EPISODE FOUR: HEALTHCARE AND HOMELESSNESS IN SARATOGA
Duane Vaughn, Executive Director, Shelters of Saratoga
Dr. Robert Donnarumma, Chief Medical Officer, Saratoga Hospital
Sam Halajian, PA, Saratoga Community Health Center
Stephanie Romeo, Associate Executive Director, Shelters of Saratoga
Transcript
Sam Halajian (SH): So having that space and freedom to be in someone’s in their environment, either on the street or at their encampment or in the motel, and just sit down and have a calm, thoughtful conversation about whatever their condition is, I’ve found that to be tremendously helpful because when people understand what they’re being treated for, they’re much more likely to engage in that treatment because they know why it’s important.
Introduction: Welcome to Crossroads, the Shelters of Saratoga podcast, giving a voice to the many different challenges of homelessness in our community. Throughout our podcast series, we’ll be shining a light on the perception versus the reality of homelessness in the greater Saratoga community. The issues we’ll be talking about are more than a bed or a cot or a roof. The reality is that homelessness is an intricate ecosystem, including mental and physical health, public safety, food security, resource navigation, community engagement, and longer-term sustainable housing solutions. However, perhaps most important is recognizing that the majority of the challenges of the homeless in our community are invisible. We are at a crossroads where the challenges of homelessness intersect.
Duane Vaughn (DV): Welcome to Crossroads, the Shelters of Saratoga podcast. I’m Duane Vaughn, the executive Director of Shelters of Saratoga. In this episode, we’ll be talking about how Saratoga Hospital, the Saratoga Community Health Center and Shelters of Saratoga work together, often side by side to provide access to healthcare for people experiencing homelessness. We’ll be talking about street outreach. We’ll be talking about clinical care. We’ll be discussing how the social determinants of health, including income, employment, food security, and housing, and how they affect health outcomes. And we’ll be talking about how important it is that we work together to treat the whole person. Joining our conversation today will be Dr. Robert Donnarumma. Did I say that pretty much right? Yes. Thank you. Second time you did. The second time. Who is the Chief Medical Officer at Saratoga Hospital and former medical director of the Saratoga Hospital Emergency Department. Welcome.
Dr. Robert Donnarumma (RD): Thank you.
DV: And can I call you Rob?
RD: Please.
DV: Thank you. And we also have Sam Halajian, PA-C, who is a Physician Assistant at the Saratoga Community Health Center. Welcome.
SH: Thank you. Happy to be here.
DV: And of course, last but not least is Stephanie Romeo, who is the Associate Executive Director at Shelters of Saratoga. So thank you all for joining us. Hi, Steph.
Stephanie Romeo (SR): Hi.
DV: We’re here to talk about healthcare for the homeless in Saratoga. Our second episode of our podcast was a conversation with Tracy Kidder, the author of Rough Sleepers and a profile of Dr. Jim O’Connell and his Boston Healthcare for the Homeless Project. So for this episode, we want to bring the conversation closer to home and talk about how Saratoga Hospital, the Saratoga Community Health Center, and Shelters of Saratoga s working relationship takes on the challenge of healthcare for the homeless, the critical role that healthcare plays in finding a path to independence. First of all, let’s talk about outreach. Stephanie, could you define for us what outreach is for our listeners?
SR: Sure. I like to keep the definition of outreach short and sweet. It’s meeting someone where they’re at instead of asking them to come to you.
DV: Sam, I’m going to bring you in the conversation here. So how long have you been joining the team of outreach? Could you explain that a little bit for us?
SH: Yeah, I’d be happy to. So I was thinking about it earlier today actually. I can’t believe it’s been almost two years since I first started doing this kind of work. So it was one of those silver lining blessings from Covid, actually from the pandemic through the Cares Act in 2020 that some of this street outreach work got started. And my understanding, correct me if I’m wrong, is that there was a need for a medical person to be brought into the great work that you guys had already been doing. Originally, my program director at the office that I work at, the Community Health Center, Kathy McNiece, she approached me and said, Hey, there’s some folks doing some street outreach with the persons in our community that are experiencing homelessness. They often have questions about medical issues and aren’t exactly sure what to do with it. Would you be interested in helping in some way? And we’re not sure what it’s going to look like, but we don’t have a map. Are you in? And I said, yes, please, absolutely. Because my route into medicine was outside of the hospital. In the beginning. I was a paramedic in New York City for years and I love being outside the office. So when they approached me with this, it made perfect sense. And so it’s been almost two years now that I’ve been doing this kind of work.
DV: Well, great. We appreciate it. We could tell you that for sure. And I also wanted to talk before we get to that point of talking about street medicine, that type of thing. Maybe Rob, you can help us out here. We talk about the hospital, the healthcare system being a bit overloaded or overcome, especially the emergency departments. What are you seeing in regard to homelessness in that regard?
RD: Sure. Hospitals nationwide or being stressed by multiple choke points. I think we’ve heard a lot about staffing, particularly nurse staffing nationwide, and unfortunately our region is not immune from that. Capacity space is an issue as well. Due to years of consolidation, the number of inpatient beds and the number of inpatient psychiatric beds has been severely decreased over the last several decades, and Covid basically helped exacerbate all of that. These things were happening long before the pandemic, but certainly brought to a head. And so for this population, often the emergency department is their first point of medical contact or their only interaction with the medical system. One unfortunate thing I think we see is that in the past they may have had a poor interaction with someone in the healthcare system, and so there’s a fear of interacting with the healthcare system, and we really tried in the emergency department to make it a good first experience. Generally, if you have that good first experience and you move on further, come to the clinics, establish your primary care doctor, receive routine care. The episodic care that you receive in the emergency department is good for emergencies. And we have staff that’s very well trained in taking care of that, but they’re not trained in dealing with chronic medical conditions. And so getting those patients referred to the areas of the hospital where we do that best, like our Community Health Center is the key. When our emergency department is overwhelmed with primary care needs, then that next patient walking with a heart attack or stroke is going to have to wait longer, frankly, to be seen.
DV: Stephanie, if you could chime in here on that and talk about the use of the emergency room.
