that would then allow them to get health care services for for other issues that they may have. And I have personally known many individuals who have taken advantage of that to eventually get permanent housing.

This last bullet point here is, again, a fairly significant issue on public health to individuals. That’s basically the criminalization of homelessness.

The criminalization of homelessness that we’re finding out here specifically here in Miami has significant health effects adverse health effects, on individuals.

We the city, unfortunately, engaged in a series of aggressive cleanups to justify dismantling of homelessness encampments, even during the covert crisis against CDC guidance.

And we have found that when they come through, they trash everyone’s value, possessions, they destroy medications, walkers, wheelchairs, canes, and the like.

That we see significant health effects on individuals, hours later.

We have documented instances of a woman going into convulsions on the street because her medication had been thrown away by city workers, just hours earlier.

And we do have documentation of individuals who are disabled, who have had their own walkers and wheelchairs thrown away.

And again, this is simply under the one component of the criminalization of homelessness.

So I can go into many, many different examples here, but but the bottom line is, one of the best way to improve the health of individuals on the street is sort of like a flip of the democratic built of Do no harm is to stop it. Stop doing no harm.

Stop criminalizing individuals, you know for being so poor that they cannot have a home and that they’re forced to conduct life sustaining activities on the streets.

So at that I want to turn things over to our next speaker, which is general colonel of Boston.

Excuse me, David. Thank you so very much. And, hello to everyone else in the audience we can’t see.

But it’s an honor to follow both Barbara, who spend a hero of mine for years and David, who, as the immense respect of all of us around the country for helping us with our consumer legal issues. I also wanted to say, I’m so sorry, I didn’t work for such Jane, but I wanted to just acknowledge what a hero he has meant to all of us, and I’m so sorry.

I did not get a chance to hear him simply send it my best.

To take a perspective from leading from David into how we sort of get started here in Boston.

Interestingly, we began in 19 85 with a grant from the Robert Wood Johnson Foundation Foundation. Sure, you’ve all heard of, But one of the things he did, very interestingly, was sea Grant was given to the mayor of the city.

What they said was immediately a Sikh coalition of stakeholders who we decide how they want a model of care to look. So we never had anything to do with how we currently books to claim it. It really came from these folks. And I wanted to show this picture so far. Consumer board, consumer advisory board back in the nineties, but the woman, third from the left and the bottom is Ellen Daily. Daily will know very well.

She was just a force in our lives, of women who was homeless, had very interesting medical problems, and she helped with the National Health Care for the Homeless constant forming the National Consumer Advisory.

But this group, just to let you know, on the next slide, came up with how they wanted it to be, sir, what they thought was, right.

And this goes back to 19 84 when they were meeting at City Hall, putting their fingers at the main issue was continuity. But they were looking for they felt their lives were full of fragmentation full of lost. The last thing they want it in their healthcare system was more frank. So they were insisted that they should be continuity of care from sheltered street to the hospital.

So an interesting part of our program, which I think is defined much of what we do, is we have to stay part of the hospital. So all of our docs and nurse practitioners a few years have to be credentialed and working in a hospital, one of our two main hospitals. But, then, do our clinics out in the street and go to wherever people are.

Chrissy said, as Steve mentioned, survival on the streets and in the shelters, It has an immediacy that makes it very difficult to make an appointment Friday at two o’clock or next week or month from now. So they wanted their clinicians to come to them.

And so, most of our model has been clinics during the day and the hospitals and clinics in the afternoon tonight, the shelters, and all. The other thing we did, which was interesting here, is they said, Please work in multi-disciplinary disciplinary teams.

That’s what that was an early thing of doing, you know, doing collaborative teamwork. What they were worried about, to be very frank, is continuity. And, they were worried about people like me, who were going to do good and go do? you know, I was gonna give a year of my life to doing this program and move on and do my fellowship and oncology, But they didn’t like that idea. They wanted to see if you’re going to be our doctor and our health care team.

We want you to do this as your profession, not as something you just do as a temporary thing, Especially if we’re gonna open up and let you into our lives. So they wanted us to work in teams. So, I’ve never had my own panel of patients. I’ve always worked with a nurse practitioner PA, and now a psychiatrist recovery coach, and we share the same panel of patients of any of us. Happens to leave those homeless folks have. A team of providers that they know. Lessing, by the way, this looks to me, like early in 19 84 version of a patient centered medical home.

Interesting that folks in the streets were really way ahead of us. The last thing they asked them was to establish respite care, and that’s the first time I’d ever seen the word rescue Kansas. In 19 84, I was coming out of the residency, I had no clue what they meant.

