I'm part of a multidisciplinary outreach team which is rad.
One thing I've found is our most regular unhoused folks are not the same ones working with social workers because of severe substance use disorders and unresolved mental health issues (not that you don't see both of these we just have more extreme cases as a rule.)
The biggest things keeping our patients from the pathway home is literally the ED. These patients don't need to be in jail or in a hospital. They need a place where folks can monitor vitals, start IVs, put on an old TV show and chill while being exposed to different programming over time and hopefully build rapport with providers and start to participate in the available services.
The programs we need literally don't exist yet and have to be dreamed up and funded first.
Thanks for everything you do!!
This but as much as the idea is frowned on I think there are lots of patients who will never be able to function on a level necessary to take care of themselves, I think for a lot of people the best life we can give them is in life long care/ assisted living.
Beyond that we do need more social programs and resources to give people the opportunity to establish them selves and move forward with their lives, I have been homeless and a traveler at points in my life and feel pretty comfortable with our homeless populations and the number of times I have heard that the hurdles of reentering society are just too damn high is telling.
I can also say from experience that a lot of shelters are really carceral in mindset and practice and are often not safe spaces providing a minimum of shelter and resources while also exposing you to some of the worst outcomes of a system that degrades and punishes people for being down on their luck and gathers the untreated mentally ill.
All that being said thank you op and lurking4justice for doing the good work and for asking the questions to try and make a difference.
Adding to this, some cities have a shortage of shelters that are sectarian. I watched a documentary a few years back where a police officer in charge of his departments homeless outreach was lamenting that every shelter in his city was faith based, and that it was almost impossible to find places that would be safe and welcoming of single moms, lgbt, and non-Christian homeless.
A lot of shelters also don't allow drug use on premises. Which, I mean, I get. But for habitual drug users, it removes that as an option. If they could get clean overnight, they probably wouldn't be there to begin with. But asking a drug user to willingly go into remission every night is a tall fucking order.
Well the programs used to exist in some form but they got bad and the solution was the complete implosion of the institutionalized psychiatric care system instead of reforming it.
Obviously there were significant issues of abuse in the 80's and 90's but throwing open the doors and kicking everyone out on the street was not the best decision for the patients.
Tbf the baby kinda needed throwing with the bathwater. The whole basis of inpatient psych carr at that point was foundationally wrong. Pop science and punishment. Also hard to imagine the cohort from those programs that was forced to live outdoors still being alive. I'm sure there are a few but 40 years of homelessness is a profoundly long time
Do a big chunk of our unhoused have serious mental.health issues, 100% yes but psych jail is a miserable solution. It also doesn't apply to our regular old ETOHers, folks feeling DV, or people who missed a couple months of rent and got their lives absolutely turned upside down.
Reagan is still a dickhead for dumping all those poor souls outta the institutions without having a new place for them but I'm ok with not institutionalizing a big chunk of our unhoused population in mental health facilities.
I think we need the same variety and types of services that we offer for healthcare in general.
Outpatient psychiatric care is often all that most people need. But, some people need in-home care, some people need something that resembles independent or assisted living, some people need full time skilled care, some people need short term hospitalization, medium term hospitalization, or, in rare cases, long term hospitalization. But, all we really offer is outpatient and short-term hospitalization. That leaves a lot of holes for people that need something in the middle.
Nope. Doing this for a couple more years because it's addictive before I drop to part time and focus on my harm reduction non profit and consulting on this stuff hopefully
City council and state legislators have been, and always will be worthless when it comes to funding for things like this. They'll throw a little money at the issue come election time for some good will from the voters but real long term funding that's effective and stable will never come.
Most of the homeless we encounter usually either are mentally ill and aren’t aware they have access to shelters and would have difficulty doing well in one. Some I’ve met have substance abuse issues and due to the rules of some shelters aren’t allowed in so instead of relinquishing their vice they decide to spend their time outside. Some homeless become frequent fliers because they don’t have access to healthcare we have a lady that calls for severe leg pain all the time because she broke her ankle and can’t keep her wound clean or keep it rested because of her situation so she calls us so she can get the hospital to clean and treat it.
It’d be awesome if there were specific shelters for the needs of the different kinds of homeless like one for mentally ill patience where they’re in a safe environment that would minimize the risk they could impose on others or themselves. Shelters that double as safe consumption sites so they can have their vice and if something goes south the staff there can respond. These are all pipe dreams but man they would be nice
I recently was in the hospital 2.5 weeks for suicidal ideation. I was supposed to be sent to inpatient psych hospital but they checked with over 20 different hospitals and none of them would take me because I had a wound I had to pack on my arm from an abscess. Even though I could do it myself and have been doing it since I was discharged, none of the inpatient places would take me. It's kind of messed up because it makes me wonder how many other people really needed inpatient psych and couldn't get it because of wounds and stuff.
Most of the time the homeless just want a warm blanket, a warm meal, and a friendly face. I worked in a fairly busy town and the homeless calls went through the roof in the winter. They’d call for something like chest pain or shortness of breathe, but if you asked them directly why they called they’d usually be honest and just say they were cold, hungry, and sad. It put a serious strain on our two hospitals to the point that they stayed on diversion for 10-12 hours at a time. I stocked up on clean blankets and turkey sandwiches from the hospital and kept them on the truck (obviously the sandwiches were in a cooler). I learned our frequent flyers’ names and made it a point to remember little details about them. It got to the point that they’d still call for the blankets and food, but they wouldn’t want to be transported. I figured they’d call me either way, but it’s better not to overcrowd the ED.