SR: Yeah, I mean, to hit Rob’s point, some clients are afraid because of past experiences. And I want to highlight too that hospitals aren’t the only healthcare that are overwhelmed. I mean, primary care physician’s offices are overwhelmed as well. So we have people on waiting lists trying to get in with primary care and trying to find an avenue so that they can be seen quickly and not have to go to the ER, but they’re waiting months and months to see a primary care physician as well, which can be difficult, which is where Sam has been super helpful if kind of bridging that gap. We also have some individuals that go to the ER because it’s sometimes a means to stay warm and they want to sit in the ER and they know that they can probably get away with sitting in the ER for quite a while before they might be noticed because they don’t have a significant medical need. We also have some clients who genuinely are lacking the education of understanding what is a medical crisis and what is just feeling uncomfortable. What is life-threatening and when is it actually appropriate to go to the emergency room.
DV: Sam, going back to Saratoga Hospital and the Community Health Center, they’ve invested in the street outreach reach program. So the number of hours you are doing per week now are..
SH: Typically around eight hours per week. And this is in addition to just the regular role that I play, which is primary care family medicine, seeing patients in the office Monday through Friday, 8 to four 4:30. So when I’m not in the office, I’m going out. Initially when I was first doing this, it was with folks like Stephanie here, but very quickly I found myself comfortable in the community and just going off on my own and interacting with folks and meeting new people and just seeing what their needs are and building those relationships. And really what’s been so I think helpful and what’s making it work in my mind is the team approach. So the fact that there’s so many different skilled people from so many organizations working together and communicating together, that’s what allows us to be successful. We were able to accomplish so much more that way than we would if we were just sitting in our office waiting for people to show up, if that makes sense.
DV: Absolutely.
SH: Yeah.
SR: I think your new residency program has added to that team approach as well. I mean, they’ve come to the shelter, they’ve actually interviewed individuals experiencing homelessness. They’ve talked about the barriers. They have a really great understanding of what has made people uncomfortable in the past of how they can help what we’re lacking, where the gaps are in services. Rob, do you think you can talk more about your residency program?
RD: Yeah. Saratoga Hospital is very excited about this program. So this is the first year that we will be running graduate medical education sponsored by Saratoga Hospital, in affiliation with our academic partner, Albany Medical Center. And really our goal is to have these new physicians, these physician learners be part of our community from day one. So that of course includes working in our emergency department, work on the inpatient units, but working in places like our Community Health Center and in our community at large, the goal is to bridge that gap between the hospital and the health home. So undoctored patients that are coming through the emergency department will be on that teaching service being seen by the resident who will then pick them up as their patient in their continuity clinics either here in Saratoga or up in Glens Falls at the new health center. And so from the patient experience, it’s seamless from door in to chronic care, they’re seeing the same doctor, the resident physician,
DV: Not to confuse, we also have a health home program. Right. So Stephanie, do you want to talk a little bit about that?
SR: Sure. We have a health home program with currently three care managers. The focus for health home program is really to shift the mindset of medical services back to preventative and not always reactionary because kind of where the direction things have gone in. So we pay close attention to the social determinants of health when you’re not feeling good on the inside, it impacts all of those social determinants of health. So when we meet with someone, we’re identifying what medical needs do they currently have, but also what medical needs might they have in the future and connecting tem with those resources before it gets to the point of being a crisis.
DV: Great. Rob, we were really excited that the Saratoga Hospital community embraced this program. When you first heard about this, what was your reaction?
RD: I think there’s a clear acknowledgement that the best medicine in the world, it doesn’t help if you don’t treat these social determinants of health. In fact, that’s now part of our routine screening process for every patient that’s admitted to the hospital as we go through these social determinants of health, and if something’s flagged in that screening, we provide the resources for them, whether it’s social work or care management and try to bridge that to the community. Echoing on Sam’s multidisciplinary approach, we even embedded those resources now within the emergency department. So we have care managers, substance abuse counselors, and social workers, brand new this year embedded within our emergency department.
DV: One thing that we did here not too long ago, I think it was maybe three weeks ago where we were, Stephanie and I were invited to come to the hospital and speak to staff, and I was pleasantly surprised when I got there and there was a full room of probably 30 or 40 people, and then there was a screen up where there was another, I don’t know how many people that were on a Zoom call really wanting to know exactly what SOS is about and what we’re doing and what we’re seeing. And that to me showed an investment that Saratoga Hospital is more than willing to put in and was really helpful I think, on our side for sure, to know that we have a partner in this, and I think it helped move through some of those myths and things that we are running into and have that really good collaboration. So I want to thank you for that. Well, Stephanie, I want to go back to your answer about outreach. It said we want to meet people where they’re at. Can you define that a little bit better for our listeners?
SR: Sure. It’s in all the pockets of the community where anyone experiencing homelessness who might be invisible, could be in encampments in the woods, sitting on a park bench at a little table inside of a gas station, or a Stewart s, in the motels, anywhere where you might not know that someone was experiencing homelessness. And Sam, I think you can probably elaborate.
SH: Yeah, I was shocked at all the little pockets that existed. And just when I think that I know all the usual spots where I can find folks, I will meet someone new and build a relationship with them, and then they’ll show me where they’re staying at and I would think, oh my gosh, I would never even have thought this tiny little strip of a couple trees or bushes just hidden very well within the community.
DV: How far are you going out, Sam, when you do your outreach?
SH: So I stay within the county and beyond that, I really mostly stay within Saratoga Springs, but I will go to, there’s an encampment near the train station that I will routinely go to that was more heavily populated two years ago, but there’s still folks there now. And I’ll go over to the other side of town to Wilton. There’s actually a couple areas that are heavily wooded there where there’s been quite a few encampments that I’ve visited folks at. But yeah, there’s really not a limit necessarily to where I’ll go. Sometimes I’ll get a text message or phone call from someone from the outreach team that I work with who will say, hey, I’ve got a client that I’ve been working with really well. He’s staying at so-and-so motel or he’s at this place in the woods. Let me drop you a pin. And I’m worried about him because he got out of the hospital a week ago and he hasn’t followed up. It could be anything, right? And I will go and check on him, see how they’re doing, and see what their needs are. And because I came from that background of field medicine, I have my little go-bag with me and we can do quite a lot in the field. I was very grateful just a couple of weeks ago right here in Saratoga Springs, there was pretty large medical conference for physician assistants in New York. Their annual CME conference was
RD: I need to plug that Sam is New York State’s Physician Assistant of the Year award recipient. That is correct. That’s
DV: Awesome.