And in the next slide, I wanted to share this is early picture I have of our respite program, so we were command. It was in the middle of TB epidemic in Boston. And we were given 25 bits corner of a of a shelter. And we had to try to figure out what respite care was. Basically.

It was for people coming out of the hospital way too sick to withstand the rigors of the lights on the streets in the shelters, but they had the whole scope. So, we have to provide sort of nursing and doctoring around the clock. OK? And as you can see here, it’s a variety of heart failure to frostbite injuries.

And what happens though, in 1985, right after we opened this September, The first person to be diagnosed with aids in the homeless community. And within a few months, we were really, essentially, have become an age.

Next slide.

I realized, as we are talking about this, that we were conceived back then in the screen epidemics of a multi drug tuberculosis outbreak, and the aids epidemic.

It feels like the bookends of my life when I think of Kobe coming and lots of reminisce about what we went through, mid eighties, where it’s going.

But in a frame shift, because I know the lens that I see, I think homelessness by the way, we should share this.

Talked about this a lot. Policies suffers from a complexity. You know, there is so there’s so many angles of homelessness are so many different groups who are experiencing homelessness, spool, and young people that trauma these people with medical problems, …, people who have learning disabilities, mental health issues, You name it. And it’s a very complicated mix. So it’s very hard to make soundbites work in the lens that we happened to look at our policies because we were given this is our mandate is how do you take care of their health.

And that turns out to be, as you’ve heard from Robert: David, actually, very difficult for systems that are set up, assume you can come to them and see.

Anyway, this picture is when I share with all the time that was taken by a homeless man. Lived under a refuge, we call the long term that is called the longfellow bridge right next semester, which is my hospital speeches. She took with a throwaway camera right at the turn of the century of her friend sitting in a ball park. And there’s about 10, or 11 or 12 men there, and there’s one woman who was hiding behind them. But when I didn’t see this picture until she was going into surgery, about five years after she took it, she handed me the longings sold onto what she went through a surgery.

Just a very common problem, by the way. You’re homeless And you need to do anything with a surgery. You have to bring all your stuff with you or put it somewhere safe.

And you have to be someone who’s able to take care.

Anyway, when I look at this picture, I knew everybody there that’s five years later.

And I was stunned by two things just to throw this into the conversation. one is these are young men average, age is about 36 years old. And they’re all because we’re Massachusetts They all have Medicaid all ensure it because we had bronchitis.

Essentially, all homeless people in our town now have access to health insurance. They’re also, secondly, they’re sitting on a park at Mass General, this is on the grounds of our hospitals. And I would argue we’re pretty good Hospital would be proud of what we do. But when I looked at this picture five years after it had been taken, there were basically just one of those.

So when I think of what goes on in the next slide, on the streets, in the shelters in our communities, mortality rates are astronomically high.

And it’s very complicated. It looks like, we’ve looked like a third world country results, despite the fact that, working in the shadows, best health care institutions. And surprisingly, the causes of death was sort of interesting. It was, cancer, the leading cause of death was not what I thought it was going to be, like drug overdose assaults, cirrhosis, cardiac disease. So if you look at this, you start to realize there’s a whole, as Barbara suggest, huge medical and psychiatric issues, which overlay experience of being homeless, and some preexisting someone like that, and others created.

But anyway, the care of these folks is complicated, and in the next slide.

Wanted to just end up by saying what we have had to do. And what we keep trying to do is recognize it.

We have to hold two things in mind. one is the solutions to homelessness go back to the roots of society, We need this. We have to fix our schools. Et cetera. Welfare systems are educations you know, the whole system.

And we have to buy houses for the platform.

But in the meantime, we have in the country’s membership, thousands and thousands of people who are experienced, homeless in our sit, in the chair, So those two things are the two things we have to hold at the same time.

And one of the things we’ve learned now, so we have clinics, and most of the shelters, doctors, and nurses are in there, and they’re integrated with our clinics, hospitals. We need the hospital, because, as you can see, people are very complicated: medical and psychiatric issues, behavioral health issues. But we learned that there are some advantages to the trust, to learn by being. So, during Soviet, which was devastating for us, 35 to 40% of everybody sitting at Boston Children’s. But we did all sorts of things, which I won’t bore you with, but we’ve also been vaccinated with an interesting twist. So, this is one day in that same park tonight.

That picture was taken, and this is Jen, Nurse, practitioner, physician assistant, giving shots. This is vaccinations to people on the street, and about 75% of everybody living on the streets of Boston has been vaccinated.

And they’ve actually, not because we have a twist to it, but it’s because the vaccine was given to them by someone they’ve known for years.

It’s not someone coming into change in the shelters at any given time, because with the denominator changes, somewhere around 80% of people were vaccinated through the clinics that we’ve had for years.