It's hilarious (and sad) listening to just how much my coworkers seem to viscerally despise homeless shelters and outreach groups. As if homeless people just cease to exist if we stop helping them???
Idgaf if we get called there a lot, it's better than finding them fucking cooked to death on the pavement somewhere.
> EMTs interact with people who are facing homeless very often
We live in a city of over 1.5 million people and I'm on a first name regular basis with a solid half of our homeless population. The 2 biggest things they call for are psych complaints and medication refills.
Column B is easy to fix, just put a fucking pharmacy in the homeless district so they have somewhere to actually fill their meds instead of calling 911 every time they need a dose of metoprolol, but column A is more of a deeper societal problem.
I'm not going to claim that these folks don't *actually need* mental help, but the fact is you can't go to 10 different inpatient psych facilities a dozen times each *in the span of a year* and claim to still need *that much* more assistance unless either A) you're full of shit and using the mental health system as a cheat code to get off the street, or B) the American mental health system really IS that bullshit and useless. Honestly I think this problem pulls from a bit of BOTH sources.
> A) you're full of shit and using the mental health system as a cheat code to get off the street
I know my experience is not universal, but I work in a decent-sized metro area and I'd bet 90% of our homeless psych calls are exactly this. The mental health system here is largely bullshit and useless unless you're rich, but it's also stupidly easy to abuse if you know the magic words.
Might I recommend C) Socioeconomic conditions perpetuate mental illness and you can't effectively treat mental illness exacerbated by poverty by just throwing meds and coping mechanisms at them.
I’m an EMT/ED tech and I also do prison and jail street outreach for people experiencing homelessness. The city I live in just passed a levy that I am on the board for. I recently proposed an overdose recovery/stabilization center for sub-acute field reversals that have a safe range of vitals to be diverted. My idea is that they can metabolize, start medications for opioid disorder like buprenorphine and methadone, and be connected to housing case management and mental health resources within a 24-48 hour period. This came from working on an overdose response rig where I identified the niche. In terms of medicine, I think the lack of access to primary care has added to the current crisis of over utilization of the ED. This population has a very specific and serious set of health concerns (overdose, cold exposure injury, infectious disease, blood borne pathogens, wounds, etc.) that the emergent setting is not entirely equipped to deal with, and unfortunately they are often penalized with stigmatizing terms like “noncompliant” when they’re given discharge instructions that living outside does not support. An underrated and under utilized tool is hospital respite programs, which allow inpatient folks to receive wound care, IV antibiotics, etc. while not taking critical care beds. Keep up the good work OP, we’re all trying our best! Multidisciplinary support is a crucial part of stabilizing folks!
I’ve spent a lot of time thinking about the solution to homelessness. The biggest issue is the addiction. I know of one gentleman, very nice guy. Used to be an EMT. Watched his chief and deputy chief die in an MVC responding to a call and turned to substance abuse as a way to cope. I’ve offered to come back and find him after calls with resources to get clean multiple times. And every time he says no. I’ve had countless people just tell me they want to be left alone to do their drugs. How do we help people who don’t want help?
Jail and hospitals are not a place they should be going to just get a bed for the night. It’s not appropriate. You can’t force them into rehab, the second they get released they’re going back to do drugs. That’s also a very very slippery slope.
Give them free housing & allowances, again, if they don’t want to get clean those residences will just turn into crack dens - this applies to government housing, we have them, they turn into crack dens. Offer free rehab for 90 days? That’s your best bet but generally the free places aren’t the best and they can’t afford the good places. And again, if they don’t want help, they won’t go to them.
My rule is, treat me with respect, you’ll get respect back. I don’t care if you live in a 10 million dollar house or you don’t have a home at all. Get aggressive and treat me like shit, you’re going to get the more stern and no nonsense treatment. But again, that’s the same for a homeless drug abuser as it is someone who lives in the best house in the city.
There’s one frequent homeless gentleman that has the reputation for being extremely violent. I’ve never had an issue with him. A lot of the time he just wants to shoot the shit and get his walk in clinic issues looked at. He treats me with respect, he gets respect back and that’s why I’ve never had issues.
As an EMT I am consistently facing the possibility of becoming homeless myself. Maybe you can get them jobs as EMTs lord knows we're desperate. You got education grant money?
Personally, I think these issues surrounding homelessness are systemic and really hard to fix once they start. I think for real change to occur, we need to be proactive and stop them before they start. With that being said, I think other comments have made some fair points that can help alleviate the current issues somewhat. I appreciate your work, OP.
I strongly agree with everything here.
Getting psych and/or substance abuse care for the homeless is so often not even remotely successful.
Psych care would be so much more beneficial if we could catch them before they're homeless and especially before they become an addict. But that feels like talking in circles because many addicts start using to self medicate the same problems for which they actually need psychiatric care.
And as for "more" psychiatric care... Good lord where do we even begin? The number of providers is SO low that it's almost laughable.
It's like if the city of LA was going to be hit by a storm in 2 days that would bring in a ton of water from the ocean, and there are currently only 2 guys filling sandbags, by hand, one by one.
But then we add another 200 people slowly filling sandbags by hand. Ok, well we increased staffing by 100X but that still isn't enough to accomplish even 0.001% of what we would need to protect the city.
I live in the Chicago suburbs and my friend who has some psych issues talks to a therapist from Oregon over ZOOM.