SH: Thank you very much, doctor. I appreciate that.
RD: We’re very proud of you, Sam.
SH: Yes, it’s a huge honor to have even been considered for that, but I did receive that a couple weeks ago, but I also at the conference was I had the pleasure of speaking about this outreach work, so it was a CME conference, so I got to speak for an hour and get really kind of in depth about the work that we do and how do we do it and the social determinants and all of these things. And it really felt like, it was like bragging, I got to brag about all these folks that I work with, like Stephanie and Duane, and it really, I could see folks eyes lighting up in the crowd as they were listening to it because oftentimes the conferences we go to can be a little drab, some of the material, and depending on the presenter and how they are, and whenever I speak about outreach, I get very excited and I love to talk about the work that we do and how unique it is. And even as a little visual, I brought in the bag with all the stuff to show people what we can do out in the field. If I’m checking up on someone who is experiencing some chronic illnesses that we need to manage, I can bring assessment equipment, I can bring medications if they’re in our system, which is really helpful, if they’ve even been to the ER once they’re in our EMR, I can send medicines just right from my phone. So we’re able to sort get things done in a way that is incredibly efficient and leads to better outcomes for the patient. So I can order blood work, I can order X-rays, and that way they can go do it in a time that’s convenient, for example, by getting a ride with one of their case managers to get it done as opposed to dropping into the ER unexpectedly and saying, I need X, Y, and Z, and now it’s all this more volume that doesn’t need to be happening as an ER patient.
DV: You talked about your go-bag and we’ve heard the words acute and chronic a couple times here. Could you kind of tell us what you’re seeing, acute versus chronic?
SH: Yes. So some examples of acute conditions would be infections, typically superficial skin infections. In the summertime when folks are living out in encampments in the woods, they have a whole variety of typically environmental exposure related conditions. So we see things from bites to cellulitis, which is just a superficial infection under the skin to very severe infections. Sometimes a lot of our patients, as the doctor here knows suffer from diabetes, and that can lead to difficult wound healing. So if we have folks that are living in encampments in the woods, maybe they don’t have good footwear, they have infections that develop in their feet and then they go unnoticed because another part of diabetes is that you’ll lose sensation in your feet. So you won’t even feel that you have an ulcer on the bottom of your foot. So when I’m examining someone out in the field, I can look at their feet and say, Hey, do we have something that we need to treat here? And I have the supplies to do it, so I have the wound management supplies. We can bring them antibiotics if we need to. And this is all, even for acute conditions these are things that we can really handle outside of the ER, but folks don’t know what to do, so they go to the ER. And if these are things that we can manage, our goal is to reduce that volume that they’re dealing with. So there’s a lot of things that we can do out in the field that we do.
RD: I think it’s also important that when those patients need the emergency department, they’ve already been seen by Sam. So we get that call, we get the heads up, we know what’s been tried, what has worked, what hasn’t worked, and having that background before the patient arrives is very important for their treatment course.
DV: Rob, you had talked, I heard you mention earlier in the podcast where you talked about trust and relationships, and that I think kind of segues really good for this point here. Could you talk a little bit more about that?
RD: Sure. A lot of these at-risk patients that we see every day, sort of think of the ED docs as their primary care doc. Sometimes I have a few funny stories walking downtown with folks coming up to me saying, Hey, doc. And my son’s asking him like, yeah, yeah, we see him once a day, but building that trust is how we move them along in that healthcare system. We want to be there for that episodic care, but what we really want is to get them into our medical home model. And echoing on Sam’s point, sometimes it’s about bringing that first door of entry to them. They may be uncomfortable walking into the clinic. They may be uncomfortable with the clothes that they’re wearing or their transportation, for example. So getting them into that first medical contact, as we say, is so important. There’s a lot of models that are bringing primary care mobile to the patients, including paramedic-based models that are doing primary care in rural areas or inner city areas. So when you build that trust, it’s the first step to moving someone along towards health maintenance. And that applies to anyone, any patient. When you trust your doctor, when you trust your clinician, you’re more likely to be compliant with routine medical care. And that prevents the chronic medical conditions and the acute exacerbations.
DV: We are seeing an uptick. We have been steadily over the years of homelessness, and I know you’re seeing it in the hospitals too. Do you find that sometimes that your staff needs additional support in any way when it comes to addressing the homelessness issues in the hospital?
RD: Certainly something that’s been recognized recently, and it’s a big drive for why we’ve added additional resources to the emergency department, specifically having a embedded dedicated social worker who has experience working with these populations that will be there five days a week, eight to 10 hours a day. Often these patients have multiple comorbidities, multiple medical problems at once and often substance abuse, history and psychiatric history as well. And so it’s important to treat the whole person all of those issues, including their social determinants of health. I think there’s some public perception out there that why doesn’t the hospital just admit every person that comes in and keep them for two weeks and sort everything out and go ahead and then they’ll be fixed and they’ll be fixed and make every problem go away. And acute care hospitals are good at treating medical conditions. So the hospital exists and we’re experts at treating medical conditions. That’s not the same thing as treating all these other social determinants of health. Of course, that’s part of healthcare. And of course we integrate that into our model of care, but the hospital alone can’t fix all these problems. We need our community partners, we need our support to be able to do that. Sam
SH: Makes perfect sense. And I like that you mentioned having expertise and skill in a particular lane. So I often talk about that when I talk about that team that we have for our street outreach, because there are things that other folks are really, really good at that I’m not. And for me, it’s been such a learning experience to see how much goes into making a person whole that I didn’t think about before I was doing this kind of work, but things that are just very, that I take for granted. What does a person doing with their time? What is their social life? Do they have friends and support? How do they get places, right? Transportation is so important, and it’s easy as the medical person to say, well, this person is on a blood thinner and he needs to get his blood checked three times a week because that’s the medicine. This is a specific patient that I’m talking about who has been struggling, say, oh, because of, and we know that because, I’m pointing to the doctor here, because we learned this and we trained on this, and we know if a patient is taking this medicine, he has to be monitored and we check his levels. But if the person doesn’t have a vehicle and it’s difficult for them to walk, for them to get from the motel where they’re staying temporarily to a place where they can have their blood drawn three times a week, it’s a five hour ordeal. How are they getting on the bus, on and off the bus? How are they affording the ride? So these are things that we don’t often think about if a person is looked at within the vacuum of them being a patient in medicine. Right?