So, I have a feeling that we’ve been working towards making sure that the population of homeless people who have these huge burdens of co-occurring medical and psychiatric work, behavioral health, and substance use disorders, that said that group of people who are homeless, really setting up the healthcare system, that glass to the boundaries and obstacles that we usually have integrates that care. Right. Where they are, so happy of psychiatry is on the speed, working with our nurse practitioners and our Recovery coaches on caring for the safety.

OK, anyway, I am going to stop here the Maybe, and let me go. one more slide, or two more slides if you weren’t, what’s the next slide? I didn’t want to go. So what I share this with you, because we in Boston, that we may be talking about this, have a real issue with a new encampment that’s come up over the last several years and where we saw it.

Only three to 4% of everybody in Boston who was living on that. Every person who was living on the streets, it’s now shifting, as we’ve had difficulty with, Sheltering Covert came along, and now, they’re large. And that was included along with the canvas.

Has given us a real compassion fatigue, it’s I could say that, and there’s a week burnout and clinicians of Brown, not only with us for the country, but I saw that I remember this was 30 years ago, in The New York Times. It was Labor Day. And the result, as you can see, the headline, there was a shift in ceilings in the Homeless.

Where he had been turned into frustration, and I hear that, we’re in a 30 year cycle, and that is what I worry about now. And I would urge you all to realize that there is a human tragedy behind what is going on. And as David pointed out so eloquently, sweeping away or getting it out of sight, is really addressing this public health emergency. So you might be interested is the New York Times correspondent who wrote that was Isabel Wilkerson, who, as you all know, has written two phenomenal books about racism in our society since that time. But, anyway, let me stop there, and I’m looking forward to the discussion, and I totally honored to be here, especially honored to be with both. Barbara: Thank you.


I think if we fast forward, or if we advance another slide, there we go. So I’m just going to pick up a little bit about where Jim left off and bring us into a policy focus here. So I just want to focus on a few things, and then let’s get to a discussion. I’m excited about a pessimist back to Ellen. So one thing, let’s just talk about Medicaid.

So, on the left, if you look at this graph, this just shows the disparities in health coverage in the United States.

And so, you can see where the general population largely privately funded with, obviously, some Medicare and Medicaid are put in. And then, of course, about 9% uninsured.

In the light green. Those of you who are familiar with federally qualified health centers or community health centers, these are Safety Net clinics that provide comprehensive primary care in an outpatient setting and support services, like case management.

Then, you had healthcare for the homeless programs, which were a subset of FQHCs. And we do more with behavioral health, a lot more of a support services, like intensive case management, outreach, and such.

So if you can take a look to about just over half of our patients now are on Medicaid, which is really great. You’ll see that there’s very limited role for private insurance at this income level. But I want to point out that about a third of our patients nationwide, and we serve nearly a million patients a year, in healthcare for the homeless programs.

About a third are uninsured. Now, a lot of this, as David pointed out, living in Miami 12, states have yet to expand Medicaid, which can, not only a moral failure, but really a healthcare failure for all of us.

So, if we shift over to the graph on the right, you can see this is just healthcare for the homeless programs.

So, the graph on the right is that million patients that we received last year in 20 20, and you can see the disparity in coverage, whether you are in an expansion state or a non expansion state, and it’s literally the inverse, so when we talk about coverage issues for this population, we’re primarily talking about Medicaid.

So for those of you in the audience who are Medicaid folks and are doing advocacy or policy work in this area, because a couple of things I want to point to, one, is that lack of access to insurance coverage as I’m sure you are well aware, specifically tied to not being able to access healthcare at all, ongoing poor health and not having anyone be able to have anyone responsible for their health care in the system.

That’s where we see a lot of ad hoc emergency room visits, hospital admissions, and things like that. But that is none of it, really kind of coms to any kind of co-ordinated care.

And what Tim and David both talked about is, we need continuity. We need comprehensiveness.

We need, basically, to, to the kind of model of care for this population, that we would want for our own cell.

Second, even when you do have Medicaid, we all are familiar with the churn of maintaining eligibility. The limited network, even willing to see Medicaid patient, let alone Medicaid patients that bring with them, comprehend complicated healthcare issues.

So willing providers, and then frankly, just the paperwork undermines the benefit. So a lot of prior authorizations and the paperwork and administrative hurdles of even delivering timely care to patients really is a problem. So anything that can make that administrative piece of continuity of eligibility, comprehensiveness of networks, and getting our reimbursement rates up to the point where we have willing providers.

And so, finally, on the policy, needs lots of areas that we can focus on improvement here, Obviously, closing the coverage gap. So, in the 12 states that haven’t expanded yet, we need to have an option for people, because it’s not an exaggeration to say that people are dying without Medicaid coverage.

