Many Layers of A Man

Yesterday afternoon, a few of my co-workers and I were walking to a picnic held on the DeSales University campus. We were admiring the beautiful weather and the beautiful surroundings. Despite my love for the urban and rural homeless population, I have to admit it is a quiet retreat to spend time on this beautiful campus of rolling hills and beautiful fields.We noted a tree that was already changing it’s leaves. This launched a whole discussion about how everything is in a hurry- A.C. Moore already has Christmas decorations for sale and emails are jamming my inbox with taglines reminding me how many Fridays are left until Christmas. I, for one, have never really enjoyed winter. If the weather could stop at late October and blend right into April, I would be happy. The prediction for our area this year is another unbearably cold winter with higher than average snowfall. Putting my own last winter-related, generator-finding-polar-vortex-enduring PTSD aside, I think to the other work in my life.

It was a Sunday at the end of February 2014.   Brett’s cell phone rang and it was Jackie, a parish nurse who works with Brett at the Soup Kitchen Clinic. She was calling because she had a patient with her who was desperate to find someone named Corinne who normally takes care of him. She wanted to know if Brett knew who this Corinne person was. Much to her surprise, he passed the phone to his right and she got her answer. It seemed that Kevin* had been asked to leave the homeless shelter he was previously staying in. He had violated one of their rules and as Kevin said, “That was that.” He was out of medications but more importantly, he was out of shelter . The only other place to find shelter was over full and Kevin had been denied entrance the prior two nights. The temperatures were drastically low and he was scared and cold. He had only been able to take the belongings that he had near his bed. All of his items in storage, he told me, were discarded. Imagine the attachment you would have to your belongings if you could count all of them on your own two hands. More concerning, Kevin suffered from incontinence. Not having a reliable place to use the restroom and clean clothes to change into worsened the situation.

Kevin has been my patient for the last two years. He comes to the Clinic religiously every Tuesday for a blood pressure check. The blood pressure check almost always reveals more information about his week, his life and his other medication conditions. Despite his chronic incontinence, he always smelled like cologne. Kevin was compliant, he was never late for an appointment I had set up for him and he never ran out of his medications. He is talkative, polite and wonderful with the students. He had often told me he liked helping the students get their education. The students felt responsible for Kevin, but Kevin also felt responsible for the students.

Kevin and I agreed to meet on Tuesday. I went to my PA students and explained Kevin’s situation. Most of the students knew him from the Free Clinic and were deeply saddened to think of him sleeping on the street. I could see it in their faces- homelessness just got real.

Being that Kevin is a very tall man, finding clothes for him would be difficult. But the students rallied and came up with clothes, toiletries, snacks and other things they thought he would need. I arrived to meet him a few minutes early. In a strange change in weather, the polar vortex had given way to an unseasonably warm that day with a high of 62. I had not even worn a coat as I walked from my car to the building and I passed a few overzealous locals in shorts and tank tops. A few minutes later, I looked out the double glass doors to see a man dressed like the Abominable Snowman. He was struggling with the heavy doors and as I walked closed to help him, I realized it was Kevin.

Everything he owned was literally layered on his body or crammed into a messenger bag that was ripped down one side. Over the course of 10 minutes, he removed from his body 4 winter hats/hoods, two pairs of gloves (both ripped), a puffy winter coat, a leather jacket, a windbreaker, two sweatshirts, a button up collared dress shirt and a long sleeved t-shirt. He had on three pairs of pants, all of which were soaked with urine. What bothered me more than his layers, was his facial expression. Minimal eye contact, soft voice. No smile, no light hearted upbeat Kevin. The Kevin was lost, buried in the pile of clothes sitting beside him. A sadness filled his eyes. He told me he was so embarrassed for me to see him this way, embarrassed to walk the streets literally wearing everything he owned. He didn’t know what to do, where to go. He was desperate. Then his phone rang and it was his mother. She wanted to talk to me. I could hear it in her voice. She begged. She pleaded. “Find him somewhere to sleep tonight! Please! Why isn’t there anywhere else for him to go? Where are all the other people who are homeless?” Her questions were valid. Her frantic tone of voice was justified. Her disbelief that we have nowhere to put our homeless at night. I apologized, I justified, I rationalized, I validated. But in the end, I had no answers.