RD: And unfortunately, that theme of noncompliance is often shifted to blame the patient, right?
SH: Yeah.
RD: Not blame the system, not blame the circumstances, but blame the patient. And of course, we know that doesn’t lead to good outcomes,
SH: And we see it often with our patients who struggle with these chronic conditions like diabetes, where you’ll see all over the chart, oh, this person is noncompliant, noncompliant. Well, sometimes they’re just not adherent with these medicines because they can’t afford them. I was shocked when I started working very closely with some of our certified diabetes educators and our registered dieticians in our office. We have a comprehensive team there to see how many folks cannot afford their medicines. It’s really baffling.
RD: I just wanted to touch based on the medicine components. So this past fall, Saratoga Hospital started their community pharmacy based out of the hospital itself, but one of the innovative programs we’ve started is a med to bed program. So our pharmacists will fill those prescriptions from the emergency department or from the inpatient unit and literally bring those medications to the patient before they leave the hospital and ensure that they have refills and arrangements to receive those medications.
SH: And that’s so important.
SR: I want to shift back too, to sometimes non-compliance of treatment of chronic conditions is yes, blame to the patient for a million of different barriers. Maybe they didn’t have transportation, maybe no cell phone, didn’t know about the appointment, things like that. But it’s also sometimes, again, the lack of education. A large portion of this population has COPD and emphysema and diabetes, and they don’t always take it seriously because everyone around them has the same thing and they might not be taking it seriously. And so, well, if we all have this and we’re all okay, then do we really need to treat it? And as serious as everyone’s making it seem like it is, and I just think sometimes it comes down to a lack of education. There’s a million other things making their day-to-day life feel extremely difficult, and they don’t always attribute it to the medical conditions, but to all of those social determinants of health to all the other barriers they face every single day. I mean, I challenge any of the listeners to think about how healthy would you feel if you’re waking up and you don’t know when your next meal is going to be or when you don’t know what you next meal is going to be? Is it going to be filled with starches because it’s cheap and easy? How healthy would you feel if you’re struggling with depression and you are struggling just to wake up and survive and then you’re asked to follow through with all these other things? I just think there’s a lot more that goes into it than just noncompliance and people don’t want the help. I think they do, and sometimes it’s a lack of education and there’s a lot of things in their way.
SH: I agree. I think you raise a really interesting point about something that we talk about, which is health literacy. So oftentimes in the office, someone will come in and we have, as soon as you open the door into the room, the timer starts, right? And you only have so much time with the patient to get through so many things that you want to talk about. And this is where the street outreach component comes in because some folks don’t have the same level of health literacy, meaning how do we talk about our health overall? Do we understand what’s our fund of knowledge when it comes to healthcare? Especially folks that are experiencing homelessness may not have that fund of knowledge to talk about health issues and in the limited space of an office visit, it can be difficult to really unpack all of those concepts. So one thing that I find is when I’m doing the outreach work, I don’t have that timer going, and I can really just take my time and speak to folks about things that maybe no one ever explained to them. Maybe their doctor, they had just told them, hey, you have X, Y, and Z, and just sort of maybe assumed that they understood what that means, but they have been going this whole time not knowing it. So having that space and freedom to be in someone’s in their environment, either on the street or at their encampment or in the motel and just sit down and have a calm, thoughtful conversation about whatever their condition is. I’ve found that to be tremendously helpful because when people understand what they’re being treated for, they’re much more likely to engage in that treatment because they know why it’s important.
DV: We talked about barriers there, which there are so many, and maybe this is the first opportunity somebody has the ability to prioritize their health because what, like Stephanie was saying, they’re thinking about where am I going to sleep tonight? Where’s my next meal coming from? I want to talk a little bit about the perception of mental health and substance abuse.
RD: It’s an important topic for this population. I think there’s often an assumption that their homelessness is caused because of some deficiency in character or some underlying mental health issue or substance abuse. And that’s just completely wrong. Just like our general population, there are some patients that suffer from substance abuse and mental health issues, and there are some that don’t. This population is no different than the folks that we see and work with every single day. It’s important that this population is treated for all of those things at the same time, to only treat one aspect of their healthcare or their life, it’s just going to lead to poor success in other areas.
SR: I want to reiterate what Rob is saying because I think sometimes there’s this ideology that mental health and substance use go hand in hand with homelessness, but in fact, there are people who are housed and have substance use and mental health and vice versa. And having mental health and potentially substance use certainly make being homeless or experiencing homelessness harder, it makes it harder to access care and to pay attention to care, but they don’t go hand in hand. It’s not synonymous. And there are plenty of people who are experiencing homelessness who have neither.
DV: That’s correct. We’re going to take a short break and be back in about a minute.
BREAK: Hi, and thanks for listening. I’m Heather Oligny. I’m the development coordinator at Shelters of Saratoga. I invite all our listeners to find out more about everything we do at Shelters of Saratoga. Our work involves so much more than the shelter we provide throughout the year. Along with our emergency and supported housing efforts, we run Code Blue during the winter. We provide health and medical resource navigation. We offer work and life-skill guidance for our guests. Most importantly, our guests know we care. I’m so proud of the good work our team provides every day of the year. Find out more at Shelters of Saratoga dot org. Thank you for your support.
DV: We’re back and thanks for listening. Next, we’ll be talking about how important it is for Saratoga Hospital and Shelters of Saratoga to work together as community partners because no single organization can do it alone. Rob, maybe you could explain to me the changes you’ve seen maybe through your career with homelessness and healthcare.
RD: So certainly in more modern economic conditions, I think we are seeing an increase in homelessness both regionally and nationally. As we know, the cost of living has just gone up astronomically for lots of folks. That is in the backdrop of other issues that we’ve been talking about with mental health illness. We’ve seen, as we mentioned, decades of closure of inpatient treatment facilities and really limited outpatient resources for patients to connect with, whether that’s counselors, psychiatrists, mental health clinics. Additionally, nationally, we’ve seen increasing rates of substance abuse. And again, this is not related to homelessness, but relate to many things. The opioid epidemic that I’m sure folks are familiar with. Post Covid pandemic, we are seeing increased rates of alcohol use disorder and alcohol abuse in the general population. And of course, this homeless population is not immune from that.