Second, we need 12 month continuous eligibility. Is that this is just the kind of thing that is taken as a standard in other health insurance programs. We need to make this a standard nationwide in Medicaid.

Obviously, it increasing reimbursement so that we can be pink provider rates up to the point where we can deliver care.

Adding optional services.

We talked about supportive housing and other things that you can make flexible in, their Medicaid plans to add those tenancy supports and other issues. I want to talk about Medical Respite care here in a second, just as an example of this.

Then finally, coven has shown us the real importance of Telehealth as an alternative to in person care. Particularly, for people who do have phones, who can be. Again, care can be delivered pretty effectively for chronic care management and other check in kinds of things.

We’ve seen tremendous benefits from telehealth here, but it means that you have to recognize an audio only telehealth benefit in your Medicaid program, and again, this is the kind of thing where we need to make conscious policy decisions to make Medicaid a better program, to specifically serve this population.

But I know when we want to get to discussion.

So if we go to the next slide, Under that rubric of adding additional services, making Medicaid work for us at the state level and use the flexibility that we have in those programs. Both David and Jim talked about the importance of medical respite care.

So for those who are new to this, this is post acute medical care for people who were homeless.

We’re too ill or we are frail to recover on the streets.

But not enough to be in the hospital. So when someone’s ready for hospital discharge, as David said, ideally, they have a safe discharge to a stable place.

Absent that though, when you and I would be sent home to rest and recuperate, where does somebody go? If they don’t have a home, shelters are uniquely not suited for dealing with a lot of healthcare issues. In fact, most shelters closed during the day. You can’t stay there all day. So, this is where we’re looking at how do we come up with medical shelter beds, staffed with medical providers, case managers, therapists?

Community health workers, a team of folks that can really help stabilize people while they are recovering, and this gives folks an opportunity to not only get connected to primary care, behavioral health, specialty providers, develop an ongoing care plan.

How, really a few weeks, or even a few months, to work with someone on their medication management on their own chronic disease management. And be able to get a more stable plan so that people can get discharged from medical respite care back into a more stable environment, or, at least when their health isn’t a more stable place.

This has got a lot of benefits to the health care system, namely shorter lengths of stay in the hospital, by giving hospitals an outlet, looking at fewer re-admission rates, so that as people are stabilized, you kind of can interrupt that cycle of admission. The admission.

Obviously, we’re seeing better health outcomes when we treat people in a more comprehensive way with more continuity of care.

And then finally, of course, for those who were really focused on the money piece of this, this does lower cost throughout the system. So again, thinking about how we can be delivering better care is really helpful.

So, the policy made here, recognizing that there is a need for medical Respite care, and providing that space for people who are homeless coming out of the hospital, and then adding those services into your Medicaid program.

Happy to talk a lot more about this, but I do want to just mention that, and the last two days, for those of you who were at the National Association of Medicaid Directors Conference, what I was really impressed to see in the last couple of days is at the highest levels of Medicaid talking about how do we make these programs work for social determinants of health?

How are we using Medicaid to be innovative and meet the needs of more vulnerable people?

And so I think medical respite care was an ideal application for this and builds on the work on the tenancy supports and supportive housing that Medicaid has focused on for this population in the last several years.

So, really excited about that.

Also, want to talk about the Build back better legislation that’s currently being considered by Congress.

The investments in housing, and the changes in health care that we need to have, in order to make inroads here, are really important.

So, for anyone who’s doing any work in that area, please understand that those components are really important for us. And for this issue here.

I can go to the next slide.

And this is just my third issue, again. I wanted to focus this around a few issues here that we can talk about in our discussion, Also, happy to, to, to branch out beyond that. But we can’t talk about any of this without talking about harm reduction.

David talked a little bit about trauma informed care, which is also a piece of harm reduction, but really what we’re trying to do is reduce the harm that’s coming to people.

Now, typically, this is when you talk about harm reduction, we’re rooting this, and what patients or clients want to see for themselves, and their own goals.

It’s often used in a reference to substance use, but certainly not explicitly so, because it can apply to a broader philosophy of care.

So, when we think about how we practice, and Jim talked about this, we don’t want a doctor who’s just looking to do this as a part-time side gate.

How is it that this is part of our committed team’s work to be able to do outreach, street medicine, meeting people where they are, doing more flexible care? We tend to have very rigid system set up in our systems, right? You’re 15 minutes late for an appointment. You can’t get it if you know we’re running late or if you didn’t have the paperwork in order. You don’t get served.

And that just doesn’t work for this population. So, we can how we’ll be removing the barriers so that this population can get connected better to care. And Then How do we think about that as in terms of our public health approaches?

