House Calls to the Homeless

From the Summer 2016 edition of Vanderbilt Medicine Magazine

 

Wednesday is clinic day for Vanderbilt psychiatrist Sheryl Fleisch, M.D. The day is packed with patients, many with multiple physical and mental issues. Fleisch is dressed in jeans, a long-sleeved Vanderbilt T-shirt and a fleece jacket. She wears hiking shoes and carries a heavy backpack. There’s no white coat. No sterile hallway. No exam room. Her clinic is the street, and her patients are Nashville’s homeless.

 

Wednesday, April 6, 8:10 a.m.

A smiling Fleisch whips into a parking spot within Nashville’s Metro Center, just in time for her weekly psychiatry rounds. Many Nashvillians know the location as the entrance to a serene greenway that runs underneath the interstate and along the Cumberland River. Some call it home.

Fleisch, founder and medical director of Vanderbilt University Medical Center’s (VUMC) Street Psychiatry Program, jumps out of her car, opens the hatch and stuffs supplies from her trunk into a backpack—clothing, hygiene products, bottled waters, hand warmers, socks, granola bars and Nashville bus vouchers.

Her dark hair pulled tightly into a ponytail, Fleisch explains that the supplies in her backpack are considered “engagement items,” used to help begin a conversation with homeless individuals. (The clothing and hygiene supplies are paid for through a $10,000 grant from the Tennessee Health Foundation, along with some other needed medical supplies. The program also accepts in-kind donations.)

From left, psychiatry resident Rissa Ivens, M.D., Sheryl Fleisch, M.D., and Erin Gauvin of Park Center, follow up with their patient, Paul.
From left, psychiatry resident Rissa Ivens, M.D., Sheryl Fleisch, M.D., and Erin Gauvin of Park Center, follow up with their patient, Paul.

Accompanying Fleisch on this cloudy and unseasonably cool spring day are Vanderbilt residents Thomas Jordan, Rissa Ivens and Jamie Sorenson, and Cayla Wilson, an outreach worker from Park Center. The nonprofit agency, which partners with Vanderbilt’s Street Psychiatry Program, serves adults with severe and persistent mental illness.

Joggers, bikers and walkers dressed in workout attire whiz past the group, seemingly oblivious to the tents on the river bank—some easily visible; some hidden by the spring foliage.

Fleisch walks down a path overgrown with brush and shouts a friendly “Good morning! Outreach! We’ve come to see how you’re doing,” to a man inside a tent adorned with an American flag. She talks quietly to him through the tent’s ventilation, and soon a tall, African-American man with salt-and-pepper gray hair and beard emerges. Fleisch offers him some supplies. He takes a pair of XL sweatpants and a sweatshirt, bottled water, underwear and a hat and invites the group gathered on the trail inside his large tent.

Seated in a camping chair with a tiny black puppy named Boo Boo, the man tells Fleisch he’s been homeless for two years. “That’s a long time,” she says. He tells Fleisch that he has an appointment with a psychiatrist the next day. The sun, momentarily out, shines through the holes in the ceiling of his tent, illuminating the litter on the floor—food, crushed boxes and clothing. After a few minutes the group gets up to leave. “Thanks for inviting us in,” Fleisch says. “Have a nice day.”

It may appear that Fleisch and her group are just chatting with the man, but in fact, she and the residents are doing a quick assessment of his mental status. “In probably 1 minute, we can figure out if someone needs psychiatric help. Sometimes we do a full evaluation and make an appointment for the next week. Sometimes we see an immediate urgent need, and we need to make some phone calls for additional medical or psychiatric help.”

Fleisch and her group always ask permission to enter someone’s tent. “Their tent is their home, and you don’t just walk into someone’s home,” she says.

 

Committed to a Cause

Fleisch, the daughter of two Indianapolis pharmacologists, graduated from Vanderbilt University in 2004 and from Vanderbilt University School of Medicine in 2008. During those eight years she took part in community outreach experiences and witnessed the inequities in health care delivery for those who can neither afford nor access care, including homeless individuals who were being discharged back to the streets with no follow-up. “Everyone deserves health care and you want to treat people the way they should be treated, with respect and dignity,” she said.

During her psychiatry residency training at the University of Pittsburgh Medical Center, she expanded programming to provide outreach services to mentally ill homeless persons, and at the University of North Carolina at Chapel Hill during a fellowship in psychosomatic medicine she partnered with a nonprofit organization to found the UNC Homeless Support Program to provide psychiatric services to homeless persons on the street.

