For the Love of Health

The Toughest Questions in Health Care: How Can Health Care Impact Homelessness? with Dr. Ben Golden and Dr. Ashley Panichelli

• ChristianaCare • Season 2 • Episode 7

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Homelessness can impact both physical and mental health, and make accessing medical care difficult. As a result, people experiencing homelessness often face higher rates of poor health outcomes than people with housing.

Which leads us to the next question in our Toughest Questions in Health Care series: How can health care impact homelessness? Dr. Ben Golden, Program Director for the ChristianaCare Medical Respite Program at the New Castle County Hope Center, and Dr. Ashley Panichelli, Clinical Director for ChristianaCare Complex Primary Care share details on the difficulties that arise in providing care for patients experiencing homelessness, steps that ChristianaCare is taking to counter those issues, and their hopes for the future in this field of care.

Dr. Ben Golden, M.D., completed his medical training at Rush University Medical Center in Chicago, IL where he took an interest in healthcare disparities and care for patients experiencing homelessness. As Program Director for the ChristianaCare Medical Respite Program at the New Castle County Hope Center, he provides complex primary care for the residents of the facility. Dr. Golden also continues to practice Emergency Medicine at all of Christiana's sites.

Dr. Ashley Panichelli, M.D., the clinical director of Complex Primary Care and Community Medicine at ChristianaCare. Dr Panichelli is passionate about teaching, mentoring, and program development, and routinely speaks to the news media about family medicine and the importance of vaccinations. Dr Panichelli’s specific interests include inpatient medicine and safe transitions of care, residency quality and safety, Just Culture, women's health, and resident simulation curriculums.

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Speaker 1:

These are people, these patients are already here. This is our issue. This is a health care issue. We can't shirk our duty here.

Speaker 2:

You're listening to For the Love of Health, a podcast about delivering care and creating health, brought to you by Christiana Care. And now here are your hosts.

Speaker 3:

Hello everyone, I'm Megan.

Speaker 2:

McGerman and I'm Jason Tokarski. Welcome to For the Love of Health brought to you by Christiana Care.

Speaker 3:

Homelessness can impact both physical and mental health and make accessing medical care difficult. As a result, people experiencing homelessness often face higher rates of poor health outcomes than people with housing.

Speaker 2:

Which leads us to the next question in our Toughest Questions in Healthcare series how can healthcare impact homelessness? Joining us today to tackle that question are Dr Ben Golden, program Director for the Christiana Care Medical Respite Program at the New Castle County Hope Center, and Dr Ashley Panicelli, clinical Director for Christiana Care Complex Primary Care.

Speaker 3:

Ben and Ashley, thank you both so much for being here today.

Speaker 1:

Thank you for having us.

Speaker 3:

Yeah, thank you, glad to be here. What do the local and national conversations on homelessness sound like right now?

Speaker 1:

Well, not great at present. The tone out in the community right now is one of concern. In 2023, nationally, there's been an 11% increase in homelessness and in Delaware alone, it's 9% increase from 2023. From 2020 until now, there's been a 58% increase in the individuals rough sleeping out on the street, and I can tell you that there's been a lot of concerns regarding the grants pass decision, which has removed some protections from the Eighth Amendment for this community.

Speaker 1:

Historically, many municipalities have been required to provide options for people rough sleeping out on the street, so not sleeping in a shelter, but sleeping in a park or in a car or out on the street itself. If there were shelter beds available, if there were resources available and patients chose not to take advantage of them, then they could be ticketed, fined or arrested not to take advantage of them, then they could be ticketed, fined or arrested. The Grants Pass decision said that you no longer have to have those restrictions, and fining, ticketing or arresting people sleeping outside does not constitute as cruel and unusual punishment. We've already seen sweeps happen in Philly, in Los Angeles and in San Francisco, and even today I've had patients express concern about what's going to happen here when it finally arrives. So there's a lot of people are very nervous about what little resources they have already.

Speaker 2:

How does health care and homelessness? How do they connect, how do they affect each?

Speaker 1:

other. So there are many responses to this question. I think, pragmatically, these patients have medical illnesses. Patients who are experiencing homelessness have been shown to have 3.5 times the mortality rate associated with their homelessness than their housed counterparts. A 40-year-old homeless patient has a similar mortality risk to someone who's nearly 20 years older. So independently based on the housing status. So these people have medical illnesses, they have risk factors and, pragmatically, they're already in the offices, they're in the emergency departments, they're in the hospital. Like this becomes an issue that we have a patient in front of us, we should take care of them and, like any other risk factor for healthcare, for medicine, these things are modifiable. Just like when we talk about smoking with heart disease, affecting a person's housing can reduce their comorbidities. So providing housing for patients, working on housing for these patients, is a medical intervention that can be done for them to have long-term benefit, but it has to be a long-term solution.

Speaker 2:

And I would assume there's also got to be an angle of the care that can be provided to someone who is homeless is different because of what you can offer them for those treatments.