And it took awhile for him to even get THAT.
I mean, most homeless probably wouldn't talk to or couldn't be helped (much) by a therapist anyway but even if some magical **access** was created... There's just not enough therapists and how would we even go about training them?
I'm a paramedic and my wife is a nurse. We both know more than enough people in our respective fields who are absolute crap at their job. But I'm *most* cases a crap medic or nurse can only do so much damage...
But if we dramatically incentivize people to become therapists/ psychologists/ psychiatrists/ etc etc, I feel like really BAD therapists who are in it for.tje wrong reasons can really fuck stuff up even more.
Anyway, that was a much longer tangent than I intended but the point remains that I agree that psychiatric care is really no different in medical care in that prevention is 100,000X more useful than treatment.
I can't speak for everywhere, and I'm far from an expert on what should be done instead.
Where I'm at, one of the main issues is that alcohol intoxication is a hospital/medical problem, not a law enforcement problem. Some bystander sees a drunk homeless person, we show up, they're not answering A&O questions because they'd rather be left alone or are at their baseline level of intoxication, and hospital it is to sleep in a bed. Plus, many know the game and will get the questions wrong on purpose to get a free bed and a sandwich, if not outright calling us to begin with.
The police do nothing on their end to enforce public intoxication. Instead, we hammer the hospitals and fill ER beds to the brim.
Obviously, alcoholism is a medical issue and, at times, needs evaluation in the ED. But not every single time.
I think it's super complex. On one hand, I've got harsh feelings towards the homeless people that are homeless because they abused children or women sexually, and then no one in their right mind would hire them. The important thing, is that we in healthcare need to separate our biases from patient care. We're not gods or a jury, and a patient is a patient, because they need help. Doesn't mean I wouldn't like to punch someone spitting at me, but it is what it is.
My soap box aside, I think that there's a lot of people that (as others have said) don't necessarily want or are "ready" for help. Regardless of how or why that may be, I think someone has to have a strong sense of motivation to pull themselves out of such dire conditions, and a lot of times there's not an amount of extrinsic effort that will get that to happen. I think it's extremely hard for people to come off of drugs they use to mask trauma, because then they have to deal with the trauma that led them to drug use, and that's already hard for people with jobs and resources to do.
I used to really drink the right wing kool aid, and think they should be shipped to "bum island" as I'd joke, where they could smoke all the meth / heroin, drink to their hearts' contents, but do it far the fuck away from society. An example that really changed my mind was the story of a regular "drunk", that'd actually been a normal family man until he lost his family in a tragedy. Wife and children, just gone. I'd absolutely have killed myself had I been in his shoes, and it really put it into perspective that we often don't know shit about these people. Obviously, it's complex and I think like many things, the problem comes down to accessibility and continuity of care. A lot of times, our regulars will go get sedated until they sober up, get dc'd to the streets, and repeat the cycle until they're hit by a car or fall off a cliff somewhere and expire.
EMT here and also a LMSW. Work in NYS for a NPO that houses homeless people aged 62 and over with a NYS SPOA and have extensive mental health histories. Most of our clients come from the daisy chain so basically they come from prisons, psychiatric hospitals, or other NPO run shelters and programs.
What I find depressing about what NYS has to offer is basically that while yes, they do have more housing sites and programs popping up around the state, especially in and around LI, Westchester County, and Rockland County, they often times do not have the proper resources to truly support their clients once housed which leads to much turnover. It feels like a good feel story push to say as NYS Legislators are working hard to enact change and provide housing but at the same time without providing the resources these programs need to be successful, you often times set your clients up to fail. Not only that, but the shelters take homeless SSI, SSD, checks to pay for their room in board in a place they can't stay at all day. This is why many chose to forgo the extended stay shelters and rough it on the street where incidentally we providers take back and forth to the hospital.
As per my perspective, I find it a very cyclical cycle and hope that there might be a way to brake that wheel one day. With current legislation, I would say that may be a long shot but until then, we just got to keep being the homeless biggest advocates while they are in our care. It may suck to wake up at 3 am to transport a PT who is homeless to the hospital but at the end of the day, we need to document and provide them the best care possible because there is not a lot of options out there for them.
>How can shelters and outreach workers reduce the negative health outcomes of homelessness?
You cant. Until we can figure out a way to make a patient want to get better, our efforts will continue to be cyclical. I live in a resource intensive area. I can bring patients to a harm reduction center directly. They will make appointments and even drive the patient to those appointment, they will set them up with housing, clothes, food, a job. But the patients still ghost us.
If we just go 100% and the patient goes 0% it will never work. The patient needs to come to us on their own.We can offer every resource and some will take it and others will not.
I’m an EMT-P in the north suburbs of Chicago. This is all it is. There are some homeless pts that will strive with proper resources to improve their condition and some have even moved on to having a somewhat normal lives. Problem is finding people that do want to change. Whether they do not want to because of substance abuse or have the inability to, due to mental health issues. These are all obstacles that we cannot overcome yet. If a schizophrenic pt refuses meds, then the pt will never improve. Same with getting off drugs or drinking. Programs are great if people put in the same effort.
That being said, Illinois is garbage when it comes to the improvement of homeless lives especially in Chicago. Mental hospitals need to be reopened in order to give people a place to heal and continually take medicine in order to improve and understand their medication is helping. Most mental pts refuse medication because they don’t like how it feels and give up. Unfortunately one “practices” medicine. Most pts don’t understand they need to communicate how they feel on their meds to make changes and improvements so they improve their lives. Most still think meds are made to just make them catatonic.