Returning to Vanderbilt in the summer of 2013, she saw homeless patients who came to Vanderbilt through the Psychiatric Consultation Service. In July 2014 she launched VUMC’s Street Psychiatry Program and has since founded and been named the Medical Center’s director of Homeless Health Services, a program whose mission is to improve health care of homeless persons through provision of direct care both in the hospital and on the streets.

Nationally, about 30 percent of homeless people have severe and persistent mental illness and about two-thirds have a substance use disorder, Fleisch said. By treating Nashville’s homeless population on the streets and rounding with them when they’re in the hospital or emergency room, the service not only benefits Nashville’s homeless population, but VUMC as well, due to the overall decrease in emergency room visits and hospitalizations.

The program also provides an educational opportunity through elective rotations for both medical students and residents. Future physicians are being taught how to deliver compassionate care to one of the most vulnerable populations.

According to Nashville’s Metro Homelessness Commission, there were 2,154 homeless individuals in Nashville in January 2015, largely single adults without children. About 25 percent are unsheltered. Many are chronically homeless, which is defined as currently unsheltered or in emergency shelter, continually homeless for at least a year or four or more times within the last three years, and with a disability that significantly impairs their ability to secure and sustain housing.

“We need a much greater understanding of the barriers that people face, and until you have physically been out on the streets and out in the super-hot weather or super-cold weather, it’s very difficult to understand how people live beyond the safety nets of society,” Fleisch said. “We have to decide how much responsibility we want to take for folks struggling with homelessness. It’s easy to blame the fact that someone is homeless on the person, without understanding the story behind it.”

The homeless population has trouble getting medical care and navigating services, such as disability insurance and Section 8 housing vouchers, that might help them get off the streets. Park Center helps Fleisch’s patients with the fast track disability application process, called SOAR (SSI/SSDI, Outreach, Access and Recovery).

“Achieving disability insurance is an independent predictor of health care status, and allows people to see doctors they normally couldn’t see,” she said. The disability process can take four months to two years to achieve, and multiple appeals can take place. Only 10 percent of homeless persons applying for disability receive it the first time, Fleisch said, “a total travesty.”

 

Wednesday, 9 a.m.

Fleisch and the Vanderbilt residents walk down a short path to an exposed tent. A very tan, cheerful woman emerges, dressed in a black dress, calf-length wool coat and nice black boots. She talks fast and has a lot to say. She tells the group that she’s hitchhiked across the United States and has been in Nashville since mid-December. “I’ve been bobbing around,” she says. “For a woman on the street, it’s better not to be in one place. When the Lord tells me to go somewhere else, I go.”

She continues talking, telling the group that she died in 2011, and was in the early stages of rigor mortis, when she was brought back to life by God. “He fully nuked me, like I was in a microwave oven,” she says. Fleisch, her arms folded across her chest, listens respectfully for about 15 minutes, then asks the woman if the group can follow up with her. She declines an appointment with a psychiatrist, saying she doesn’t believe in psychiatry or psychology, but agrees to let the group visit again. She mentions she needs flashlight batteries and paper towels, but Fleisch and the residents don’t have those items. Instead, they leave her with a bus pass and an individual coconut pie, which she at first declines, then changes her mind and accepts.

Fleisch says she knew right away that the woman was psychotic (has lost touch with reality) and paranoid. While she declined psychiatric help, asking for the pie was considered a victory. “The exchange of socks, food and hygiene products can lead to medical or psychiatric care and shows a level of trust that perhaps this person has never had,” Fleisch said.

The next stop is at a larger tent by the riverbank. David, 33, has been on his own since he was 14, and has been at the campsite for more than three months. He has a nice tent, covered by blue tarp for additional insulation, and has built crude wooden shelves beside his tent to hold pots and pans, cooking utensils and some canned food. He’s also attached a solar panel to a board that provides some power inside his tent. Police visiting the camp thought he was making a bomb, he said. “I care about what people think,” he tells Fleisch. “There’s a lot of discrimination that takes place.” Fleisch agrees.

Earlier in the year, David lived at the Fort Negley encampment, Nashville’s largest homeless camp, which was shut down to the homeless population in mid-April. There, he and another homeless man were robbed at gunpoint, and his friend was run over by a car and was left paralyzed. David said he still has nightmares about the accident.

