Prioritizing Equity video series: Health care planning and caring for patients experiencing houselessness

In this June 2, 2023 edition of the Prioritizing Equity series, we explore the unique health care and social needs of patients experiencing houselessness and discuss the importance of equitable, holistic, cost-effective, evidence-based discharge planning.

Dr. Cleveland Manchanda: Hello everyone and welcome to Prioritizing Equity. I'm Emily Cleveland Manchanda, and I'm the director for social justice education and implementation at the American Medical Association and an emergency medicine physician at Boston Medical Center. I have the pleasure of filling in today for Dr. Aletha Maybank, our chief health equity officer, and the usual host for these conversations. Thank you for joining us for a new episode in the Prioritizing Equity Series.

Today, we'll be discussing the unique health care and social needs of patients experiencing homelessness, as well as exploring the importance of equitable, holistic, cost-effective and evidence-based discharge planning. Ultimately, we're seeking to inform physicians of their critical role in improving care for people experiencing homelessness.

The AMA has an interest in educating physicians about the unique health care and social needs of patients experiencing homelessness. The rate of houselessness is increasing in many parts of the country, including in major cities like New York and Los Angeles. Although white individuals constitute 50% of the housed population, people of color have disproportionately higher incidents rates with Black individuals being four times more likely than their white counterparts to experience homelessness.

The root causes of these occurrences in the U.S. can be attributed to the history of oppression tactics including redlining, displacement of communities and housing exclusion policies that people of color have endured as indicated by numerous studies. Additionally, housing costs have increased and there's insufficient affordable housing in many, if not most areas of the country. And this impacts the country on a national, on a state and on citywide levels. Governments across the country are figuring out ways to address this nationwide through innovative policies, practices and community-based approaches, and many of our health systems are also looking at some of these strategies as well.

Recently, the AMA recognized the link between housing security and health outcomes with policy and supports a coordinated, collaborative approach to caring for patients who are experiencing homelessness by combining both clinical and social services. Embedded in these policies is a direct call on physicians, specialty societies, insurers and other involved parties to join in developing, promoting and using evidence-based discharge criteria that are sensitive to the physiological, psychological, social and functional needs of our patients.

So, I'm honored today to welcome an incredible group of thought leaders to discuss this matter. I'll introduce them to you and then we'll jump into the conversation. First, would like to introduce Denise De Las Nueces, who is the chief medical officer at Boston Healthcare for the Homeless Program. Denise, thank you so much for joining us today.

Dr. De Las Nueces: Thank you.

Dr. Cleveland Manchanda: We're also joined by Dez Martinez, who is the founder of We Are Not Invisible, a 501(c)(3) nonprofit, whose mission is to respond to the needs of our chronically homeless, to bridge the communication gap between the fortunate and less fortunate communities, and to address local homelessness issues while also working to end hunger and homelessness. In addition, she's a member of the Benioff Homeless and Housing Initiative Lived Experience Advisory Board and the Fresno Madera Continuum of Care Lived Experience Advisory Boards. Thank you so much for joining us today, Dez.

Martinez: Thank you for having me.

Dr. Cleveland Manchanda: We're also joined by Margot Kushel, who's the professor of medicine and division chief at the division of vulnerable populations at the University of California San Francisco. Margot, thanks for joining us.

Dr. Kushel: Thank you for having me.

Dr. Cleveland Manchanda: Stephen Brown is the director of preventive emergency medicine at University of Illinois Health. Stephen, thank you for joining us.

Brown: Thank you.

Dr. Cleveland Manchanda: Yinan Lan, who is the hospital health medical director at New York City Health and Hospital Corporation rounds out our panel. Yinan, nice to see you. Thank you.

Dr. Lan: Good to be here.

Dr. Cleveland Manchanda: I am incredibly honored to be in conversation with all of you, brilliant and dynamic leaders, and want to make sure that each of your voices are heard. So please feel free to jump in on any and all of these questions. I'd love to just go around and start by asking, how are you coming into this conversation today? How are you feeling when we think about these big topics? If you want to just share a few opening thoughts, would love to hear from each of you and maybe, Denise, we'll start with you.

Dr. De Las Nueces: Absolutely. Thank you so much, Emily. I'm coming into today's conversation hopeful, really, and I think the fact that we are being brought together today by the AMA to talk about this, to really focus on transitions of care specifically for people experiencing homelessness is a step in the right direction. There's more attention towards the real need to better coordinate transitions of care for people experiencing homelessness.

Importantly, however, I'm coming to this as a primary care physician who understands really deeply really from learning from my consumers, from our consumers at Healthcare for the Homeless Program, how incredibly vulnerable and experienced it is to be hospitalized—and how powerful it is for our patients to know that the inpatient care teams are conversing, are communicating with us on the outpatient end and also to see our faces when they're there. So I'm really hopeful. I'm really excited to hear and to learn more from co-panelists today, but also to share more about what we are doing at Healthcare for the Homeless Program towards improving transitions of care for our patients. Thank you.

Dr. Cleveland Manchanda: Great. Thank you. How about you, Dez? How are you coming in today?

Martinez: Thank you so much for having me on this panel and for including members of the unhoused community in this conversation. I'm coming into this conversation today as somebody who's experienced homelessness for the past five years. I became unhoused fleeing domestic violence and ended up on the streets because I couldn't get a bed at the domestic violence shelter. I have a spinal fusion, degenerative bone disease, high blood pressure, diverticulitis. When I became unhoused, I had lost my disability and insurance, which is very hard to get back while you're unhoused. I have a bad heart. I've suffered a heart attack out there and had to ... I had fractured ribs, so I had to recover, basically, sleeping on the concrete from fractured ribs. The only medical care that I could get was the emergency room during my experience with being unhoused. I just want to say I am so grateful to be part of this conversation with y'all today. Thank you.