So I think Cov at 19 has certainly Illustrated, not only the connection between housing and health, but also the importance of taking public health approaches to homelessness.

So when we think about syringe service programs making fentanyl, test strips available, distribution of Narcan, things that are making overdoses. Less prevalent. I think that we just saw the headline this morning that we’ve now hit 100,000 deaths and overdose.

And that is just an epidemic in and of itself.

As we think about moving towards shape consumption spaces, and other really innovative ways of being able to meet people where they are, reduce the harms behaviors, and keep people alive, so that we have another day, will be, can do the outreach necessary to get them connected to care. So I think a lot of this is just thinking broadly about, How do we improve systems? How do we elevate staff training so that we’ve got good communication skills? And good ways of approaching patients in a way that engaging rather than alienating? And how do we really expand public health policy approaches, so that we’re not scared away from all of all the typical, you know, syringes and all of that? We need to meet that head on as a way of acknowledging the problems that we currently have.

With that, if we just go to the next slide, I believe the slides will be made available. I just got some resources here that we’ve put out around a number of these areas when they’re available. There’s certainly happy to share the links here.

But with that, really, I’m going to turn it back over to Ellen so that we can get started with our discussion. And really interested to hear what’s on your mind and what areas here that you want to talk about. So, thank you.

Great, thank you so much, Barbara.

Thank you, David and Jim, as well, for your perspectives, and, and expertise, and grounding this conversation. And we’re gonna dive into our Q&A portion.

Just a reminder, you can submit questions using the question mark button on your attendee interface, and I have some follow-up questions that I’d like to ask.

But we have some questions that have already come in through the chat.

So I’m actually gonna kick it off with questions from the audience, and just a reminder to all of you out there as you’re pondering. What you’d like to know, this isn’t all star panel experts at the top of their field.

And it’s a really unique opportunity that you have to, um, ask, follow up questions from Barbara, David or Jim, pose any kinds of questions or challenges or suggestions that you want to.

So please, tap right in there and, and let us know what you’re wondering about. So I’m gonna kick it off.

We have a question about Medical Respite care. Asking, where has Medical Respite care been tried? What studies have evaluated it and how has the program been targeted?

So I don’t know if that’s for Barbara because I know you tackle that, but anyway, I’m happy to start.

But I’ve already talked. So I’ll turn it over either to Jim or David to talk about medical respite. Certainly, Jim is one of the founders of Medical Respite.

Know, I’d be happy to throw it out, David, jump in when you need to be. So our experience now, is that, along to the last 36 years. And so we realize that the definitions of respite care can be very local.

Depends on what you eat in your local situation. What we have found, We have now a 104 bits in our main Respite program 20 and another one, and try to close it, You know, every time there’s an open bed, we would get 20 calls for. A need is huge. It evolves over time, Though, I have to be careful on this.

So, whereas initially, we used to think it was for people coming out of the hospital, about half of the people are coming out of the hospital.

The other half is really interesting mix of people who, for example, need IV antibiotics for awhile, They don’t need to be in the hospital. For people who really need a searcher code, need a place where they come to be delivered to the hospital, to their surgery, picked up that the anesthesia will stop.

We have a lot of people who are end of life care no place to go.

And we’re also evolving that we cut a lot of people who have been on the streets for a long time now and housing in the single apartment somewhere. And when they get sick, they have some recipes becoming, so, that’s also a, kind of a safe place for people to cover.

So, all sorts of things Where they are alone.

So, I think you will. If you look around the country, you’ll find different needs. Respite has always had to try to be flexible enough to address those particular issues of respite program. For example, one floor became a cozy inpatient, drink, coffee. So, we had to give up a lot of the other stuff to do just. But, anyway, let me stop there. David haven’t, where there’s all sorts of funding issues and all sorts of development issues, which we can talk about that.

That’s kind of, that means.

Yeah, really can’t talk too much about the funding issues, that those are the types of things that we’re exploring right now here at Miami.

I just couldn’t really, really, really, unfortunately, document the compelling need for some type of solutions for individuals who are being discharged from the short-term acute care setting Because you’re not sick enough to fit within the DRG that would justify them being in this setting.

But there’s simply don’t fit within long term care, for instance.

Settings either know, they kinda follow in-between that crack. And that is, you know, here in Miami, for instance, a very large number of people.

We’ve got a colleague, physician whose internal medicine finishing up her residency and she just tells me on a, on a daily basis because like a half a dozen, anywhere between 4 to 6 people every single day, different folks who are …, who are being those others frantically trying to find a place to place them.

That’s not on the sidewalk.