There is currently only one sanctioned homeless camp site in Nashville— at Green Street Church of Christ, near Hermitage Avenue.

David says he grew up in foster homes and was abused. He’s suffered with addiction for many years. “When I was younger I had a lot of hate in my heart. A lot of people have friends and family to rely on. I’ve had no one. This is home to me,” he says, gesturing toward his tent.

David says he believes homelessness in Nashville will continue to grow along with Nashville. “There’s a lot of mental illness on the street. Every day you’re out here is a struggle. We don’t even have a place to shower,” he says, estimating that he walks at least 10 miles a day for food, hygiene needs and shelter.

“The city isn’t very happy with the homeless community being here,” Fleisch says, looking around her. “This camp is next to a nice running path, and the city doesn’t like that, but there’s no place else for people to go.”

“After years of living in this community, I’ve learned a lot about homeless people,” David tells Fleisch. “They’re all going through their own issues with their own demons. They’ve had a lot of internal pain in their lives. There’s a lot of loneliness and a lot of loss. People are struggling, but people are people no matter what.”

Fleisch asks David for advice on how to teach future health care professionals not to stigmatize the homeless. “I feel like you can’t teach it,” he said. “To become humble, you have to go through it.”

“But I think we can teach it,” she tells him. “If we do stuff like this (rounding on the streets), I think it will help people get an inside view.” David agrees. “God bless y’all for coming out here. Keep doing what you’re doing. Keep coming out here. Don’t discard us,” he said.

 

Shared Value

Through Vanderbilt’s Homeless Health Services, Fleisch and others receive notifications when a homeless person is being seen in the emergency room or is admitted to the hospital. She sees the patients in the hospital, and then makes arrangements to see them again on the streets for follow-up. The Vanderbilt program has also hired a psychiatric nurse practitioner to assist with inpatient consultations on homeless persons, a disability coordinator to pursue fast track disability claims for individuals who are homeless with severe and persistent mental illness, and a housing navigator to help patients who are interested in achieving housing (not all are).

Vanderbilt is the first hospital in Tennessee and one of a few in the country to have its own disability coordinator and housing navigator for the homeless, Fleisch said.

“The success of this program is due to the fact that we follow people from the hospital to the streets. We experience their plights with them. We know them by name,” Fleisch said. “So many are struggling and they’re viewed in a negative way. I’d like our residents and medical students to see homeless people, as David said, as people.”

“Another goal of this program is to reduce the emergency room and hospital stays for this population. They’re one of the highest utilizers of our hospital system and data shows that if you can treat homeless persons on the streets, there are decreased emergency room visits and hospitalizations,” she said.

The Vanderbilt Psychiatric Hospital’s pharmacy provides Fleisch and her team with a mobile pharmacy to treat patients on the streets with psychotropic medications for depression, psychosis and anxiety and medications like antibiotics and inhalers for infections and respiratory illnesses.

Left to right: Rissa Ivens, M.D., Jamie Sorenson, M.D., and Sheryl Fleisch, M.D., talk with David, who has been on his own since age 14. “This is home to me,” he says.
Left to right: Rissa Ivens, M.D., Jamie Sorenson, M.D., and Sheryl Fleisch, M.D., talk with David, who has been on his own since age 14. “This is home to me,” he says.

But when they do become hospital patients, Fleisch and her team see them each day. “We see people in the hospital provided with a level of care and dignity they’ve never had before. These are complex individuals with many medical and psychiatric issues. We help them come up with a discharge plan that hopefully includes some time off the streets.” If the discharge plan does include the streets, homeless patients are sent “home” with a camping kit, which includes tents, sleeping bags, tarps and camping supplies that the Vanderbilt team assists in setting up at their site.

John A. Morris, M.D., professor of Surgery and associate chief of staff of the Vanderbilt Health System, is Fleisch’s immediate supervisor and one of her “internal champions,” along with Stephan Heckers, M.D., professor and chair of Psychiatry and the William P. and Henry B. Test Professor.

“Dr. Fleisch is a remarkably committed and gifted physician,” Morris said. “Her passion is the homeless population. For me it’s a treat to be able to watch a young faculty member develop from being a good clinical doctor into someone who can leverage their clinical skills and create a cutting-edge program that is receiving national attention.”