Dr. Cleveland Manchanda: Thank you so much for sharing your story, Dez, and for being here with us to help us understand this issue from people closest to it. Let's see. Margot, how are you coming into the conversation today?

Dr. Kushel: I'm coming in with deep gratitude. I'm so honored to be on this panel and particularly to be here with my friend and colleague, Dez Martinez, who I think is really the true expert on this panel. I also am a practicing primary care physician, although I spend most of my time these days when I'm not practicing working on research and policy work around homelessness. I'm so thrilled to see the evolution that the AMA is doing this panel, that physicians see themselves as part of the solution and are interested in learning about how they can do a better job both in their practice and also in their policy work and thinking about the bigger issues. So, I'm feeling deep gratitude to be here today.

Dr. Cleveland Manchanda: Wonderful. Thank you so much. Stephen, I'd love to hear how you're coming into the conversation.

Brown: Yes, thank you. I'm just really honored to be here and to be on a panel with such dedicated and passionate people that would like to make sure that more people have access to housing because we all recognize the connection between the lack of housing and health outcomes. We've all experienced tragedies. We've witnessed them firsthand with our patients. So, I'm really interested in digging into the conversation.

I have a advocacy and policy role, and it came out of a frustration about five years ago, having taken a career transition in 2005. I stepped out of a corporate world and went back as an entry-level social worker in the ER at University of Chicago and recognized that behavioral health issues were driving a lot of the utilization of individuals, and yet the systems that were designed to address those things were inadequate and poorly coordinated, underfunded.

So, five years ago, I had this epiphany, nothing much has changed in the 15 years I've been in health care. So, I'd been observing a lot of the behavior of the state here in Illinois and recognized that there were a lot of policy decisions that were being made or not made that was not representing this population very well. So, I asked for this position to be created. I think my primary role is to address the structural determinants of health. We're very familiar with social determinants of health, but there are these ingrained administrative burden in all the systems around us often specifically designed to keep people from getting the entitlements, which they deserve, and those are legacy systems that need to be broken down.

So, I'm optimistic we're doing some great work here that we're doing that and we at UI Health, we're a state hospital, we have a great partnership with our Medicaid agency and the division of mental health and there's been a big commitment within the state to address a lot of behavioral health issues here.

Dr. Cleveland Manchanda: Great. Thank you so much. I'm very excited to hear more about that. Yinan, I would love to hear from you as we open up the conversation.

Dr. Lan: Absolutely. It is great to be here. I am overall, I would say, a combination of feeling excited and also feeling like there is so much work to do and in such a good way. Previously, I work in New York City where the population density is very high—same for the homeless population as well. So, when we're approaching the problems, very challenging to imagine the scale of solution that is necessary. Now, I feel that we are in a place over the past five to six years. It really has changed the conversation in terms of what we're talking about. We're no longer talking about smaller programs, smaller efforts here and there. We're talking about coordinating larger structural changes that are part of the mainstream medicine to really accommodate and really prioritize various types of the vulnerable population, especially people that are unstably housed.

As a primary care physician as well, I feel that many of us get the privilege of watching someone over the course of a while, many years perhaps. So, for the people that we're taking care of, we notice the minor details in their body that are changing, the skin level that's changing, the thickening level, the diseases that are accumulating, the mental health and other factors that are adding up as people are being relentlessly exposed to the environment.

So, I feel that with that level of information backing within ourselves as humans that we are, it really put many physicians in an advocacy role and also allows us a perspective to see what is needed in terms of system and structural change. Part of my work or, actually, a very large part of my work focuses on the public health system, the safety net system within New York City, how we can incorporate this as part of the mainstream care and not just a side pocket that will do a limited amount of effort. So, I’m really looking really looking forward to digging in and discuss just everything that's going on.

Dr. Cleveland Manchanda: Wonderful. Well, thank you all for being here with us. I know our audience will appreciate each of the perspectives that you bring to this conversation. It sounds like we're setting ourselves up well to have a conversation at multiple different levels, both at what the individual physician can do at the bedside and in collaboration with teams, as well as at city-level interventions and thinking about those structural determinants of health as well, the big P policy. So, I'm excited to get into all of those spaces with you today.

I'd love to start at the bedside and ask for some thoughts on evidence-based processes that our health care teams, our physicians, and others on the health care team, should follow when discharging patients who are unstably housed or who we know are experiencing homelessness at the time of discharge. Would love to just open it up and hear from whomever feels compelled to jump in and answer.

Martinez: I'll go. Processes that health care teams should follow when discharging patients, it would be helpful to follow the guidelines that are set up already in the hospitals—a shower, a meal, a change of clothes, a ride back to their place of home, regardless if it's a bench or a sidewalk. I've experienced being an advocate. Many of my street family members call me from the hospital because they've been discharged. They're under the narcotic that they were given inside the hospital and there's no ride. It takes four and a half hours to walk from the hospital back to the shelter. So, I think to start with the hospitals starting to follow the guidelines that are already set into place, that would be helpful.

Dr. Cleveland Manchanda: Absolutely.

Dr. De Las Nueces: I would add to that, which is all fantastic, Dez. One thing that we could also do is ensure medications are at the bedside for patients before they're discharged. They have so many examples of individuals, of patients who were discharged with prescriptions in hand or prescriptions that were sent to pharmacies, but they were never able to actually fill them, and that just sets them up, sets us up for readmission for worse outcomes. So, I think medications at the bedside along with everything that you described would be really helpful as we think about the micro level starting at the bedside.