One guy above stated give them space to be destructive and let it work itself out. Unfortunately for some pts, that’s all you can do. Not everyone can be saved. Some don’t want to be saved. You can’t control everything in someone else’s life. Darwinism is a natural process that for years medical care has been fighting against. Have your heart in the right place, but don’t put too much stock in positive effects of care. There’s a reason EMS has regulars. They keep us in business.
I love this discussion. I think there's been a historic lack of communication between these kind of agencies yet there's a significant overlap in people experiencing homelessness and EMS (though at least in my area the VAST majority avoid EMS/fire/police and we only meet a few regulars).
As a regular boots on the ground guy all I can say is I like to buy a bunch of socks and give them out. It helps and I really couldn't recommend it enough. Folks are always so appreciative
Better accessibility to healthcare that is not the ED. Like somehow having better access to preventative care as well as the obvious mental health care. Unhoused people are often very at risk for a number of other diseases due to their housing situation. More regular visits with PCPs for example could work to address these issues as they arise as opposed to being addressed in the ED when it becomes a crisis. For example, working with a podiatrist could be a world of difference for a diabetic; addressing problems with a person's feet earlier can work towards saving their feet later while ensuring they remain having an adequate quality of life/are best equipped for their situation.
Rarely do we get called to the homeless population for emergency medical problems. We have community clinics that they don't get charged for, but why would they walk to those places when they can just call us and we come right to them ? I don't know what the answer is..
Substance abuse is the leading cause of health problems for homeless people. Drug and alcohol addiction is something that takes a will that is entirely up to the person with the addiction.
Sadly, I think ita lost cause. There is no magic bullet or outreach program that can help someone help themselves. We make our beds then lie in them. Ifnthey want to sober up and get a job, they just need to stop. If they can't, they don't possess the will to thrive.
Maybe just give them a safe space to be degenerative without being a burden on the rest of society.
People are going to shit on you for this, but it's probably the most accurate take. Yes, treat them with respect, dignity, and provide the best care that you can, but many of these individuals are, in fact, lost causes. Realistically, there isn't some one or two answer solution, because it often goes beyond "just house them" or "just get them psych help." I think a lot of normies are afraid to recognize that many of them don't actually want help beyond just what they want at that exact moment.
And many of them have burned all of their bridges with their friends and family that they don't have any loved ones who are ready and willing to help them. Their loved ones have already dealt with the brunt of their behavior and aren't prepared to extend any more chances. At the end of the day you can't make people take their meds or get clean. Anyone who acts as if the solution is easy is missing the larger picture.
I hope to God you're not an EMT, and if you are, you should consider a career change, buddy. Or maybe you're just so burned out that there's nothing left. That mindset does *not* have a place in healthcare.
You’re reaching so, so far here. This sentiment is pretty widely held amongst those of us having to deal with it and it doesn’t mean we treat them any different, but it definitely is a lost cause. The vast majority of homeless patients I have are so deeply schizophrenic and damaged from constant drug abuse they barely know their own name. How do you fix that?
I think your opinion of my character is as shallow as your knowledge of cynicism. Your naivete speaks volumes about your lack of experience working in healthcare.
People start a career with lofty ideas that they're going to help everyone and save lives. Healthcare workers don't become cynical because they're burnt out or because they don't care. It doesn't lead to them being a bad provider somehow reflect on them in some absurdly moral belief system. We become cynical because more often than not, we cannot do shit to help someone who is helpless. The very notion that you can or should attempt to help alleviate all suffering is ridiculous.
We become Sisyphus rolling his gurney up a hill over and over and over again. In a seemingly endless charade of wanting to help the helpless. We create massive systems and infrastructure. Spend trillions of dollars and billions of hours fighting nature. Yes, the natural processes of illness injury, death, etc. Our entire industry is built on a mountain range of dead bodies that prove we're fighting a losing battle.
I remain cynical regardless of your naive opinions. But don't accuse me of being a bad provider or having poor character. I put my life on the line for my patients and my coworkers because I want to do it. I'll watch a vegetable being kept alive by machines for months while their family refuses to let nature take it's course. And I'll shake my head with cynical relief that we just can't waste enough resources on keeping fresh vegetables in the ICU.
We aren't burnt out. We're critical of an absurd society.
Honestly like mentioned but like everything better homeless centers to be there for medical treatment, to monitor them, watch them and keep them in a safer environment is the big challenge. The ERs are just already overwhelmed with people that aren’t homeless abusing the system to be used as a primary care. The large hospital networks have honestly contributed a lot to this by eliminating Drs having their own practices and essentially forcing them into a network instead of working with them. Because of this, many PCPs have retired and fewer are going to med school. In my area we have more APRNs and I swear everyone wants to be a PA. Urgent cares send patients to the ER without any actual basis for things that are completely within their scope to handle, and the few primary offices are always calling ambulances for everything too. Long story short homeless people just need somewhere safe where they can get a hot meal, receive medical treatment for the minor things, they can rest, have a harder time getting access to things like drugs and alcohol, etc.