And because we know that once he discharged on the sidewalk, their health condition status is going to plummet. In fact, we have documented instances, as I said, of people have been devastating consequences of dying.

Just literally across the street from the hospital.

So, the need is there, and, and we’re hoping, I think, through initiatives, the NASA Healthcare, the Homeless Council, we have established a new Institute National Institute for medical respite care that’s can provide technical assistance that’s going to help, too, Um, find those sources of funding, and to connect communities with those findings.

And so, I would encourage folks to go to our NASA health care wellness.

That’s, that’s the Health Care for the Homeless Council website, and connect with the National Institute for Medical Respite Care, and I think we can find some solutions to finding funding and establishing russet programs in communities.

Shane, thank you, David, and Jeff.

I’m sorry, I just wanted real quick. I just want to say that, thanks for the shout out for nine Mark, or the National Institute of Medical Respite Care. Just answer to the question was about 120 medical respite programs nationally that we’re currently aware of, and most of them are funded to hospital grants or local private foundation grant funding this, but we’re seeing a lot more interest from Medicaid systems. California in their Cal Aim is going live on January one, with an in lieu of service for medical respite.

Washington State right now, is pursuing a statewide benefit. Utah is putting in an 11 15 waiver for medical respite. New York, Michigan, Colorado. All of these states are really looking at how they can be more flexible with Medicaid on medical respite. So, I just wanted to give that context.

Great. Thank you so much for that, Barbara, very concrete.

And it tells our questioner that this is a practice that is really making progress. I want to remind folks that we did extend the time for today’s webinar. We knew that we would have lots of questions, which we do. So, just want to remind folks that were here until 1 15, so keep the questions coming, and we’ll keep the policy and community insights coming. I have another question here, I think goes to David, and certainly Barbara. And Jim, feel free to comment.

And here’s the question, going back to trauma informed care. I understand some people may be so traumatized that they lose trust.

In the healthcare system, This will probably lead to some cases of non compliance. How can we better facilitate trust? What programs can we be aware of to help this high risk population?

So I think we’d love to hear each of you. A couple of remarks on that question.

Sure, sure. Trust is. Trust is a big deal. As I mentioned, because people are so emotionally and physically traumatized from living on the streets, you just feel vulnerable to quite literally, everybody.

And so that normal systems, normal institutions that I think has people might trust are considered to be a threat to folks are on the streets. You know, such as police, for instance, are often viewed as predators and not so much as protectors and doctors as well.

And people just have a general feeling that there are only out there to get us and for our social Security numbers, you know, to get our around food stamps, you know, and to get our money, and that they don’t have any real security toward towards improving our health.

So peer support specialists, I think, are a huge, huge, effective way.

Because these are individuals who have overcome the challenges of homelessness, overcome the challenges of addictions and mental illness, and stabilize these conditions.

And so they’re coming from the streets, or they’re coming from that setting. And they’re much more effective in terms of connecting with people. And again, it’s extremely important to do this under the rubric under the umbrella.

Under the paradigm, if you will, of a trauma informed system, and not so much trying to coerce people and and look down on them and the judgement of fashion and try to get them to change their behavior as much as looking at the systemic structural issues that created those conditions for homelessness. I’d like to say that homelessness is a choice, but it’s not a choice of the people who are homeless.

It’s a choice of the politicians who have created the unfortunate conditions that have led to homelessness.

So if we stop thinking that people want to be homeless by choice or they’re all just drug addicts and mentally ill, and they’re there because of character defects, or they’re just bombs, I think that’s a big way towards changing the way that you approach people, to re-establish that trust. That allows you to bring them in.

OK, thanks, David. Other thoughts?

Barbara, Jam, got some other comments coming in.

But, You know, just listening carefully, what David just said, but I think trust is whenever, I mean, it’s fundamental.

And the key to trust this time, and time is one of the things, at least, valued by the healthcare system, This first part of the healthcare system, and I think, know, we all have our own narrow lens. But, for me, trust years, you had to be there. As we present, you have to stand with people.

You had to, to take care of them, and just be on their faces. When I first started, you probably know, this story, but the nurses in the clinic, as a doctor, we’re trained to be quick. We’ve got to make diagnoses to move on to the next person. And the nurses made me spend two months doing new doctrine.

You invite people into the clinic, and they stop.

Hundred and 25 miles an hour, and go, just so people cheat for two months and that earned so much trust, I keep clicking the investment in that time is probably what gave me the best version of stuff. The other thing I’ve learned is, you know, getting people, getting out to where people are not expecting things to change right away is a key component of trust that people are going to have to get to know you would get to see you using peers, which I’ve always had the blessing of working on it. And that goes overnight, that’s run by one of our local shelters with Department of Public Health money does out every night from 90.