Dr. Kushel: I think there's ... 100% to all of that. There's a strong evidence base for the use of recuperative care. Obviously, not every hospital or physician has access to that, but when there is access to that or to help do as best you can as close to that recuperative care is a post-hospitalization place where patients can go get both shelter, as well as some light touch medical services, in a sense so that we don't send people out to the sidewalk when we can avoid it. We don't send people out to a shelter where many physicians don't realize that many shelters discharge everyone during the day that they need to walk around during the day. Also, just to be mindful. We may need to change our discharge criteria. If you were sending someone home, we often send them home thinking, "Well, their spouse or partner will check in on them. They'll be able to spend all day in bed and be brought chicken soup, and if they're not doing well, maybe they'll call us and then their partner will drive them back to the hospital."

If someone is going to the sidewalk, as Dez so poignantly talked about, and they don't have a telephone, they don't have a bed and they don't have access to food or need to walk three miles to get there, they may well, if you have no other option but to discharge them, you might need to keep them in the hospital longer to make sure that they've healed that that becomes possible. So, knowing the context of what you're discharging your patient to is so important.

Dr. Lan: Tagging onto that, I would say the lived reality of exactly what we are discharging people into and what outcome are we expecting, so that could be part of the inpatient treatment team. I know that USC had done research where they included the house bed, Siri, which is a listening tool to collect information on people's everyday reality in terms of where they're actually living, the exposure they're experiencing, where is food and drink and water coming from, what kind of medication makes sense, what's the access to bathroom and all these factors are taken into account. So that's a very useful tool in addition to just any other ways of finding out the reality that we're discharging people into, and that's often the first step in physician advocacy and knowing what's the gap that's needed.

Brown: A couple of practical things we're doing at the bedside is we have a list of all of the $5 formularies at some of the nearby retail stores like Walmart and Target. We bought a bunch of those gift cards, and we encourage our ER physicians to write for generics and that way assured that they're going to get the medication even if they can't afford it, one, and then two is since that we deal with … my role is more in behavioral health. I did some research just looking at the literature describing neurocognitive impairment in a lot of the common populations that come to the emergency room, especially those with behavioral health issues, but also people with diabetes and hypertension, and the word epidemic kept coming up in all of the research I'm doing.

So, we are training all of our social workers in the Montreal Cognitive Assessment. There's a bit of a cost to it, but they get certified in it, and that can be really helpful to understand the level of impairment that your patients have and perhaps think about a new care pathway for someone and thinking about whether or not they're going to need additional assistance. We see this as a key tool of interacting with the court system and civil commitment cases where, empirically, we can demonstrate to the court that this person is having difficulty comprehending the instructions they've been given or even understanding that they have a mental illness or a medical condition.

Dr. Cleveland Manchanda: That's great. All incredible advice and I'm just hopeful about the different experience that our patients would have if everyone followed all of that and advocated to ensure that each of our health systems created that possibility as well.

Denise, you mentioned a little bit earlier about how your program integrates with or interacts with the inpatient teams at Boston Medical Center. So, I was wondering if you could tell us a little bit more about how Boston Healthcare for the Homeless works with Boston Medical Center clinicians to provide more coordinated transitions of care and share your thoughts on that.

Dr. De Las Nueces: Absolutely. So, for the entire 30 plus almost 40 years of our existence, we've, again, informed by consumers really at the founding of our program have recognized the importance of having the partnerships with our hospital, with local hospital partners in Boston Medical Center, certainly, as well as Mass General Hospital, our two main local hospital partners. So, what that looks like in terms of a partnership is manyfold. First and foremost is that we have had, and continue to have, at least at one of those sites—MGH—hospital-based clinics, which allow us to just have a team embedded within the hospital, and just by sheer co-location has really helped with communication between emergency room physicians, inpatient care teams and our outpatient practitioners.

Our physicians as well are all credentialed and privileged at one of these two institutions. So, there's admitting privileges and there's just ease of communication by virtue of being part of that community of the hospital communities as well.

We have, over the course of our—especially in the most recent 10 years or so—have been able to, at least at Boston Medical Center, develop a role in partnership with BMC that liaises between inpatient care teams and our recuperative care site. One of the medical respite facilities that Margot alluded to earlier, which is called the Barbara McInnis House. So, we have 104 beds right across from Boston Medical Center for patients, just as Margot described, who are no longer need to be in the hospital but are too sick to be in a shelter or streets. So they would be discharged here and get 24-hour nursing care and be followed for, roughly average length of stay, of about 14 to 21 days. So, it could really be a long time followed by a multidisciplinary care team.

So, the liaison position is one that initially was embedded at BHHP and was grant-funded, but subsequently was taken over by BMC and is now funded by BMC. It's really a seminal role who informs inpatient discharging care teams about the resources at BHHP and helps to really coordinate transfers from BMC, from the inpatient care teams to the Barbara McInnis House. That's been really a fantastically impactful partnership and communication.

Also, excitingly, we are about to start just in a few weeks actually another outreach liaison team. This team now will consist of a peer recovery coach, a nurse and a case manager, and the team will specifically be employed by us at BHHP, but will be deployed to meet patients who are currently hospitalized at Boston Medical Center with a serious injection-related illness, who is deemed by the inpatient care team to be at high risk for self-directed discharge—or leaving AMA—and who if they were to leave via self-directed discharge, our team would be deployed to actually continue the antibiotic treatment to make sure that those individuals get completion of their antibiotic treatment and get the care that they need. We're really excited about that. That's based out of a model by Dr. Lauren Marks and colleagues in St. Louis, Missouri at Wash U. So, we're really excited about that. That's just one example of how we strive to do better at really liaising well with our hospital partners like BMC.