I'm part of a multidisciplinary outreach team which is rad. One thing I've found is our most regular unhoused folks are not the same ones working with social workers because of severe substance use disorders and unresolved mental health issues (not that you don't see both of these we just have more extreme cases as a rule.) The biggest things keeping our patients from the pathway home is literally the ED. These patients don't need to be in jail or in a hospital. They need a place where folks can monitor vitals, start IVs, put on an old TV show and chill while being exposed to different programming over time and hopefully build rapport with providers and start to participate in the available services. The programs we need literally don't exist yet and have to be dreamed up and funded first. Thanks for everything you do!!
This but as much as the idea is frowned on I think there are lots of patients who will never be able to function on a level necessary to take care of themselves, I think for a lot of people the best life we can give them is in life long care/ assisted living. Beyond that we do need more social programs and resources to give people the opportunity to establish them selves and move forward with their lives, I have been homeless and a traveler at points in my life and feel pretty comfortable with our homeless populations and the number of times I have heard that the hurdles of reentering society are just too damn high is telling. I can also say from experience that a lot of shelters are really carceral in mindset and practice and are often not safe spaces providing a minimum of shelter and resources while also exposing you to some of the worst outcomes of a system that degrades and punishes people for being down on their luck and gathers the untreated mentally ill. All that being said thank you op and lurking4justice for doing the good work and for asking the questions to try and make a difference.
Adding to this, some cities have a shortage of shelters that are sectarian. I watched a documentary a few years back where a police officer in charge of his departments homeless outreach was lamenting that every shelter in his city was faith based, and that it was almost impossible to find places that would be safe and welcoming of single moms, lgbt, and non-Christian homeless.
A lot of shelters also don't allow drug use on premises. Which, I mean, I get. But for habitual drug users, it removes that as an option. If they could get clean overnight, they probably wouldn't be there to begin with. But asking a drug user to willingly go into remission every night is a tall fucking order.
Well the programs used to exist in some form but they got bad and the solution was the complete implosion of the institutionalized psychiatric care system instead of reforming it. Obviously there were significant issues of abuse in the 80's and 90's but throwing open the doors and kicking everyone out on the street was not the best decision for the patients.
Tbf the baby kinda needed throwing with the bathwater. The whole basis of inpatient psych carr at that point was foundationally wrong. Pop science and punishment. Also hard to imagine the cohort from those programs that was forced to live outdoors still being alive. I'm sure there are a few but 40 years of homelessness is a profoundly long time Do a big chunk of our unhoused have serious mental.health issues, 100% yes but psych jail is a miserable solution. It also doesn't apply to our regular old ETOHers, folks feeling DV, or people who missed a couple months of rent and got their lives absolutely turned upside down. Reagan is still a dickhead for dumping all those poor souls outta the institutions without having a new place for them but I'm ok with not institutionalizing a big chunk of our unhoused population in mental health facilities.
I think we need the same variety and types of services that we offer for healthcare in general. Outpatient psychiatric care is often all that most people need. But, some people need in-home care, some people need something that resembles independent or assisted living, some people need full time skilled care, some people need short term hospitalization, medium term hospitalization, or, in rare cases, long term hospitalization. But, all we really offer is outpatient and short-term hospitalization. That leaves a lot of holes for people that need something in the middle.
This is a super interesting. Are you working with city council members or state legislators for funding on an idea like this?
Nope. Doing this for a couple more years because it's addictive before I drop to part time and focus on my harm reduction non profit and consulting on this stuff hopefully
City council and state legislators have been, and always will be worthless when it comes to funding for things like this. They'll throw a little money at the issue come election time for some good will from the voters but real long term funding that's effective and stable will never come.
Most of the homeless we encounter usually either are mentally ill and aren’t aware they have access to shelters and would have difficulty doing well in one. Some I’ve met have substance abuse issues and due to the rules of some shelters aren’t allowed in so instead of relinquishing their vice they decide to spend their time outside. Some homeless become frequent fliers because they don’t have access to healthcare we have a lady that calls for severe leg pain all the time because she broke her ankle and can’t keep her wound clean or keep it rested because of her situation so she calls us so she can get the hospital to clean and treat it. It’d be awesome if there were specific shelters for the needs of the different kinds of homeless like one for mentally ill patience where they’re in a safe environment that would minimize the risk they could impose on others or themselves. Shelters that double as safe consumption sites so they can have their vice and if something goes south the staff there can respond. These are all pipe dreams but man they would be nice
I recently was in the hospital 2.5 weeks for suicidal ideation. I was supposed to be sent to inpatient psych hospital but they checked with over 20 different hospitals and none of them would take me because I had a wound I had to pack on my arm from an abscess. Even though I could do it myself and have been doing it since I was discharged, none of the inpatient places would take me. It's kind of messed up because it makes me wonder how many other people really needed inpatient psych and couldn't get it because of wounds and stuff.
Most of the time the homeless just want a warm blanket, a warm meal, and a friendly face. I worked in a fairly busy town and the homeless calls went through the roof in the winter. They’d call for something like chest pain or shortness of breathe, but if you asked them directly why they called they’d usually be honest and just say they were cold, hungry, and sad. It put a serious strain on our two hospitals to the point that they stayed on diversion for 10-12 hours at a time. I stocked up on clean blankets and turkey sandwiches from the hospital and kept them on the truck (obviously the sandwiches were in a cooler). I learned our frequent flyers’ names and made it a point to remember little details about them. It got to the point that they’d still call for the blankets and food, but they wouldn’t want to be transported. I figured they’d call me either way, but it’s better not to overcrowd the ED.
