House Calls for the Homeless

Pops is a fixture of the stretch of Cambridge Street winding down to Boston’s Charles River, but he can be a hard man to get to know. On any given day, this slightly built, bearded man is usually shuffling up and down the steep hills of Beacon Hill. His legs swollen, he walks slowly and leans heavily on a cane. He carries a coarse blanket under his arm and has a plastic grocery bag in tow filled with prescription medications for his high blood pressure. Pops might smile and wave to a familiar face, but he’s likely to slip away quickly when approached rather than strike up a conversation.

Pops is in no one’s way. But his poor health, coupled with his reserve, puts him at great risk. He’s a perfect example of why James O’Connell, MD, regularly hits the streets with his team 
from the Boston Health Care for the Homeless Program (BHCHP) to bring health care to those who need it most. BCHCP, comprising two hospital-based walk-in clinics and more than 80 other sites throughout Boston, makes high-quality care accessible to the homeless in soup kitchens, shelters and city streets.

“Pops is one of our ‘rough sleepers’ — homeless people who choose to sleep on the streets rather than in shelters,” explains Dr. O’Connell, a Massachusetts General Hospital primary care physician and president of BHCHP. “Doctors and nurses may be only steps away, but most of these folks won’t seek them out. They aren’t going to see the inside of the hospital unless they’re rushed here in an ambulance.”

For nearly 25 years, Dr. O’Connell and his colleagues at BHCHP have worked to identify and address obstacles faced by homeless patients like Pops, who prefers not to go by his given name. A one-time Mass General resident headed for a prestigious oncology fellowship at New York’s Memorial Sloan-Kettering Cancer Center, Dr. O’Connell was approached about a position working with homeless patients by the late Thomas S. Durant, MD, an MGH physician famous for his work with refugees. Excited about the idea, Dr. O’Connell delayed his fellowship and committed a year to helping BHCHP get off its feet. That was 1985, and Dr. O’Connell — known as ‘Dr. Jim’ to his patients — was the program’s only physician. Today, BHCHP employs nearly 300 staff.

All health care is administered by paid clinical staff, ensuring the kind of continuity of care which volunteer-based organizations so often lack due to high employee turnover. Financially stable since obtaining its first grant in 1984 from the Robert Wood Johnson Foundation and the Pew Charitable Trust, BHCHP is now funded by a mix of government agencies and grants, local healthcare organizations such as Mass General and private philanthropy.

A model for similar organizations nationwide, the program has pioneered methods of healthcare delivery as unique as the population it serves — including medical respite care at the 104-bed Barbara McInnis House, shelter-based clinics throughout the city and a street clinic at Mass General. In 1992, BHCHP even launched a dedicated clinic located at the Suffolk Downs Thoroughbred Racetrack that serves more than 500 homeless and migrant backstretch workers who live in the stables and barns.

Notwithstanding all of these services, addressing the health needs of the homeless is a daunting task. It involves performing regular check-ups and providing comprehensive, continuous care to patients who shy away from clinic and hospital settings and can be mighty challenging to physically locate.

“I won’t go to the clinic, but Dr. Jim is ok with seeing me on the street,” Pops says, as the physician takes his blood pressure on a public bench and hands him a package of warm socks.

In 1994, in an effort to respond to such patients as well as to the growing number of reported deaths on the streets, Dr. O’Connell’s program founded the ‘Street Team’. The Street Team seeks out Boston’s rough sleepers, making improvised ‘house calls’ under bridges and on city benches as well as operating a make-shift clinic out of the Overnight Rescue Van. The multi-disciplinary Street Team is made up of two MGH internists, two psychiatrists, a nurse practitioner and a physician assistant, Jill Roncarati, PA-C.

“We have teams on the streets every day of the week,” says Ms. Roncarati, “so that our patients recognize and trust us. Building relationships is the key to delivering quality care.”

Kacia Wilkinson, a long-time patient in the program, lived under the Longfellow Bridge with her boyfriend for years until she won a coveted place in a housing program. Back on the street now and working to stay healthy, Kacia relies on the care she receives from Dr. O’Connell and his staff. “Dr. Jim is just the best,” she says. “No matter what’s happened, I can come see him. He keeps us going.”

“It’s critical that we meet the patients where they’re at,” says Dr. O’Connell, “and that we’re ready to treat a pretty complex set of conditions that are often unique to homeless people.”

Rough sleepers face hypothermia, malnutrition and violence. But many of Dr. O’Connell’s patients also suffer from what is known in the medical community as ‘tri-morbidity’ — when someone experiences simultaneously a chronic physical condition, psychiatric illness and one or more substance abuse problems. Each condition, on its own, is often easily preventable or manageable. In combination and left untreated, however, such health problems become compounded and, all too often, fatal.

Whatever the complexity — whatever the challenge, BHCHP has reacted and adapted to address it. Supported by MGH funding, the Street Team added psychiatrist James Bonner, MD, a clinical assistant in Psychiatry at MGH to its ranks in 2002, thereby seamlessly integrating medical and behavioral health care for Boston’s rough sleepers. After the statewide push to house an ever greater number of homeless individuals and families, the Street Team has added more traditional house calls to its repertoire, dispatching healthcare workers to follow up with former street patients in their new environments. And, working with the Mass General Laboratory of Computer Science, Dr. O’Connell designed and implemented the country’s first electronic medical record for the homeless, enabling healthcare providers to coordinate care safely and effectively.

The need continues to grow: BHCHP has delivered services to more than 11,000 homeless men, women and children in 2009 alone. O’Connell says there is great room for philanthropy to play a major role in expanding services to this community.

Since his earliest days with BHCHP, Dr. O’Connell’s devotion to the program and his patients has been celebrated throughout the medical and homeless communities. In recognition of his work, he was awarded the inaugural J.H. Canter Prize in August 2009 for, according to the prize committee, his “tireless efforts and creativity in developing ways to eliminate health disparities and improve health care for homeless persons in Boston.”