Dr. Cleveland Manchanda: Fantastic. It's a privilege to work at an institution that has programs like that. So, thank you so much for sharing. I'm really excited to hear about that new program as well.

Dr. De Las Nueces: Thank you.

Dr. Cleveland Manchanda: Other thoughts from folks on specifically the discharge transition of care that come to mind after hearing from Denise?

Dr. Kushel: At San Francisco General Hospital where I practice, which is the public hospital for the city and county of San Francisco, we have a team called the Social Medicine Team that is a multidisciplinary team, so physicians, nurse practitioners, social workers and case managers who can be called by anybody in the hospital from clinics, emergency department, inpatient. They meet regularly, multiple times a week, with all of the city resources and they can help optimize transitions of care, can help identify and advocate for the appropriate resources, whether it's recuperative care, one of our drop-in centers, they can activate street medicine and provide the bridge, and you can call them from anywhere.

So if I'm seeing a patient in my clinic who I'm worried about, if you're in the emergency department or inpatient team—and they really serve as the glue for the system and they bring so much expertise. They're physicians who can help talk about the medical regimens, pharmacists, et cetera, but also folks who know what the resources are available in the city and can help get the person to the right resource.

Dr. Cleveland Manchanda: Oh, that's fantastic.

Dr. Lan: I'll add, and it's very hard not to mention, that a few of our physicians having done inpatient for a long time themselves are coming to become very frustrated about the discharges and the gap that there are. So, they actually initiated efforts to, very similar to what's been mentioned, as an inpatient consult effort and that's with the intention of connecting very complicated people dealing with multiple issues to whatever warm handoff that may be necessary, recuperative care outside, and also the hospitals-based clinic and other services in order to make that transition meaningful. So, I think really wired the effort for a physician who saw the gap there and just took the initiative to build that up here within Health & Hospitals as well. So, we're hoping to expand that further.

Brown: I think there's an opportunity, what's been mentioned here is recuperative care and medical respite care, and this is more on a structural issue, but having the American College of Emergency Physicians advocate for Medicaid agencies to make that plan amendment. Here in the state of Illinois, we just extended our 1115 waiver, and they decided not to go. They were actually going to be put into the ... It'll be a defined benefit in Medicaid too that would increase capacity. So however, we can advocate for more medical respite care through some of the associations that we belong to, I think would be a worthy cause.

Dr. Cleveland Manchanda: Love that. That sounds great. Guys, do you have any thoughts on these transitions in particular? In your experience, I don't know if you've been able to access respite-type care or experience any of these coordination opportunities, and if not, what the experience is like in the absence of these types of supports.

Brown: Well, we take our lead from Boston Healthcare for the Homeless. We've had a conversation with Jim O'Connell a couple of weeks ago, and one of the things we're pursuing now is we have two health care for the homeless providers. I got to say we're not as coordinated or advanced as what Boston is doing, but we're trying to get there. So, one of the first things we're working on is creating care coordination notes that can be shared among each other and using a company called Collective Medical Tech, CMT. So, we'll know who the health care provider is in the emergency department, hopefully, talk to them and have more coordination of care than what we currently have. That's one thing.

The other thing is on a different panel I sit on, we're looking at interoperability as another key. I have one physician here, Tom Hagett. In order to see what's going on within the different hospitals on the west side of Chicago, he's got four links, what's called CareLink within Epic. He's got to sign on to four different portals to try to get that information. What we're trying to be able to do now is we have a group that is exploring true interoperability. For all of us on Epic, Care Everywhere is great, but we also have about six million lives on the west side of Chicago that are not covered in any kind of interoperability because we have a smattering of other electronic health records. I don't even remember all the names of them, but there's six or seven different EHRs that don't talk to each other. I can't think of a more vulnerable population that needs intense coordination of which is severely lacking in this space.

Dr. Cleveland Manchanda: Yeah. Thank you. Dez, I'd love to hear from you on this, specifically around the transitions of care piece. I think you've offered some really wonderful practical advice. I don't know if you have had the opportunity to experience respite care or that transition from an inpatient setting to one of these transitional spaces, and/or if not, what discharge looks like without that?

Martinez: I never got to experience respite because we have a limited amount of beds. It can go from 10 to five respite beds only available. So, I never got to experience that. I had to experience what it was like to go from the hospital straight to the street. It's not fun. It's exhausting. You're depressed, you go into depression because you're in pain. You can't make it to the pharmacy. You don't get to recover. You end up back in the hospital if you don't have respite care somewhere where it's clean and sanitized. We have many multiple people going back to the streets with open wounds. Medicare runs out after a week, I guess, at our hospital, so go back to the street after a week, even after a heart surgery. I've seen heart surgery patients come back to the street because we don't have enough beds for respite.

So unfortunately, I never experienced it and I only know two people that did get to experience it in our city and these respite beds were basically put in a lobby of a shelter. So I don't know what ... It wasn't care. It was 24 hours, people were there, lights were on and stuff. So I think we need a lot of changes here. I think what I'm hearing from these other hospitals, it's like I'm jealous. It's amazing what you guys are doing and the amount of work that you're putting into care for individuals such as myself and others that are out there. It's amazing. Thank you guys so much from the unhoused community because to sit here and hear you guys talk about what we need and there's people out there that know and are working towards it to make the change. I just want to say thank you guys because it's amazing what you guys are doing. So thank you.