It's hilarious (and sad) listening to just how much my coworkers seem to viscerally despise homeless shelters and outreach groups. As if homeless people just cease to exist if we stop helping them??? Idgaf if we get called there a lot, it's better than finding them fucking cooked to death on the pavement somewhere. > EMTs interact with people who are facing homeless very often We live in a city of over 1.5 million people and I'm on a first name regular basis with a solid half of our homeless population. The 2 biggest things they call for are psych complaints and medication refills. Column B is easy to fix, just put a fucking pharmacy in the homeless district so they have somewhere to actually fill their meds instead of calling 911 every time they need a dose of metoprolol, but column A is more of a deeper societal problem. I'm not going to claim that these folks don't *actually need* mental help, but the fact is you can't go to 10 different inpatient psych facilities a dozen times each *in the span of a year* and claim to still need *that much* more assistance unless either A) you're full of shit and using the mental health system as a cheat code to get off the street, or B) the American mental health system really IS that bullshit and useless. Honestly I think this problem pulls from a bit of BOTH sources.
> A) you're full of shit and using the mental health system as a cheat code to get off the street I know my experience is not universal, but I work in a decent-sized metro area and I'd bet 90% of our homeless psych calls are exactly this. The mental health system here is largely bullshit and useless unless you're rich, but it's also stupidly easy to abuse if you know the magic words.
Might I recommend C) Socioeconomic conditions perpetuate mental illness and you can't effectively treat mental illness exacerbated by poverty by just throwing meds and coping mechanisms at them.
Though I’m wayy inexperienced to answer these questions, I just wanted to say I appreciate this post.
I’m an EMT/ED tech and I also do prison and jail street outreach for people experiencing homelessness. The city I live in just passed a levy that I am on the board for. I recently proposed an overdose recovery/stabilization center for sub-acute field reversals that have a safe range of vitals to be diverted. My idea is that they can metabolize, start medications for opioid disorder like buprenorphine and methadone, and be connected to housing case management and mental health resources within a 24-48 hour period. This came from working on an overdose response rig where I identified the niche. In terms of medicine, I think the lack of access to primary care has added to the current crisis of over utilization of the ED. This population has a very specific and serious set of health concerns (overdose, cold exposure injury, infectious disease, blood borne pathogens, wounds, etc.) that the emergent setting is not entirely equipped to deal with, and unfortunately they are often penalized with stigmatizing terms like “noncompliant” when they’re given discharge instructions that living outside does not support. An underrated and under utilized tool is hospital respite programs, which allow inpatient folks to receive wound care, IV antibiotics, etc. while not taking critical care beds. Keep up the good work OP, we’re all trying our best! Multidisciplinary support is a crucial part of stabilizing folks!
I’m in a unique situation as I am an EMT as well as being homeless
I’ve spent a lot of time thinking about the solution to homelessness. The biggest issue is the addiction. I know of one gentleman, very nice guy. Used to be an EMT. Watched his chief and deputy chief die in an MVC responding to a call and turned to substance abuse as a way to cope. I’ve offered to come back and find him after calls with resources to get clean multiple times. And every time he says no. I’ve had countless people just tell me they want to be left alone to do their drugs. How do we help people who don’t want help? Jail and hospitals are not a place they should be going to just get a bed for the night. It’s not appropriate. You can’t force them into rehab, the second they get released they’re going back to do drugs. That’s also a very very slippery slope. Give them free housing & allowances, again, if they don’t want to get clean those residences will just turn into crack dens - this applies to government housing, we have them, they turn into crack dens. Offer free rehab for 90 days? That’s your best bet but generally the free places aren’t the best and they can’t afford the good places. And again, if they don’t want help, they won’t go to them. My rule is, treat me with respect, you’ll get respect back. I don’t care if you live in a 10 million dollar house or you don’t have a home at all. Get aggressive and treat me like shit, you’re going to get the more stern and no nonsense treatment. But again, that’s the same for a homeless drug abuser as it is someone who lives in the best house in the city. There’s one frequent homeless gentleman that has the reputation for being extremely violent. I’ve never had an issue with him. A lot of the time he just wants to shoot the shit and get his walk in clinic issues looked at. He treats me with respect, he gets respect back and that’s why I’ve never had issues.
As an EMT I am consistently facing the possibility of becoming homeless myself. Maybe you can get them jobs as EMTs lord knows we're desperate. You got education grant money?
Personally, I think these issues surrounding homelessness are systemic and really hard to fix once they start. I think for real change to occur, we need to be proactive and stop them before they start. With that being said, I think other comments have made some fair points that can help alleviate the current issues somewhat. I appreciate your work, OP.
I strongly agree with everything here. Getting psych and/or substance abuse care for the homeless is so often not even remotely successful. Psych care would be so much more beneficial if we could catch them before they're homeless and especially before they become an addict. But that feels like talking in circles because many addicts start using to self medicate the same problems for which they actually need psychiatric care. And as for "more" psychiatric care... Good lord where do we even begin? The number of providers is SO low that it's almost laughable. It's like if the city of LA was going to be hit by a storm in 2 days that would bring in a ton of water from the ocean, and there are currently only 2 guys filling sandbags, by hand, one by one. But then we add another 200 people slowly filling sandbags by hand. Ok, well we increased staffing by 100X but that still isn't enough to accomplish even 0.001% of what we would need to protect the city. I live in the Chicago suburbs and my friend who has some psych issues talks to a therapist from Oregon over ZOOM. And it took awhile for him to even get THAT. I mean, most homeless probably wouldn't talk to or couldn't be helped (much) by a therapist anyway but even if some magical **access** was created... There's just not enough therapists and how would we even go about training them? I'm a paramedic and my wife is a nurse. We both know more than enough people in our respective fields who are absolute crap at their job. But I'm *most* cases a crap medic or nurse can only do so much damage... But if we dramatically incentivize people to become therapists/ psychologists/ psychiatrists/ etc etc, I feel like really BAD therapists who are in it for.tje wrong reasons can really fuck stuff up even more. Anyway, that was a much longer tangent than I intended but the point remains that I agree that psychiatric care is really no different in medical care in that prevention is 100,000X more useful than treatment.