DV: In previous podcasts we’ve talked about that homelessness is really non-discriminate when it comes to age male, female, anything like that. So we are seeing if I’m correct, Stephanie, that we are seeing more people starting to, we have higher age people, people needing assisted living, things like that. Could you talk a little bit about that?
SR: Yes. We are seeing a huge increase in clients who need nursing home or assisted living level of care, and they’re facing incredible barriers to getting that assistance. And whether that might be because they don’t have the income already turned on, they don’t have SSD or SSI turned on, they don’t have the correct insurance. A lot of assisted living facilities are full, and they don’t have open beds necessarily the moment you need them. So it’s hard to get a bed to bed transfer. And then also the barrier of other housing options and other shelter options have the mindset of, well, they need a higher level of care, so we won’t take them with the disregard of, if we won’t take them and help them get to the higher level of care, they won’t be able to get to the higher level of care. And I think there’s kind of a back and forth of they end up in the hospital, but they can’t get them to the higher level of care, again for the reason stated with the bed to bed transfers and vice versa.
SH: So you’re saying there’s a bit of a Catch 22 when it comes to so they can’t go into the shelter. They have so many medical problems
SR: But well, so they end up at Code Blue because other locations will say they need a higher level of care. We can’t take them here. So they end up, we take most of them into Code Blue or our Walworth Street shelter as often as we have a bed available. And there’s just a lot of barriers to getting them into the appropriate level of care. And they certainly aren’t appropriate for a shelter. I’m not saying they are. We recognize it’s better than them being on the streets and needing an appropriate level of care. Rob, can you talk more about what you’re seeing in the hospitals?
RD: Yeah. So the staffing crisis has affected what we call post-acute care as well as the hospitals. So that’s our nursing homes, our assisted living facilities. They too have been hit really hard with RN and certified nurse assistant shortages. Unfortunately, that has resulted in some bed closures. And really it’s a through-put issue. So if patients cannot be discharged that post-acute care, they have extended stays in the hospital, and if they have extended stays in the hospital, that means longer wait times in the emergency department. If we can’t move patients through, then it gets clogged up and we’re seeing this nationwide.
DV: Sam, tell me some of the things you’re seeing when you’re out doing the outreach in regard to age.
SH: Yeah, that’s a good point. It’s interesting because folks will often ask me, what is the most common person you will encounter with regard to either age or gender? And there’s a huge variety of things that I see, but the truth is there’s a lot of, I would say, older folks that I find myself taking care of. And that surprised me when I first started doing the work to see that a lot of the patients that I’m taking care of are either in their mid-50s, but sometimes even over 65, experiencing homelessness and dealing with lots of other medical concerns. A patient that came back to the area recently that just established at our office is 72, and she was living in a park. And it’s hard to see that and to see that folks are not able to get what they need. And that’s difficult. And I know that that over 65 population is going to keep growing and getting bigger as time goes on. And it certainly presents a lot of challenges.
RD: I think sometimes there’s a misconception that for that older population, well, if they’re over 65, they must have Medicare and I have Medicare, so of course all their healthcare needs are being met. Do you want to speak to that, Sam?
SH: Yeah. Wouldn’t that be nice?
SR: I think we’ve all had a lovely experience with Medicare.
SH: Yeah, it’s difficult. Government Health insurance, I have to be careful what I say.
RD: We need to get paid
SH: And I’m still in the military, so extra careful. Yeah, extra careful about how I talk about government-sponsored healthcare. But yes, again, that’s one of the things that shocked when I started doing this type of work, seeing, because before I came into medicine, I kind of, like you said, I just assumed, well, people get what they need. They have this insurance in place. If someone needs to go into a nursing home, why don’t they just go into the nursing home? What’s the problem? And it’s been really eye-opening to see the difficulty in accomplishing some of those tasks sometimes and getting folks where they need to go. It’s not as simple as we would like it to be.
DV: Well, sometimes the perception of homelessness out there as somebody in their 20s or 30s or something like that. And we know right off the bat when we opened Code Blue this year, one of our very first people that showed up the door was 88-years old. So we see a lot of seniors at Code Blue. Would you say, Stephanie?
SR: I would, I think so far this year we’ve probably seen the highest amount of seniors, and we’ve only been open a month. So it’s concerning. And to Sam’s point, you just assume that that population of people will get the care that they need. We’ve all been told since we were young, take care of your elders. And we just kind of all assume as a community that happens and to see that that’s not necessarily happening because of all the barriers in place. It’s extremely discouraging.
DV: Or I think that maybe people are thinking they must be refusing the care or refusing
SR: The assumption that they’re noncompliant.
DV: We talk about the relationships with the Community Health Center, the hospital and Shelters of Saratoga and Stephanie, you’d said in the past when we had conversations when this also could be preventative when Sam visits somebody. So can you talk a little bit about that?
SR: Sure. I mean, there’s been plenty of times where we have seen someone with our outreach team in the woods and given Sam a call and Sam will come right out to see them, or vice versa. We have someone who may be discharged from the hospital and came to our Walworth Street shelter and was in need of primary care physician to follow-up with. And we call over to Sam’s office and he says, sure, of course, give a call and we’ll get ’em scheduled right away. So kind of skipping that wait time to be seen by a primary care physician, which would likely have led to another ER visit, which is avoidable in most cases. So
SH: It’s interesting too, it’s dance when you’re getting to know someone and building that relationship. So sometimes I will go follow up with that person and I don’t often immediately say, here’s my card, come see me. Because it’s almost like there’s a little bit of warming up that has to happen. And once they do trust me and they see that week after week, there’s some consistency. So in that in-between time, maybe they do go back to the ER for something, and then I’m able to see their name pop up on our tracker and I recognize the name. And so when the folks in the ER are saying, do you have a primary? And they go, no, not really. I can say, oh, I saw that guy. And when I see them the next day, I could say, oh, I saw that you were in the emergency department again. I’d love to see you in the office. And eventually I’ve had a lot of success where folks do come in, and I think at this point, it’s up to somewhere in the mid-30s, probably 33, 34 patients that have actually come in and established on my panel.