5 of them when it comes to city brings soup sandwiches and blankets and we get to write a long serving sandwiches and then say by the way, if you need anything, we’ve learned that that that door is frequently working with the all the people statement is described is really a key. And when you step back and think about that, it’s very hard to orchestrate in most for health care settings.

Some of the things I, I would urge Medicaid and everyone else to think about is, how do you fund those that time in between?


I would just finish by saying, a way for us to think about this, and not only in healthcare practice, but also healthcare policy, if, in order to have patients trust us, we have to be trustworthy.

And so, what does it mean for us to be worthy of trust? And Jim and David just described how we need to be changing in the health care sector, and the delivery of our services, we need to be worthy of that trust.

And I think that starts with not using terms like non compliant, because we really need to be thinking about, well, why didn’t someone take their medication? Maybe it’s because they’re living in the shelter, or they had their medication thrown out by the last. I can’t sleep.

So, I think, we need to, we need to go deeper.

Great, thank you.

I have a direct follow up on respite care, question to read medical respite programs address health needs of pregnant people who are experiencing homelessness in your experience, or maybe, Barbara, you might have insight: Given your role, I don’t see any reason why not. Certainly if there’s medical needs that need that can be accommodated in that setting, and that’s appropriate for that setting. Now, medical respite care, it’s important to say it’s not a replacement for skilled nursing. It’s not a replacement for nursing home or higher levels of care. So it is specifically for non acute. Does not need that level of acuity. However, is certainly if a patient is pregnant that you can address their medical needs.

But Jim, am I talking out of school? here? On clinical work.

We’ve had lots and lots of pregnant women.

Respite can be critical because often I mean, all the examples come to mind.

You know, we’ve had some women struggling with cocaine living in tunnels, who would only go to someplace like a respite program, where each little bit, except to say, We’ve had lots of examples, finally, learned people in. The women will stay until they deliver and we can make the connection gets them into the prenatal care through the prenatal care.

And some of those experiences have been the most rewarding. So, the answer is certainly yes. And that would really leverage the level of acuity is going to depend on the type of respite.

And, you know, we have 24 hour nursing around the clock medicine, so you can, in some ways, to develop more acute things, where you can work in concert and pregnancy. It’s rare that you have to go.

So, doing that Shared Respite is actually something the hospital helps us with. So that’s kind of another angle.

Great. We have Another question. Actually, kind of a comment, to, I guess you could say, is, do jails also released into the streets?


Every day. Right.

Um, another comment and question here from a participant. I found the point about Continuity of Care to be particularly pertinent.

one of the things that evokes for me is a question of how to attract and retain physicians early on in their medical career, recently completed Medical Education or residency in the shadow of Medical Student Loan debt and loan forgiveness programs, targeting physicians in high need areas.

Do they apply when working with unsheltered populations as well?

So, we’d love to hear from any of our speakers about that topic.

I’m happy to go on that, but about any of you guys. this is a topic near and dear to my heart, by the way, please.

Jim, I don’t think this is this is squarely in your bucket.

You know, just little, personal side is when we, when the national health Care for the Homeless program was started, we started with the express purpose. And the problem that brought up by homeless people is, how come doctors are not in the shelters to nurses and others.

It was how do you attract doctors with just that question.

And, and the answer was pretty careful. Be careful, there was no career. There was no place. You could go and work and sustain yourself and do this, and you can only do it as a short time, and they wanted to.

So one of the mandates we had, still brick, that was the head of our program back. He was in a community medicine at CPSC oversaw that.

But it was, How do you get residents and students and everybody involved in the care of homeless people?

And that’s what, I think, if you look around the country at Health Care for the Homeless programs, whether they are, you know, in health centers or free standing, you will see that the really wonderful places for students to come in and take care of people in work side-by-side with the clinicians, and nurses in the teams were taken care of.

We never had that when I was a medical school. There was no opportunity to do that. And the only jobs you could get with not for you of living wage, so you had to always do this as a volunteer or something on the side.

But we’re, you know, over time, I think of the doctor, we have about close to 40 doctors working in our program.

Now, almost all of them were came through our program when they were residents or when they were medical students, and we have even more nurse practitioners seem to students there, social work students, etcetera.

So I think having a vibrant educational component of healthcare for the homeless programs offers a way to be to regenerate or or generate workforce it’s willing to do the share that we’ve all been trained to describe.

I would add to that maybe a different angle here. increasingly you are hearing about burnout amongst clinicians, particularly driven by moral injury.

They’re working in a system that does not allow them to practice medicine because there are so many factors that are undermining their work. Homelessness just being one of them.