Dr. Cleveland Manchanda: That's great. I'd love to turn a little bit further upstream in the conversation. So Margot, maybe we'll start with you. Your work involves both the local as well as the state and national levels talking about the issue of houselessness and you've provided testimony to legislative bodies. So maybe you could share with us some ideas on key policies that would address systemic issues of homelessness and the role that physicians in particular can play in advocating for those policy changes at different levels.

Dr. Kushel: Absolutely. Thanks so much. Obviously, we need to clean our own house first, doing the 1115 waivers, making sure we have medical respite and recuperative care set up. So as Dez so poignantly says, we're not discharging people with open wounds to the streets. Setting up case management and other interdisciplinary teams, but I think we have another role too. People still listen to physicians. Physicians wield a lot of political power and we often leave that power on the table. We also sometimes think that we have the solutions for everything and don't involve our colleagues who are doing the work. We just need to say the solution to homelessness is housing, right? That the public often thinks about this as a problem with mental health or substance use disabilities, and yet the research is clear rates of homelessness in communities vary by the level of housing affordable for the lowest income household.

To give some perspective on that, across the country, there are 33 units of housing for every 100 extremely low-income household. In Nevada, the worst state in the nation on this measure, there are 17 units of housing for every 100 extremely low-income household. If you look at the states with the highest percentage of their population experiencing houselessness, those are the states with the lowest level of housing. So, we need to raise our voices and say every place we can that the solution to homelessness is housing. We also need to talk from experience as long as we're not talking over our colleagues with lived experience, but we need to join them and together say there is no medicine as powerful as housing and explain to the public why if they want a population that's thriving—if they want people to be healthy, we need is to fix the fundamental problems.

There are legislative fixes at the local, state, and national level. The local level, we need to fix zoning. We need to fix enforcement of fair housing laws, so people with housing choice vouchers are not discriminated against, so people of color are not discriminated against, that we enforce those laws in the books. That can be done at the state level too, all of those fixes—zoning, enforcement of the law, creation of new anti-discrimination laws. The state can also fund some housing programs, housing start programs to help build affordable housing.

The federal government needs to get in on the act. Right now, only one in four households in this country who qualify for housing choice vouchers, housing choice vouchers sometimes called Section Eight apts the amount of money that a household pays for housing at 30% of their income and the federal government pays the rest. Right now, only one in four households who qualify get it. If you could imagine if we said, and when you signed up for Medicaid, "Oh, I'm sorry, you need to wait another six years because the list is full. We've given out all of our Medicaid slots," that just isn't how it works.

We need to increase that so that those are fully funded. We need the federal government to help fund more housing. There is an evidence-based method to house people even with the most significant mental health or subsidies, disabilities, using the principles of housing first, where you start with the housing, you offer services, you make them low barrier, accessible, but you don't make them a precondition because as we all know, when someone is homeless, that is not the time to engage in motivational interviewing or to get someone involved in housing. We also know that people with behavioral health disabilities have every right and ability to thrive in housing.

In fact, housing is the foundation. Right now, there's so much pushback against it. I like to say to people, we know how to manage people with mental health and substance use disabilities. These are not moral failures or flaws. These are problems that can be managed and dealt with, but we really can't do it without the housing. So I guess I would ask every physician listening to this to show up, to show up at their local meetings when there are zoning decisions, to show up and give their two minutes of testimony, to write to their electives and to say there is no medicine as powerful as housing, and to push back against this notion that people are homeless because they have mental health or substance use disorders. I often stand up there and say, "I'm not afraid of mental health and substance use problems. We know how to manage them. Those are not the problems, but I can't do it if people don't have housing."

Dr. Cleveland Manchanda: Thank you so much for that. That's incredibly helpful and a really important perspective I think for folks to hear because it's such a common misperception I think not just among the public but among physicians that you have to get sober before you get into housing—and flipping that script—changing that narrative I think is a really important part of this work. Do others want to jump in and offer thoughts on that?

Dr. De Las Nueces: Wanted to second everything that Margot said, and it was really fantastic, Margot. You hit it on the nail. We've had many case examples at Healthcare for the Homeless Program of folks who have been housed but haven't been able to maintain tenancy because there are no supports around it. So I just want to also second really the importance of permanent supportive housing with the services that folks need from the case management and from the management of budgets, from cooking, all of the supports that they need, as well as the clinical services, ideally co-located, in order to really help our patients, people experiencing homelessness once they get into housing be able to successfully maintain tenancy and stay in it.

Dr. Cleveland Manchanda: Great. Go ahead, please.

Martinez: Ways that physicians can work to advocate more effectively in supporting individuals experiencing homelessness. With my experience, I would add that, like Denise was saying earlier, I'm sorry, am I pronounce your right name right? You handing the patient the medication at the hospital at bedside instead of expecting the patient to go to a pharmacy with a copay. My copay was $3 or $4 for my medication, and I didn't have it after surgery pain medication. My copay was $31, so I did not get it to be out of pain. Arranged follow-up appointments would be great because a lot of us don't have access to a phone, and if we do, they get stolen a lot. So, we go through a lot of government phones, which our doctors don't have a direct number to contact us at all times. It would be helpful to try and communicate through emails because one thing we can do is go to the library and check our email to see if there's any type of communication with our doctors and physicians.

Yes, definitely expand medical respites in every single city and county because we do have the majority of elders that are passing on our streets. We have about 70 to 120 individuals that die on our streets every single year here in Fresno. The only thing on their death certificate is because they were old, and I know it's because of the elements. They couldn't survive the elements on the medication they were on or because they had heart problems or breathing problems. A lot of them have Lupus that are out here and struggling—and not on medication.