RD: In fact, with our latest transition of care, open access policy with the Community Health Center, that’s exactly what the health center is doing is scanning for patients that have been admitted to the hospital that have had contact with the Community Health Center and actually booking their appointment for Follow-up before we even discharge the patient.
SR: One of my favorite ways that we work together too is to Sam’s point saying about how we build rapport, and we build relationships is when you’re working with other providers who are all building the rapport and building the relationships. And then we’re working together is sometimes we can skip that step because maybe Sam’s referred someone to me and Sam said, I was a great provider, and so now this person is meeting with me. And it’s immediately, well, Sam said, you’re okay, so you’re okay in my book, and vice versa. And we see that even with insurance representatives and other healthcare providers, well, this person’s a really great asset to the community, and you’re going to love ’em and they’re going to help you and it’ll work out and they’ll be able to get you to where you need to go. And then someone who maybe is hesitant to trust, it’s like, well, so-and-so said you were good. So I’m willing to work with you. And it’s just a way that even any single one of us building rapport and trust within the population, it kind of helps other providers build rapport and trust.
SH: Word of mouth is huge. And that’s why, again, every time I talk about the outreach work, it goes back to relationships because there’s one particular person I’m thinking of, I won’t say since we’re recording a patient or client who is, I think of him as pretty much like the mayor of this patient population. And we have a great working relationship, and he has never come to see me in the office, but I am his defacto PCP, but he lives in the woods. He doesn’t like coming into the system as he sees it, but we work really well together, and he will often refer folks to me. And coming from him, it carries a lot of clout. So, when I go out every week, it’s almost like a touch point to make contact with this individual. He will literally say to me, Hey, by the way, there was a new kid that showed up, 19, 20. He’s new, he’s homeless. He doesn’t have a doctor or anything, but he mentioned to me that he’s really struggling because X, Y, and Z. It could be he was prescribed a medicine before, but now he doesn’t have it. He doesn’t know where to go. And so I gave him your card. I go, that’s great, and I’ll get referrals from that relationship. So it’s really, it’s great when we see that happen.
DV: So Sam, when you’re talking about this patient, it immediately makes me think about Tracy Kidder’s book, Rough Sleepers and a character that’s talked about in that book, Tony, who this exact same scenario, which I’m finding, especially after talking in Tracy Kidder and reading the book and learning about Dr. O’Connell that were experiencing many of the exact same things that they see in Boston.
SH: And that book actually was brought to me about a year and a half ago when I first started getting into this work. It was a patient at the Community Health Center of mine who had read the book and thought it was fascinating, and she saw through a local newspaper article about the work that I’ve been doing, and so she brought the book to me and gave it to me as a gift, and I saw it, and it just, I know that there are folks all over the country doing really great work like this, but it was neat to see it all followed up in a very unique way in that book.
DV: One of the things that we worry about in shelter work, and I’m sure you both do too, the medical field, is sometimes we see some really tough things, and what do we do or what do you do for self-care?
SH: Oh, no, see, you don’t want to ask the soldier because I’m just going to break out that dark humor and then it’s going to be all downhill from there. I will say, yeah, as someone who worked, I got a lot of my dark stuff out early when I was working as a paramedic in a high volume system that was trying, and there were things that I saw and things that I did that are difficult to this day to cope with. It’s funny. As healthcare providers, I think we’re great at taking care of people sometimes not as good at taking care of ourselves. And I will say that for myself in particular, I’m certainly guilty of that. And self-care is huge, right? We talk about burnout, and it’s important to make sure that we’re maintaining that balance where we’re doing good work and taking care of the folks that we want to take care of, but also taking care of ourselves. So for me personally, that comes down to setting limits. So I set limits and I say, okay, no matter how much I’m into what I’m doing right now, whether it’s seeing folks in the office or finishing my notes or being out in the field taking care people there, I’m going to set a limit and say, I have to go home at some point. My family’s the most important thing to me. I have to be there for my family and take time for myself. Because the truth is we love what we do and we do. I mean, we absolutely love it, and that’s why we do it. And so it can be difficult to walk away from it sometimes and say, Hey, I need to pause and spend some time with my family. So yeah
RD: I think that sense of purpose is more important than ever. As we’re seeing this healthcare worker shortage, that renewed sense of why do you do what you do every single day? At the same time, I’m often asked, what’s the one hobby for doctors? Do they read medical journals late into the night and do research? It’s like, watch mindless TV. Just completely unplug and disconnect yourself from those realities, and then wake up the next day and just get right back to it.
SH: I think you need something that’s not cerebral in any way. That’s right. Yeah, you need to just turn off.
RD: Get outside, take some time off. We saw a lot of folks in healthcare working through the pandemic nonstop, really not giving themselves any time off. And that’s been a big encouragement this year is to take that time off that you’ve earned to unplug and then come back refreshed.
DV: Sure. And that’s where we see a correlation too, in that aspect because during the pandemic, shelter workers didn’t have the option to stay home. All of us here at the table had to go to work, and the additional stress on the people that we’re trying to serve through the pandemic and post pandemic has certainly been difficult on everybody. So we’re happy that we’re all still in the game here.
SH: Well, I mean, just from a medical standpoint, if we look at disease spread, right, congregate living is, I mean, that’s the worst we can think of in terms of trying to contain a disease. So can you actually talk a little bit about what it was like in a shelter system in the early days of the pandemic?
SR: I can, but we actually at no point got hit too terribly hard within the shelters, and I think that was a huge misconception, and actually it exacerbated the stress on the population because there was almost this idea that it came from homelessness and that would spread the disease more. But in fact, we didn’t have an insane amount of cases in either shelter, not in our emergency year round shelter, and not in our Code Blue. I mean, there was little pockets where a couple people had covid at a time, but rarely could we actually trace it to any type of connectivity between the couple of individuals. I think our team did a really good job of minimizing that. We were able to separate people, whether it be with rooms or motel rooms for Code Blue as soon as we knew someone had covid, but it wasn’t as bad as I think the general public thought it was inside of shelters. And the perception
DV: Well, I think we were prepared.
SR: We were certainly prepared.
DV: We took advice from our county public health. We took advice from Saratoga Hospital and the clinics and things like that. We were prepared. We had the proper PPE to fight this before it would hit us, and we were everything from putting up screens or anything like that in Code Blue. Those precautions were taken. So because frankly, we were expecting to get whacked.