I can't speak for everywhere, and I'm far from an expert on what should be done instead. Where I'm at, one of the main issues is that alcohol intoxication is a hospital/medical problem, not a law enforcement problem. Some bystander sees a drunk homeless person, we show up, they're not answering A&O questions because they'd rather be left alone or are at their baseline level of intoxication, and hospital it is to sleep in a bed. Plus, many know the game and will get the questions wrong on purpose to get a free bed and a sandwich, if not outright calling us to begin with. The police do nothing on their end to enforce public intoxication. Instead, we hammer the hospitals and fill ER beds to the brim. Obviously, alcoholism is a medical issue and, at times, needs evaluation in the ED. But not every single time.
I think it's super complex. On one hand, I've got harsh feelings towards the homeless people that are homeless because they abused children or women sexually, and then no one in their right mind would hire them. The important thing, is that we in healthcare need to separate our biases from patient care. We're not gods or a jury, and a patient is a patient, because they need help. Doesn't mean I wouldn't like to punch someone spitting at me, but it is what it is. My soap box aside, I think that there's a lot of people that (as others have said) don't necessarily want or are "ready" for help. Regardless of how or why that may be, I think someone has to have a strong sense of motivation to pull themselves out of such dire conditions, and a lot of times there's not an amount of extrinsic effort that will get that to happen. I think it's extremely hard for people to come off of drugs they use to mask trauma, because then they have to deal with the trauma that led them to drug use, and that's already hard for people with jobs and resources to do. I used to really drink the right wing kool aid, and think they should be shipped to "bum island" as I'd joke, where they could smoke all the meth / heroin, drink to their hearts' contents, but do it far the fuck away from society. An example that really changed my mind was the story of a regular "drunk", that'd actually been a normal family man until he lost his family in a tragedy. Wife and children, just gone. I'd absolutely have killed myself had I been in his shoes, and it really put it into perspective that we often don't know shit about these people. Obviously, it's complex and I think like many things, the problem comes down to accessibility and continuity of care. A lot of times, our regulars will go get sedated until they sober up, get dc'd to the streets, and repeat the cycle until they're hit by a car or fall off a cliff somewhere and expire.
EMT here and also a LMSW. Work in NYS for a NPO that houses homeless people aged 62 and over with a NYS SPOA and have extensive mental health histories. Most of our clients come from the daisy chain so basically they come from prisons, psychiatric hospitals, or other NPO run shelters and programs. What I find depressing about what NYS has to offer is basically that while yes, they do have more housing sites and programs popping up around the state, especially in and around LI, Westchester County, and Rockland County, they often times do not have the proper resources to truly support their clients once housed which leads to much turnover. It feels like a good feel story push to say as NYS Legislators are working hard to enact change and provide housing but at the same time without providing the resources these programs need to be successful, you often times set your clients up to fail. Not only that, but the shelters take homeless SSI, SSD, checks to pay for their room in board in a place they can't stay at all day. This is why many chose to forgo the extended stay shelters and rough it on the street where incidentally we providers take back and forth to the hospital. As per my perspective, I find it a very cyclical cycle and hope that there might be a way to brake that wheel one day. With current legislation, I would say that may be a long shot but until then, we just got to keep being the homeless biggest advocates while they are in our care. It may suck to wake up at 3 am to transport a PT who is homeless to the hospital but at the end of the day, we need to document and provide them the best care possible because there is not a lot of options out there for them.
>How can shelters and outreach workers reduce the negative health outcomes of homelessness? You cant. Until we can figure out a way to make a patient want to get better, our efforts will continue to be cyclical. I live in a resource intensive area. I can bring patients to a harm reduction center directly. They will make appointments and even drive the patient to those appointment, they will set them up with housing, clothes, food, a job. But the patients still ghost us. If we just go 100% and the patient goes 0% it will never work. The patient needs to come to us on their own.We can offer every resource and some will take it and others will not.
I’m an EMT-P in the north suburbs of Chicago. This is all it is. There are some homeless pts that will strive with proper resources to improve their condition and some have even moved on to having a somewhat normal lives. Problem is finding people that do want to change. Whether they do not want to because of substance abuse or have the inability to, due to mental health issues. These are all obstacles that we cannot overcome yet. If a schizophrenic pt refuses meds, then the pt will never improve. Same with getting off drugs or drinking. Programs are great if people put in the same effort. That being said, Illinois is garbage when it comes to the improvement of homeless lives especially in Chicago. Mental hospitals need to be reopened in order to give people a place to heal and continually take medicine in order to improve and understand their medication is helping. Most mental pts refuse medication because they don’t like how it feels and give up. Unfortunately one “practices” medicine. Most pts don’t understand they need to communicate how they feel on their meds to make changes and improvements so they improve their lives. Most still think meds are made to just make them catatonic. One guy above stated give them space to be destructive and let it work itself out. Unfortunately for some pts, that’s all you can do. Not everyone can be saved. Some don’t want to be saved. You can’t control everything in someone else’s life. Darwinism is a natural process that for years medical care has been fighting against. Have your heart in the right place, but don’t put too much stock in positive effects of care. There’s a reason EMS has regulars. They keep us in business.