In 2015, the Vanderbilt Street Psychiatry program received the Model Project Award from NAMI (National Alliance on Mental Illness) Tennessee as the program that exemplifies best practices for those living with mental illness, and Fleisch received the Well Within Challenge Award from NAMI Davidson County for the development of the Street Psychiatry program “which has made measurable impacts on the community and for continued advocacy on behalf of homeless persons.”

“The Street Psychiatry program is a big win for VUMC, the School of Medicine and the Department of Psychiatry,” Heckers said. “The integration into the psychiatry consult service is particularly compelling.”

It’s also a win for society. Vanderbilt’s Street Psychiatry initiative is an example of the “shared value” framework coined by Harvard Business professor Michael Porter, a leading authority on competitive strategy and head of the Institute for Strategy and Competitiveness at Harvard Business School. The framework involves creating economic value in a way that also creates value for society by addressing its needs and challenges.

 

Wednesday, 10 a.m.

Further down the greenway, a woman has a large tent of her own, a guest tent and a separate covered area where she invites Fleisch and the residents to join her. She’s lived at the site for seven months. Beside her neat tent there are rain boots, a large box of fudge-striped cookies, a shrine made of toys from children’s fast food meals and a fire pit.

Fleisch sits down next to the woman. “Hey, I need to ask you, I was hanging out with some friends recently and we tried to build a fire. It was a total disaster. How do you do it?” A lesson in fire-making 101 ensues before the group moves on to a tiny tent with two men. Their dilapidated tent is partially covered with a Barney the dinosaur quilt. They accept socks, water and hygiene products, but don’t have much to say. “You seem tired,” Fleisch says kindly. “We’ll come back another day.”

On Wednesdays, Fleisch and the Vanderbilt residents visit at least two homeless camps, to check on the residents and for appointments that had been scheduled the previous week. “Every day is different with our program,” she said. “We never know who we’ll speak to and what they’ll teach us.”

 

Wednesday, 2 p.m.

After a quick meeting with Jim, a formerly homeless patient who is in recovery for his addiction, the group moves on to South Nashville. Steps away from a busy retail corner, Fleisch and fourth-year resident Jamie Sorenson, M.D., walk down a steep and rocky embankment toward Mill Creek and stop to talk with three men at a campsite. Paul, who Fleisch had treated weeks before for a lingering cough, is obviously inebriated, and still has a deep barking cough. He sits in a broken Auburn University camping chair. A canned ham and a quart of beer are on the ground beside him. When Fleisch gave him antibiotics, she also gave him an inhaler and a new tent. His girlfriend had died of pneumonia inside his previous tent and he didn’t want to go back inside.

Paul asks for more antibiotics and says he also needs a new backpack. Fleisch listens to his chest with her stethoscope. “Your lungs sound better, so I’m going to hold off for now. I’ll come back in two weeks and bring you a backpack and we’ll re-check your lungs.” Sorenson asks him to demonstrate how he uses his inhaler to make sure he’s using it correctly. He is.

“I’m so glad you came back to check on me,” Paul says, his voice raspy as he begins to cry. “I’m so grateful. It touches my heart so much that you came back to see me, Sheryl. Thank you. I knew you’d come back.”

 

Fleisch said following up with her patients is essential.

“A lot of working with homeless persons is building trust—when you say you’re going to follow up, you need to do it,” she said.

She recalls one patient where building trust wasn’t easy, but the results were worth it.

“This woman had struggled tremendously. She was very difficult, had no insurance and was costing the hospital hundreds of thousands of dollars. She was ungrateful and was very challenging in all aspects. She wanted help, but rejected all help that was offered to her,” including a tent that Fleisch tried repeatedly to get her to take.

“I sat on her bed and said ‘you have exhausted all of your options. If you don’t take this tent you’re being offered, I’m worried you’re going to die. This is your only option.’”

The woman took the tent, and Fleisch and the Vanderbilt team continued to follow up with her even while she took part in an intensive six-month outpatient program at Park Center.

“I attended her graduation. I felt it was an important day for me, too,” Fleisch said. “We celebrated her one-year sobriety with pizza and Diet Coke, and two years with Kentucky Fried Chicken, ice cream and Diet Coke. She has a home now and disability insurance.”

Fleisch and the woman recently spoke at an event sponsored by Park Center where they were seated next to Nashville Mayor Megan Barry. “She’s turned her whole life around,” Fleisch said of her patient. “She was going to die. There was no doubt about it. Seeing her recover is a remarkable experience. It’s incredibly humbling.”