SR: But I think the misconception hurt the population because a lot of people went behind screens or behind phones, and that is extremely difficult for anyone experiencing homelessness to navigate. They might not have a phone, or more importantly, it’s like Sam said, it’s really important to build a relationship, and it’s extremely hard to do that just over a phone or just over a Zoom call or a screen. We had a lot of outreach teams stop doing outreach in the really early stages of Covid because they were worried that going to this population might result in them getting covid. I remember packing boxes of food and delivering it out of my Honda Civic just as an example, because there wasn’t many people on the streets. This is long before Sam. So the misconception that congregate living was the place you would get Covid, I think, hurt our volunteers. It hurt the access to resources for the people who needed it the most.
DV: Do you think that we saw a separation during those times between homeless able to access services?
RD: I think for all people access to certainly preventative and primary care services was challenged. We’re starting to see that now in increasing rates of cancer diagnoses from all that three years of delayed screenings catches up with you eventually. And so we’re seeing high rates of breast cancer screening, colon cancer screening, et cetera, moving more from that clinical role to the administrative role. Now, as chief medical officer for the hospital often asked about, why does the hospital get into these things like Community Health Center, it’s because it’s who we are. We here to serve the people of Saratoga County. Frankly, we don’t care if you could pay or not. We often tell folks in the ED, we’ll figure that out later. Let’s take care of you right now. And that’s shown not just our investment in our Community Health Center, but in our backstretch clinic, in our outreach work, in our expansive primary care network that’s extend throughout Saratoga County and into other counties, and frankly into our rural as Albany Med Health System, acknowledging that if it’s something that we can’t handle, then we’ll get you to a doctor that can handle it somewhere within our system. Of course, there’s cost to delivering this care, and in part, we depend on our community benefactors. The Community Health Center is funded by Saratoga Hospital. It’s also funded by generous donations from our community, the annual summer gala, which support the Community Health Center, other fundraisers for the backstretch clinic throughout the year. So we are community supported, but we’re here for the people of our region.
SH: I could piggyback on that just to say that while there is an alarming amount of folks experiencing homelessness in the county, there’s also conversely, a shocking amount of philanthropy that I see in this county. Just for as an example, Business for Good, which they’re all throughout the county. I’m not going to do a good job of speaking about what they do. I don’t want to do them a disservice. They’re amazing. But they made a pretty sizable donation to the Community Health Center specifically for the outreach work that we do. So we do exist partially through those donations, but also through reimbursement. A new change, just I think it was October that I saw is that we can actually start billing for homeless outreach visits, which is a new change under Medicare and Medicaid. So we’re still navigating how we’re going to make that happen, what the exact criteria are. But it was just so exciting to see that. I think it was our Family Medicine Residency director that sent me the email initially, and I kind of jumped out of my chair when I saw it. I said, oh my gosh, what? We can actually bill for these visits, which is just incredible because a lot of up until now, the work that I’ve been doing, it’s not obviously not billable. I’m not going to talk to someone for an hour in the woods and give ’em their bill, kind of like it defeats the purpose of me building a genuine relationship with them. But if we can actually get reimbursement from the insurers for this, it’s a huge deal. So it’s great to do good work, but we also want to find a way to do it that is sustainable financially, which can be challenging sometimes, but there’s really good folks making that happen.
DV: Stephanie, I ve got a question for you. If you had a wish list when it comes to prevention or medical activities out in the field, I mean, what would that be? Would it be more of Sam’s hours or what would you like to see?
SH: Lice kits.
SR: Funny enough
SH: She’s always asking me for lice kits.
SR: My Code Blue staffer actually last night called me from the grocery store. It was her one day off, and of course she’s calling me from the grocery store and she’s like, I’ve got the Hannaford gift cards and I’m buying lice kits. And I’m like, come on, you have one evening. And that’s what you’re doing.
SH: It’s the number one item.
SR: So no, we’re actually good on lice kits. Thank you. It probably sounds silly and it wouldn’t work in theory, but like a van where a dentist and a doctor and a psychiatrist and a social worker and a therapist and a peer just could all fit and all of their medical supplies could fit, and it would have to be the biggest van ever. But if we’re talking like my craziest wish list item, that’s where my dream, I’ll dream big.
SH: I feel like we could turn this into a cartoon like superheroes.
SR: Maybe that’s how we would pay for it.
SH: Or Power Rangers. I am imagining a team rolling up
SR: Yeah, we could do a reality TV show, and that’s how it would pay for the van.
SH: I think that’s fantastic. Yeah, we actually did talk, in reality, we are talking about doing a mobile
RD: Mobile health clinic which our CEO Jill, that is something that she had in her previous life in Baltimore, and it is something we are looking at.
SR: I’ll drive the van.
SH: It’s exciting. It’s almost like a merging of somewhere between the office and an ambulance, just kind of in the middle.
DV: So, we talked about barriers. Now we’re talking about gaps in, right? So this is a place where, let’s visit this a little bit. I mean, where else do you see gaps?
SH: Yeah, I mean, it’s so funny. Now I got to get the image out of my head of the cartoon superhero team so I can focus.
SR: I didn’t expect someone to deliver on my wish list
SH: But if we have a vehicle, it’s easier for me to do things like delivering immunizations to folks because I can show up in that vehicle and say, okay, all right guys, come on and just knock it out. And it’s easier for us to accomplish a lot of those sort of preventive health measures, doing things like phlebotomy and things that I can do in the field now, but obviously are easier in a vehicle.
RD: You talked about a shortage of primary care doctors, and that’s one of the reasons we started Family Medicine Residency at Saratoga. We figured let’s grow our own. And if you grow your own that means they come up in that Saratoga Hospital model. So you know that the doctors that are going out there into community, really understand the community. It is a new program and there are other opportunities to expand to other specialties where we also see that need. So we’re having discussions with our academic partner, Albany Med, to look into other specialties. We could expand our graduate medical education into.
SH: Those residents. They have, I think we already talked about earlier in the podcast, but they have come out with me out to the woods and their eyes light up. They love it. These doctors are passionate about what they’re doing and it’s great to see them come out and do that with us.
SR: We had a great experience with them. They actually both spent time. I think there’s, is there two, three?
RD: Well, there’s six total for the year.