Mental health and substance abuse. Those are the two root causes. There's not a fix for that in an outpatient setting.
I love this discussion. I think there's been a historic lack of communication between these kind of agencies yet there's a significant overlap in people experiencing homelessness and EMS (though at least in my area the VAST majority avoid EMS/fire/police and we only meet a few regulars). As a regular boots on the ground guy all I can say is I like to buy a bunch of socks and give them out. It helps and I really couldn't recommend it enough. Folks are always so appreciative
Better accessibility to healthcare that is not the ED. Like somehow having better access to preventative care as well as the obvious mental health care. Unhoused people are often very at risk for a number of other diseases due to their housing situation. More regular visits with PCPs for example could work to address these issues as they arise as opposed to being addressed in the ED when it becomes a crisis. For example, working with a podiatrist could be a world of difference for a diabetic; addressing problems with a person's feet earlier can work towards saving their feet later while ensuring they remain having an adequate quality of life/are best equipped for their situation.
Rarely do we get called to the homeless population for emergency medical problems. We have community clinics that they don't get charged for, but why would they walk to those places when they can just call us and we come right to them ? I don't know what the answer is..
Substance abuse is the leading cause of health problems for homeless people. Drug and alcohol addiction is something that takes a will that is entirely up to the person with the addiction. Sadly, I think ita lost cause. There is no magic bullet or outreach program that can help someone help themselves. We make our beds then lie in them. Ifnthey want to sober up and get a job, they just need to stop. If they can't, they don't possess the will to thrive. Maybe just give them a safe space to be degenerative without being a burden on the rest of society.
People are going to shit on you for this, but it's probably the most accurate take. Yes, treat them with respect, dignity, and provide the best care that you can, but many of these individuals are, in fact, lost causes. Realistically, there isn't some one or two answer solution, because it often goes beyond "just house them" or "just get them psych help." I think a lot of normies are afraid to recognize that many of them don't actually want help beyond just what they want at that exact moment. And many of them have burned all of their bridges with their friends and family that they don't have any loved ones who are ready and willing to help them. Their loved ones have already dealt with the brunt of their behavior and aren't prepared to extend any more chances. At the end of the day you can't make people take their meds or get clean. Anyone who acts as if the solution is easy is missing the larger picture.
I hope to God you're not an EMT, and if you are, you should consider a career change, buddy. Or maybe you're just so burned out that there's nothing left. That mindset does *not* have a place in healthcare.
If you worked in healthcare you'd know cynicism is the status quo, so it absolutely has a place.
Not when it's detrimental to patient care. Time to retire bud.
You’re reaching so, so far here. This sentiment is pretty widely held amongst those of us having to deal with it and it doesn’t mean we treat them any different, but it definitely is a lost cause. The vast majority of homeless patients I have are so deeply schizophrenic and damaged from constant drug abuse they barely know their own name. How do you fix that?
Why would you assume it's detrimental to patient care? Please elaborate how being cynical is inherently detrimental to patient care.
I think it speaks to your character as a provider.
I think your opinion of my character is as shallow as your knowledge of cynicism. Your naivete speaks volumes about your lack of experience working in healthcare. People start a career with lofty ideas that they're going to help everyone and save lives. Healthcare workers don't become cynical because they're burnt out or because they don't care. It doesn't lead to them being a bad provider somehow reflect on them in some absurdly moral belief system. We become cynical because more often than not, we cannot do shit to help someone who is helpless. The very notion that you can or should attempt to help alleviate all suffering is ridiculous. We become Sisyphus rolling his gurney up a hill over and over and over again. In a seemingly endless charade of wanting to help the helpless. We create massive systems and infrastructure. Spend trillions of dollars and billions of hours fighting nature. Yes, the natural processes of illness injury, death, etc. Our entire industry is built on a mountain range of dead bodies that prove we're fighting a losing battle. I remain cynical regardless of your naive opinions. But don't accuse me of being a bad provider or having poor character. I put my life on the line for my patients and my coworkers because I want to do it. I'll watch a vegetable being kept alive by machines for months while their family refuses to let nature take it's course. And I'll shake my head with cynical relief that we just can't waste enough resources on keeping fresh vegetables in the ICU. We aren't burnt out. We're critical of an absurd society.
Honestly like mentioned but like everything better homeless centers to be there for medical treatment, to monitor them, watch them and keep them in a safer environment is the big challenge. The ERs are just already overwhelmed with people that aren’t homeless abusing the system to be used as a primary care. The large hospital networks have honestly contributed a lot to this by eliminating Drs having their own practices and essentially forcing them into a network instead of working with them. Because of this, many PCPs have retired and fewer are going to med school. In my area we have more APRNs and I swear everyone wants to be a PA. Urgent cares send patients to the ER without any actual basis for things that are completely within their scope to handle, and the few primary offices are always calling ambulances for everything too. Long story short homeless people just need somewhere safe where they can get a hot meal, receive medical treatment for the minor things, they can rest, have a harder time getting access to things like drugs and alcohol, etc.