So, I think by supporting us would be more doctors standing forward and making programs like a mobile clinic bus. The mobile clinic buses are amazing, you guys, but we need them more than once every three months in our neighborhoods. These mobile clinics, they could possibly hand out care bags, healthy ways to eat while you're unhoused, a small brochure to educate us on what we can eat to help us with our health. Tangerines, because you could think we don't really cook a lot out there. So tangerines, vitamin D, I learned that from an amazing doctor that I finally met. Bananas, because we walk a lot, the cramping, the laying on the sidewalk. What oranges … so what fruits and vegetables can help us with and what they mean to our body while being unhoused. These are things that we come across easily, vegetables and fruits, that are always handed out. So, it'd be helpful to have some type of brochure to educate us on why I need to eat tangerines and bananas while I'm unhoused. Also, some medical supplies to leave behind such as bandages, gauze, bacterial ointment, et cetera, so that they can take care of themselves until the bus comes out again.

Dr. Cleveland Manchanda: So many important pearls in there, Dez. Thank you. That was just a whole bunch of knowledge you dropped on us.

Martinez: Thank you.

Dr. Cleveland Manchanda: Really, really appreciate all of those ideas. Yeah, incredible. Yinan, your work and interests focus on building a houseless health continuum to simplify the delivery of houseless resources. Can you tell us a little bit more about in an ideal state what would that look like and what would physician's role be in that continuum? Help us imagine a future state.

Dr. Lan: I would love to. So currently, as many of us know, to navigate the resource landscape for anyone who's unhoused is a huge challenge. There are many different pockets to go through, and often, it's a very fragmented state or it can be a fragmented state, especially when you're juggling quite a bit. You can almost compare it to, let's say that if any one of us are critically injured or sick and we get admitted to the ICU, imagine trying to coordinate all the specialties ourselves—getting the IV ourselves, getting everything there in order to receive the treatment. That's unimaginable, and yet that's what our patients are dealing with.

So the continuum has the idea of looking at anyone's need in terms of their intensity and how critical it is, and then supplying it to that level similar to inpatient in the hospital that you may get everything within the ICU for someone who's critically ill and then stepping down from there. The hospital-based clinic that Denise mentioned, that's the network that we are building here at the public hospital system. So at least four of our major hospitals right now are starting this more intensive, integrated homeless clinic that allows for this level of complexity and acuity to be careful in the outpatient setting, and then branching out from there, we have some of the inpatient liaison efforts that were mentioned in order to bridge from the inpatient world, from the emergency room world. And then furthermore, we have the street medicine teams that are out in certain neighborhoods that are providing more community-based outreach and more basic primary care as an extension of the complex care clinic.

The idea is that for any person who is falling in a hard time, who is unhoused, who's dealing with a lot of issues, that they'll fall somewhere along that spectrum, and that spectrum is further connected to shelter-based clinics or other community-based clinics and the many other community-based organizations that are already doing this work. The idea is that any person who's experiencing it, they don't have to be the one navigating it. The poverty context, we as physician and health care workers are navigating that on behalf of people who are experiencing it.

From a physician angle, that means looking at your environment, looking at the landscape and learning what is there already, in any given city what's actually a decently robust setup and what's severely lacking, and then advocating or pushing energy in that direction to fill that gap. So, then you have various level of acuity of services that are available bridging this divide between health and housing these ... I think our profession, it's got to go hand in hand.

What does that mean in terms of which organizations do you work with? How do we partner and how do we offer both essentially at the same time more or less otherwise, as Margot mentioned here, it is just not going to work. So that's the continuum that we're building. The goal of that is that any starting point may feel like a more isolated program, but the idea is that hopefully this all gets integrated more and more into mainstream health care in any given city. Ideally, that will also flow into medical education as part of our requirement for training and many other elements that might go into just the basics of understanding more of the population care.

Dr. Cleveland Manchanda: That's great. Thank you so much. It sounds incredible. I'm looking forward to seeing it come together through your work. Stephen, you mentioned earlier, and I love to hear your thoughts on this a little bit more, that we, I think, as a medical community have increasingly recognized the importance of addressing social needs. I think that we know food is medicine and I think we hear a lot, housing is health—and I think we understand as physicians now more than we did a generation ago, certainly, the connection between the social needs of our patients and their health.

I think we're still not quite there though on understanding the connection between structural drivers of health and our patient's experience in the day-to-day and the policy and the link to how we address these bigger systems and how we make changes at that scale as individuals or as part of a single health care institution. So maybe you could talk about how your work is addressing some of those upstream structural barriers that result in a lack of access to housing or lack of coordinated care for patients who are experiencing houselessness.

Brown: Sure. A couple things come to mind. One of the project we're working on is what we call Healthcare Presumptive Eligibility, and that is in Medicaid expansion states that people, given a set of criteria, most likely will qualify for Medicaid and therefore we should go ahead and apply on their behalf. I think Massachusetts actually has a very good program here. We're looking at that, but that requires intervention by state legislatures to mandate that. Right now, I think one of the biggest challenges we have here is our HFS, or Healthcare and Family Services or the Medicaid agency. Everyone there is an inch deep and a mile wide. They just don't have the time to do a lot of these things.

So what we're trying to do as a university is make ourselves useful to them, but we need to offer the resources for them to be able to do the good work in a lot of ways. I know that's a vague answer, but I just want to set the ground that that will be a structural issue you're going to run into at almost any state government, but that would incredibly benefit our patients, especially those folks that are coming in that we often have to transfer to a state psychiatric hospital because they're unfunded, right? If we can get them funded, oftentimes they often comes in with very complex medical and behavioral health needs, and if we could keep them in the hospital, we could better manage their care, so Hospital Presumptive Eligibility.