Then it was my turn to beg and plead. Could he come home to her? Were there resources for homeless in her town? Could she think of a family member, a friend, anyone who would take him in? All the answers were no. And while she wouldn’t elaborate as to why, I could sense that her answer was non-negotiable. There was no answer for Kevin that night. He had nowhere to stay and nowhere to go. It was gut wrenching. As a health care provider, I felt horrible. As a mom, I cannot imagine laying in my bed at night wondering if my son was sleeping outside in the cold. As a friend, I felt helpless. I could work no miracles that night. He slept outside behind a YMCA and waited for another day.

Eventually, we were able to convince the shelter that had asked him to leave to reconsider their decision. Kevin was permitted to return to the shelter and has been diligently working on filling out government paperwork, attending doctor’s appointments and applying for housing. Last week, he proudly reported that he had work with a local resource to update his resume and had interviewed for three jobs. Progress was being made and I am so proud of his recovery trajectory. As summer fades to fall, I know that Old Man Winter is waiting just around the corner. He lurks and just when you have almost forgotten the bone chilling cold that makes you want to pack up and move South for good, he snaps you back into His frosty world reminding me that “Walking In A Winter Wonderland” could have only been written by a person who was housed.

 

Nursing Homes = Homeless Shelters?

I have been working weekly at several nursing homes in our area for the last few years. I could spend an entire posting talking about how I think our elderly nursing home population ought to fall in the ‘underserved’ category but I will spare you that soap box for today.   I am extremely grateful to have bosses who understand my predilection for the homeless population and for leaving no stone unturned when I’m interviewing patients. It never ceases to amaze me that was the right series of questions you can uncover a world of hurt that the patients been through. When we close our eyes and picture a typical nursing home patient we are stuck with an image of grandma- with her tight rows of freshly curled hair resulting in the beloved (and highly flammable) grandma-helmet-hair. Or maybe a shuffling old man proudly sporting his WWII VFW hat with pins from his uniform.

You are far less likely picturing someone whose reflection resembles yours.

Many of my younger patients have lived in our nursing home system for quite a long time for one reason and one reason only. No one realized they were homeless at any point during the hospital stay or early on in the nursing home stay. Once they started to complete the rehab goals, the social services team comes to the realization that there is no discharge plan. I sometimes referred to this phenomena is the “fog of war- medicine style”.   After 9/11, George W. Bush made many decisions that he later reflected upon in his book “Decision Points”. He realized that perhaps they were not ultimately the best decisions, however, he felt he had done the best he could with the information available and the time allotted to make the decision. He cited the fog of war it during the decision-making process. This is common throughout history and no one really (successfully) faults people for it.

This phenomena also happens in medicine.

It goes like this: Patients are banged up, super sick or maybe have had a decompensation an otherwise chronic stable medical condition which leads to the hospitalization. In the world of hospital medicine, length of stay in the hospital is looked at very closely. In the haste of making a reasonable discharge plan there’s often a lot of questions that frankly just aren’t asked for a variety of reasons. Case managers and medical teams have a difficult job and are often asked to do the impossible. But sometimes, I think we don’t dig deeper into the answers our patients give us about their living situation. For example, patients often say they are going to live with their friend after discharge. At face value, this sounds great. Discharge plan complete. Until you ask if they have talked to their friend about this plan. Often, the answer is no. Or, another common scenario- a patient says they were living with a brother, sister, friend etc. prior to coming to the hospital. Somehow, this is translated by the discharge team that the patient will be discharged back to their prior living situation. No one asks, and the patient doesn’t mention that they can’t or don’t know if they can return. The patient is discharged from the acute care setting (hospital) to their short-term rehab facility and everything seems great until a simple question like “Hey, where you going next?” is asked. The response – a blank look from the patient and then silence sets in.

In the time that Brett and I have been in the nursing home system, we’ve noticed a large variety of patients whose social situations and living situations perhaps were tenuous at best prior to hospitalization. Homeless or not, many people’s social support is based on superficial interaction. Hanging out, watching TV, playing card, shooting the bull (not to be confused with cow-tipping. I am from Indiana after all). In the face of acute illness, that social ‘support’ is tested and often disappears when these patients need the most. The couch is suddenly unavailable. The car has been repossessed because of missed payments. The housing has dried up. Perhaps your truck driver who is now an insulin-dependent diabetic or perhaps had seizures and is no longer allowed to drive the truck. Not only does this person suffer from a loss of employment but many truckers sleep in the cab of their truck. They don’t have permanent housing because they live a life on the road.