And so, as we’re seeing more clinicians get angry at the conditions that they are being asked to work in, and treating patients that are not in a position to be able to do care plan because of other factors, Again, this is the social determinants of health piece.

I’m seeing a lot more. young physicians want to get active, and advocacy, want to change the system that they’ve been asked to work in.

So medical debt certainly is obviously one worthy area, but I’m just thinking about, how is it that we have our student medical groups, who have been more active in state legislatures, more active in our advocacy, federally, too? Like, asked for, why is it that my patients don’t have housing? Why is it that my patients can’t afford food? I can’t write a prescription for housing. I can’t write a prescription for food. But yet everything I’m going to do here is going to be undermined by the absence of those things.

So, I’m really excited about not just us having more internships available to do this, but having more medical schools, nursing schools, almaty all of our professional schools, doing more on poverty, medicine, at social determinants of health.

But getting pathways for our young doctors, and new people, new clinicians, coming into the field, to be able to change the system, so that it works for them, and allows them to practice in a trade that they’ve been educated.

I think you can agree, David, here here, and we’ll add law schools in there, too, as well.

Sorry, go ahead.

I have another question, and we’re coming close to the end of time. We’ll see, but maybe want to kick off here, Barbara, with your thoughts on this, which is, what are the early first steps that states can be thinking about in terms of getting more street medicine covered by Medicaid?

And you’ve talked about some of those, but, But maybe you want to expound a little more, Cure Street Medicine. So, basically, identifying the providers that are poised to do this, how is it that your reimbursement, or the what’s preventing people from billing for the service that they deliver on the street? So, oftentimes, there are rules governing where you can deliver services. Are those two rigid? Do you need to establish specifically a street medicine benefit in your Medicaid program that allows that flexibility? A lot of times, in a managed care system, for example, Kim can be on the street. And he can be delivering care. But if that person, he’s not be enrolled provider to that patient, then Jim, It doesn’t, isn’t able to bill for his services.

So, again, making sure that we can be more flexible, so that providers get paid for the care they’re delivering to a client and making that more flexible.

So, because Medicaid differs so much from state to state, it’s going to depend on the specifics of how your plan is put together. So, you may already have the authority to do this, or you may need to craft something, but happy to talk more about that in another setting. But definitely, there’s ways that you can be more specific.

And, Jim, you may have to pause here to since you are a street medicine doc.

November, I think you articulated it really perfectly. But the, I think, the issue that we always run into is the work of the work you’re doing as whatever profession. You’re in. Whether you’re a doctor or nurse practitioner is, the work you do in the speech should be billable if it’s a medically necessary. Because the way Medicaid sets it up, and we’ve learned that almost everything you do out there is potentially fillable. The question is, can you do that?

So, one thing that I would just add, it’s going through my mind, and I didn’t say it very well, but you are consumable by the. We have 5 to 7 people on our Board of Directors. They still do it. It’s the best thing that ever ask. But we still are required to stay part of the husks.

And I looked around the country, and the hospitals, we get more clinically involved with health care for the homeless programs because when I’m taking care of somebody under a bridge now needs cardiac surgery, Know, because I’m part of Mass General, I don’t refer this person. Just make the point. That is huge to a homeless person. That’s what are our board members want. They want to know that they are part of the system. And every time I see us being pushed out to the edge, I get nervous. And the more I see us being part of embraced as part of what big hospitals, Academic Health Center, should be doing, and I would argue this is complicated work, is, they should have some medical schools, nursing schools on that.

But it’s hard to get them to embrace that, other than to maybe give us some money and say thank you. You’re doing good work.

I think we should force ourselves to get integrated.

You know, like our doctors have to attend on the wards, we have to teach medical students. We have to have clinics onstage in the hospital.

So we’re seen as part of the structure of the hospital and the care giving homeless people is not seen as something that is separate from where they’re from, And I think that’s a challenge. But the reward is huge, and it answers the questions that you just.

Great. Thank you for that. And I’ve just been given the warning here that we’re almost out of time.

And I just want to thank our panelists for your insights on these topics, just really compelling and essential information. Thanks to all of our participants for your time today. Please take time to complete the brief evaluation survey that you’ll receive immediately after the broadcast ends. Via e-mail later today, joined the Alliance Tomorrow, their voices from the Front Lines program where you’ll hear from an incredible lineup of public health workers, community service workers, and public service figures about their contributions to public well-being throughout the pandemic.

And a recording of today’s presentation and any additional materials will be available on the Alliance website. So this concludes our time today.

Thank you so much to everyone for joining us. Thank you, especially to our panelists, for your wonderful insights and expertise.

And have a wonderful afternoon.

Thank you, everybody.

Thank you. Thank you.