The other thing we're working on here too is the idea of Medicaid budgets consume anywhere between a quarter to a third of all state budgets. It's probably one of the largest line items in a state budget, and yet we've seen this trend nationwide where a lot of state governments outsourced to manage care organizations with the expectation that they would lower costs and utilization and that hasn't occurred. Now, why is that? Some of that is because the structural issues are everybody just looks at this year's budget. As health care, we're not showing the preventive nature of the work that we could be doing because our time horizons are too short. We're looking at one year, but oftentimes with some of these preventive measures, like for example, a 23-year-old male comes in, family says he is beginning to act bizarre. He has some delusional content to it and we know this guy's headed for his first episode of psychosis.

If he comes from a poor family, he's going to spin out into homelessness within a year because the family doesn't have the resources—and I've seen this profile over and over again. 20, 30 years later, he's still homeless, right? Now, if we could convince where all the purse strings are that it's money well-spent to get this person back into treatment and resolve their first episode of psychosis, we know that the probability of recovery goes way up, but the longer we have untreated psychosis, the worse the prognosis.

So all that to say as an example is we need the econometrics to demonstrate for the state that we need to invest in more prevention, and our time horizons need to be five or 10 years to demonstrate these things. I've talked to economists. I don't know what they do, but I said, "Can you tell me the prevented lifetime spend if we were to take that individual and put them into treatment when they were 24 after their first step into psychosis?" and the guy said, "Sure, we can do that." I don't know how they do that, but we ought to be doing that as a collection of medical providers really putting an emphasis on prevention.

Then I'll add one more thing. So we looked at a cohort of 500 homeless individuals that came to UI Health that had County Care. County Care is the other public hospital next to us. It's both the hospital and an MCO. So it's an integrated health system. So we were able to pull the claims on those individuals. Now, you tell this to insurance people, this may not mean anything to anybody in this room, but the key metric in the insurance world is what we call medical loss ratio, and they have to keep it within an envelope between 80% to 90%. Anything less than that, regulators are going to say you're denying claims, anything more, they lose money. So, at 90%, they start losing money. The average MLR was 330% for this, and we saw outliers going out to 800, 900% MLR.

So I think there is an economic incentive, but we haven't done the job. I don't want to frame this as just an economic issue either, it's an ethical and medical issue too, but we could attract more state governments to invest in the preventive things like housing if we could present the case to them cogently.

Dr. Cleveland Manchanda: Thank you so much for those thoughts. I think in the health equity space we've found the different arguments resonate differently with folks. If I'm talking to a quality and safety person I can say, "There's no high-quality care without equitable care. There's no safe care without equitable care," and that makes sense to them. For the insurers, making an economic argument and for the folks who hold the purse strings, doesn't have to use the same language if we're all driving toward the same result. I suspect that none of the primary care physicians here will argue with you on the importance of preventive care and longer time horizons.

We are coming close to the time for the end of our conversation, and I would love to just hear some final thoughts from each of you, particularly if there's one thing that you could recommend to improve the care of patients who are experiencing houselessness. One main takeaway for physicians, what that might be. So maybe we'll go in the same order that we've gone through. Denise, start with you.

Dr. De Las Nueces: Yes, happy to. I'll say too, I'm sorry, I can't win without too much. The first is I think all successful interventions and defining success in terms of patient experience, as well as health outcomes is warm handoffs as Yinan had commented on. I think a lot of the liaison work that we're working on has that as a core tenet, warm handoff, communication between outpatient teams who know patients, who care for patients in their settings and then also inpatient discharging teams.

The second one is medical respite and recuperative care. Just really the importance of having an alternative, a supportive alternative for patients to go to and be discharged to when they are in this exquisitely medically vulnerable state that is not a shelter and is not street, is not doubling up on someone's couch. So that's what I would say. Again, thank you so much for the opportunity to learn from these exquisite colleagues and also to share some of our experience in Boston.

Dr. Cleveland Manchanda: Thank you so much. Dez, anything you would like to underscore for us, one thing for our physicians to remember?

Martinez: Be kind to us. I'm sitting with a group that I have sat here and listened to you guys, and you all sound amazing and I wish I had you guys over in my city and were my doctors when I was going in. Patience with us, understanding. There's so much to reiterate. There's so much that everybody has said that is so much in common, but I think making sure that we have our medication before we leave, possibly having a way to communicate with me after I leave if I have to follow up with doctor's care or maybe sending us to the pharmacy that is at the hospital instead of sending us to Walmart or Walgreens or someplace that we have to use transportation for.

Follow-ups are very important. So I always advocate for a mobile van to go out to do follow-ups for individuals that have undergone surgery, that are now back out on the streets. When we have a lack of beds for them not to go to respite, then I feel it's very important for a mobile van to go back out to the streets to look for the individual or maybe visit them at their camp to make sure that they are properly taken care of, and they're not brought back to the hospital with septic, and their blood is poisoned and they just haven't been able to take care of themselves.

I've seen multiple people come back out and not take care of their wounds and the doctors told us that they lived because of the amount of maggots that were on their legs, that it actually helped them. I don't want us to have to go through that. I would prefer to have more respite beds and a mobile clinic going out to the streets to follow up when discharged from the hospitals—but yes—the showers, the food, the clothes, that helps us, and transportation definitely back to our place of living so we don't have to walk four hours in the heat back to where our shelter that we were at.