A few weeks ago, Brett and I asked case managers from three different nursing homes in three different parts of the Lehigh Valley how many patients they thought were homeless in their facility. Without consulting a census or really doing anything scientific, they came up with 22. That’s 22 patients who have absolutely no where to go if they were to be discharged right now. This is astonishing. What complicates the situation further is that case managers who work in skilled rehab facilities don’t have the training to find housing for patients who are homeless. This isn’t a typical part of any case management training and is purely learned on the job or because of personal interest. And therefore the patients who are easier to move out of the nursing home seem to move out of the nursing home. The homeless patients tend to sit … hang out… and stay. There’s nowhere for them to go and no resources by which to move them.

The Point In Time (PIT) is a physical head count of the homeless on one given night that is universally chosen. Over 3000 cities participate in performing the PIT on this date in an effort to count the homeless and attempt to extrapolate trends about homelessness in your area and nationally. The data is reported to the U.S. Department of Housing and Urban Development (HUD). While HUD says it “does not directly determine the level of a community’s grant funding” (hud.gov), it is required information to report when applying for HUD funding. It would be hard to imagine that those numbers are not somehow taken into account when determining distribution of funding. It is not a perfect sampling tool by any means (a different soap box for a different posting) but it is concerning that these ‘nursing home patients’ are unaccounted for. These are patients that if they were not in a nursing home would be in one of our shelters, on the street or perhaps (if lucky) squeezing out another couch to sleep on. In essence, they should be recognized and counted.

In the last post, I talked about recognition of existence in the context of being a fledgling street medicine program. This same concept applies here too. In order to properly allocate care to the homeless, we must first know where they are. To know where they are, you have to know where to look. The homeless are all around us, hidden in plain sight, waiting to be recognized.

Small Victories

Any person who has worked in the field of homelessness has experienced the frustrations that naturally come with the job.  You love the job. You have often allowed the job to change who you are, what you believe and how you view the world. But this field certainly comes with it’s challenges.  In our experience, the frustrations has rarely come from our patients. Of course they are don’t always follow the ‘rules’ of engagement with the medical system. Sometimes their logic makes us take pause. Maybe you have orchestrated a fantastic plan only to find that your patient is not interested in your version of ‘saving’ them.  But these encounters do not deter. My frustrations usually come from things like funding, funding and funding. I am sure many community health providers could lull you to sleep with their creative strategies to get blood from a stone. 

On the other hand, there are small vicotories aboud. 

4 months ago, Brett launched an inpatient consult service at Lehigh Valley Hospital (PA).  It had never been done before and no one knew what to expect once it went live. The day the Street Medicine Consult Service was an option in our computerized ordering system, Brett texted me a screen shot of the order set. We sent it to friends and family (half of which probrably looked at it wondering what the heck they were looking at) like a picture of a new child.  It may not have meant a lot to others, but to us, it was a huge step.  Recognition of existence. 

Now we waited. Would anyone know it was available? Would they think of it? Would they recognize a homeless person even if they didn’t ‘look’ homeless?  Brett embarked on an education blitz. He met with nurses, residents, administrators, case managers. Anyone who made eyecontact with him in the hallway got a quick innoculation of street medicine news. 

Yesterday was a cause for celebration in our house.  Brett completed his 50th Street Medicine consult. A handful (less than 5) were repeat consults. This is an astounding number of people who were never identified before and the overwhelming majority had no connection with any homeless services in our area. This small victory belongs to the many people who took the time to ask the right questions and placed the consult.  

I always tell me students that the challenge of being new in medicine is that you don’t know what you don’t know. The same goes for helping the homeless in our area. Without being identified, no one can recognize your existence and reach out a hand. 

Brett and I are reading a book about Mother Teresa. In the introduction, she is describes herself as a tiny pencil in God’s hands. He can sharpen or dull the pencil and do what He wills on the blank canvas. When the work is done, she says, we do not sit back and admire the pencil. But rather, admire the work that He has done. 

Job well done Lehigh Valley. Job well done. 

 

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