SH: Yeah.
RD: So it’s an 18 resident program once we have all three years filled.
SH: Yeah.
SR: We had two of them come to the shelter on different days, not together, and each of them kind of took the same approach. They gathered whoever was home and had a little pow-wow in the yard. It was warmer and just kind of had a little circle of exchanging of words and laughter and stories and barriers and they just really made everyone feel very comfortable.
DV: So who’s guiding that process?
RD: The residency program? That falls under me now. Okay. So our pioneer though, well our pioneer was Dr. Rich Falivena, the former Chief Medical officer of Saratoga, who just recently retired. Happy to report that he’s still actively involved in graduate medical education and it’s helping us steer the ship the right way. Building this program over the next five years. When we look at other gaps, I think primary care is certainly part of that and we have touched upon behavioral health and substance abuse treatment. I think it’s well acknowledged that there’s gaps in those arenas as well. We do what we can at the Community Health Center, but certainly they don’t have the capacity to treat all those issues that we see in our region.
SH: But we do have a dedicated addiction medicine service at the Community Health Center through Dr. Zamer, which is great. So in addition to the primary care doctors that can obviously write for things like buprenorphine, which is suboxone, we have a dedicated addiction medicine service and we actually have walk-ins on Fridays. So today before I came here was covering down on the addiction medicine side. Excuse me. And we had a patient walk in who needed help and we were able to connect and get him what he needs and I was able to prescribe for him until Monday when he can see the doctor there.
RD: So we also do medication assisted therapy like suboxone out of the emergency department. And when I mentioned that Community Health Center can’t accept all the value, we’ve partnered with New York Matters, which is a statewide MAT referral program. What’s nice about this is it’s patient driven. So if the Community Health Center is the most convenient option for them, then they’ll follow up with them. But we see folks from all over the region. They may be from Schenectady and it would be much easier for them to follow up with a clinic near Ellis Hospital and then we can make them an appointment with that hospital as well. So we are looking at partnering where it makes sense to bring these services to patients.
DV: So it looks like we started on our wish list. We’ve got some work to do there. Alright, so I was trying to get something for us to wrap up with a little bit there where I was kind
SR: Going with my wish list, but then they had my wish list item. So
SH: I’m just picturing this. Action hero therapists.
SR: Yeah, one’s a dentist, one’s a therapist. That’s the best. They can all have different outfits. They kind of look like similar outfits.
SH: Just on that topic of the different specialties, dental is so important. You mentioned it and I have to put in a plug for dental because we have dental services at the Community Health Center and dental health is such an important part of your whole health and primary care medicine, and it’s something that we’re trying to advocate for and push more and we’re incorporating that into our residency program, making sure that these doctors are appreciating the value of having sort of more detailed training when it comes to oral health than we typically think of. We don’t want it to be, oh, well, I can’t go to my regular doctor about this because this is anything in this region of the mouth. We’re not going to touch that. It’s just go to your dentist, go to your dentist because there’s a shortage there, a significant shortage. So there are a lot of things that can be done in primary care to aid in facilitating good oral health. So we’re pushing that big time.
RD: I think for us at Saratoga Hospital, one of the big acknowledgements is that we’ve realized the hospital is much more than what happens in the four walls of the actual hospital. In fact, this was the first year where we saw more patients outside of the hospital in our clinics than we did in the hospital itself. And there’s a recognition that the hospital of the future isn’t inside those four walls. They’ll always be there for the sickest of the sick when you’re having that heart attack, when you’re having that stroke, of course we’ll be there for when you need us, but the acknowledgement that the hospital now extends far out from the main campus is our future.
DV: I just want to say that the collaboration between Saratoga Hospital, the clinic and Shelters in Saratoga is something that we’ve enjoyed and that we’re so proud of and we’re so thankful of. I want to thank Rob for being here and Sam for being here and of course, Stephanie, but if there’s anything that you feel that we’ve missed or any final comments, love to hear ’em from Rob or Sam.
SH: The collaboration is huge. I mean, without that, I would basically be flying blind, so to speak, because a lot of these patients, I would not know how to approach them had it not been for the model that I was shown from the case managers and case workers through your agency. So I mean, I knew that I wanted to help people in this population, but I really had no idea how to start it. So the fact that I’m able to continue that relationship and that allows me to get those folks into the clinic where I can take care of them or just continue to see them where they’re at and take care of them that way. But being able to talk and share our information is just, I mean, I feel like I talk about it over and over again, but it’s invaluable being able to work together.is what makes this work.
RD: I would echo that on the hospital side, we had mentioned that collaboration that happens with our care managers in the house and with the Shelters of Saratoga, and we’re really looking to broaden that relationship so that folks are on a first name basis, one phone call away. Hey, I have your patient here from shelters and vice versa, so that we really are treating the whole person. As I mentioned, the hospital’s there to treat every medical need that we possibly could, but we can’t do it alone. And we rely on our partners like Shelters of Saratoga to treat the whole person.
DV: And like I said earlier in the podcast, to show up in that meeting at the hospital and have 30, 40, 50 people engaged in listening and making sure that we all understand each other and how we can work together better showed me that you are all invested in this and that’s really important to us to do our work. We can’t do it without you, and we really appreciate both of you. Thank you very much.
RD: Thank you.
SH: This was great. Thank you.
SH: Are we done?
SR: I’ll be waiting on the van.
SH: I just want to see Stephanie in her super-person uniform.
SR: Yeah. Do I get a uniform? If I’m just the driver? I’m not a medical professional.
SH: Yeah, you’re just the driver. Yeah, yeah, yeah.
DV: Thank you for listening to this episode of Crossroads. Healthcare for the Homeless is such an important factor for any individual walking the path to independence. Sometimes that could be taken for granted. We wanted to share with you the critical role. Saratoga Hospital, the Community Health Center and Shelters of Saratoga play together to take on this challenge. And we want to thank Saratoga Hospital and the Community Health Center for all of their good work. We couldn’t do it without you.
CLOSE: Crossroads is produced by Shelters of Saratoga, a nonprofit human services agency serving the greater Saratoga area. Our mission is to transform the lives of our neighbors facing homelessness with support services, safe shelter, and a path to independence. Your support keeps our mission alive. Find out more about how you can help at Shelters of Saratoga dot org.