If you are getting people from shelters, communicate with the shelters. We have a lot of individuals that leave the shelters and they go to the hospital. There's no emergency contact. People do die in the hospital without anybody by their bedside. No family members are being contacted. So, it's very important that if we do have somebody in the hospital that we do have our, they call them homeless advocates inside the hospital, the case workers, if they could follow up, if they can get a notification that, "Hey, we have somebody who's unhoused. We need to make sure that we contact the shelter. If they don't answer the phone, we send a team out there. We need to get information. They only have so much time to live." Usually, hospitals will call me as an advocate and ask me to go out and find these families, so they have those couple of hours left to say goodbye.

This would be very helpful if we can set up some type of program where there's communication with the shelters and the hospitals, but also the street outreach is very, very important. Preventive care is, like Dr. Brown was saying, oh, my gosh, preventive care is so important. So many people have been out here for 30, 40 years that I'm working with on the street and if they would've had the help mentally back then, they wouldn't be where they're at today. A lot of us are sent away without our medication. A lot of people self-medicate—and self-medication turns into addiction and now we're working with something different. We need more help. So, if we can prevent all this from happening and our doctors and our hospitals working with housing, working with the outreach teams, working with more respite cares and pushing for this, then I think we'll be able to help a lot more people live longer, but also be more aware of their health.

We need to find out how to get oxygen tanks out here to people that need oxygen just to walk from their tent to the store. There's so much, you guys, but there's only a little bit of time. So I just want to say thank you guys so much. I love everything you guys are saying and everything that you're doing. I am so blessed to be a part of this. Once again, thank you guys for including the unhoused community in your conversations. It means a lot to us. Thank you.

Dr. Cleveland Manchanda: Thank you so much. Again, so much wisdom in there. Really appreciate you sharing that with us. Margot, we turn to you.

Dr. Kushel: One of my favorite community leaders always reminds us to step back and step up. So, I would ask physicians to step back and listen to the patients they work with. Listen to those with lived experience and adapt their care accordingly, to use every resource you have at your disposal, but when you don't have respite, when you don't have recuperative care, then at the very least, adapt your care and then step up. Don't leave your power on the table. I would love everyone listening to this to commit to take at least one action right to your member of Congress, show up at a zoning board meeting, show up to give testimony and remind the world that there is no medicine as powerful as housing.

Dr. Cleveland Manchanda: Thank you so much. Stephen, final thoughts?

Brown: Yeah, and sorry, my internet glitched up there for a second. Just to reiterate more medical respite care I think is definitely something that we should think about investing in. The other thing too is that, especially from emergency medicine's perspective, we need to partner with integrated health homes, where there's the combined set of services for all these individuals and think about how we can transition those individuals there. We're starting a program in a couple of weeks where we'll have peer recovery support that will make a relation. They call it relentless engagement, and I love that term, with this population so that we can help navigate them into a medical home that can provide not only their needs for their health care but also the behavioral health needs too.

Then I love what you said, Dr. Kushel, about use your power. I think if we could start branching outside the walls of our hospitals and clinics and thinking about who are some of the natural and organic partnerships we could have in the community, every community in the United States has what they call a continuum of care provider. That's the coordinated efforts of all folks that provide homeless services within your geography. Now, a community here is the city of Chicago. We have a COC. We also have one in Suburban Cook, but a community as broad as this entire state of Montana too. So, think about reaching out to your COC.

Dr. Cleveland Manchanda: Wonderful advice. Thank you. Yinan, final thoughts?

Dr. Lan: Sure. So I believe that humans are meant to exist in collective, and when there's a disconnect between people without house to those of us who are physicians and who does have access to certain things, that can be a very painful disconnect. In order to utilize, I think, the access that we have and what we're able to offer, I encourage that our fellow physicians to, similar to some the others have mentioned, to sit with anyone who's experiencing houselessness and just allow that existence to sink in and then to decide what that reality, what that means to any one person.

With that perspective in mind, often—and this is my go-to in terms of refocusing on any perspective at work—with that perspective in mind, then we can think about, "What kind of privileges do I have access to?" and it may not be a system-level change or even a major policy level change that we personally have access to, but if that means enough to advocate for one patient, to do something differently just for a few cases, I think that's very much worth trying.

Then for those of us who have access to other areas in terms of patient care leadership, policy system setup, that definitely warrants even more thought, but I think the first level is to fill in that disconnect between the two and start to really understand someone else's reality.

Dr. Cleveland Manchanda: Absolutely. Thank you, thank you, thank you to each of you for joining us in this conversation today. What a thought-provoking and forward-looking conversation with some incredible, practical advice for folks. In closing, I want to highlight two opportunities to join others who are engaged in advancing health equity across the country in different ways. Rise to Health, a national coalition for equity in health care is bringing together individuals and organizations to advance equity across the health care ecosystem. I'd encourage everyone to visit our website at risetohealthequity.org for more information. There'll be a big public announcement at the end of the month and a lot of opportunities for folks to get involved either as organizations or as individuals.

In addition, I'd encourage you to register for our next National Health Equity Grand Rounds event at healthequitygrandrounds.org. The next conversation in this series is called "Breaking Down the Ivory Tower: Building the Healthcare Workforce America Needs," and that will air on August 8. We also want to remind folks to visit the AMA's Ed Hub page for equity-related content and CME credits for the physicians who are listening and to learn more about our other initiatives, our resources, and our programming on the AMA website.

Thank you again for joining us for this conversation, the Prioritizing Equity Series. We appreciate your time and appreciate you tuning in. Have a great rest of your day.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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