Speaker 1:

Absolutely, as we've found in our time working with the mobile clinic. The strategy for healthcare delivery has to be unique, because these patients' journey and medical conditions are unique. These patients don't have places to store medications, they don't have ready access to things like bathrooms, so if you have a person on a diuretic or a person on insulin, they have no place to regularly use the restroom or refrigerate their insulin. So you have to be more creative about these things. In addition to this, many of these patients have severe comorbidities. One in five have a communicable disease. Two of three meet criteria for severe mental illness, when it exists. Most patients have been exposed to violence and hunger. 30% reported substance use disorder, and so you have to be able to tailor a lot of the textbook healthcare delivery to their unique environment. We'll have five patients with a similar complaint, but we'll have five different strategies.

Speaker 3:

Let's talk more about what ChristianaCare is doing to directly find this and help this population. You've mentioned the mobile van, the mobile health services van, of which, ben, I know you are the lead physician on the van that's based in Wilmington. Talk about how that works, how people can find you and really the purpose of this van.

Speaker 1:

Our vision has really morphed over the year that we've been out doing this and we've had great expansion. We now have seven sites around the greater Wilmington area. Patients can find us a variety of ways. We are setting up hotlines for people to call in to find out where we are that day at that time and we're working to increase services so that we're out every single day, not just twice a week right now.

Speaker 4:

And we really partner. You know, and are continuing to learn and evolve in this process and learn you know who our community partnerships are and to help best serve community members. You know, I think one of the great things about this is maybe we went in and our partners went in with ideas of where would the best places to be and how to best serve patients, and then you know we're learning and maybe a community member from a community organization is reaching out and saying, hey, I have, you know, a lot of maybe parishioners or people coming to my community center who need help or from different you know types of organizations and are asking for us to partner, and it's been really great. We can kind of pivot and figure out who to best partner with to help you know the patients that are most in need and, quite frankly, maybe the most unlikely to come to some of our brick and mortar practices, which is, I think, the most rewarding part and our favorite part.

Speaker 3:

Your team also does a lot of work in the Newcastle County Hope Center. Talk to us about that.

Speaker 1:

The Newcastle County Hope Center is a large transitional living facility housed in the old Sheraton on Airport Road just outside of Wilmington. Christiana has partnered with them since they opened to provide healthcare services on site. A few years ago we established a 36-bed medical respite program. We're the first and only medical respite program in the state of Delaware. We provide services to patients that have complex health care needs but don't require full hospital level of services. So we accept many patients from the hospital that require a little bit more care, and being out on the street or being in a shelter would be detrimental to the healing that's already occurred. We have a very dynamic model and a multidisciplinary model to try and connect with multiple domains within the social determinants of health, medicine and healthcare being sometimes a smaller portion of some of their overall needs.

Speaker 2:

Obviously, the goal is for any patients that you're seeing not to be stuck in this situation forever. So do you have any procedures that you go through to try to help someone transition from the Hope Center, maybe to then being out elsewhere, so that they can receive services from the mobile van and maybe even then to the brick and mortars, as you say?

Speaker 4:

Yeah, that's something that in complex primary care we're really thoughtful about and always kind of shifting and changing and are very dynamic in that both our clinicians and our operational team about how our you know, our spaces really fit together best.

Speaker 4:

Because we do have multiple, you know, patient stories of patients who may go from inpatient setting at the hospital, who then may transition to the Hope Center and then, once they're, you know, able to leave the Hope Center. We understand and value that they still need that primary care and are going to need ongoing management and they may be able to transition maybe to the mobile van or to one of our brick and mortar practices. And I would say we're still learning, but we're trying to make workflows and strategies to really best connect patients in a streamlined fashion so that they know that, you know, despite this next transition point, their health care is still going to be managed and they're still going to be able to get what they need. Luckily, some of our clinicians cross different spaces, which is a really valuable thing, I think about our group, but even not if not, we have great communication between our teams and between our different locations.

Speaker 3:

Ben, earlier you mentioned social determinants of health. How do you dig through that? I know, Ashley, a lot of the practices that you work with now are doing social determinants of health screenings. Are you also doing those screenings as you meet with these patients?

Speaker 1:

Ours has a little bit more of an organic feel to it at the moment because many of these things come up in conversation. Sometimes people will enter into the mobile van not because they want to be seen by a provider, but because we have bottled water, because we have snacks, we have hand warmers, things like that, and so a lot of these discussions happen because that is their presenting need and we're trying to capture more of the formal data to truly understand the needs of our various communities, our seven sites.

Speaker 4:

And I would say that's one of the things that we've really kind of evolved with our work on the mobile van is, you know, we had one vision coming in of this is how we would care for these patients and this is what we should do. And then we learned, oh, actually, you know, we really need to pivot. We're excited to talk to you about your preventative health and your chronic disease, but that may not be first thing on the list, and so when we're really thinking about the mobile van and what we have access to and the work that Dr Golden is doing is, let's really shift that priority list around, because it may look different in this setting than it does in maybe one of our brick and mortar practices, and that, you know, is something that we're is constantly evolving, based on season, based on location that we're in, and so something that you know we take in our operations team takes, you know, takes a lot of our time and what we're what we're really thinking about.

Speaker 3:

What do you want someone to understand about the population that you're working with?

Speaker 1:

These are people. People experience homelessness and it's complicated and it's messy, but at the end point, even if we can't solve a very complex issue in the immediate moment, we can always be kind and we can always have a sense of empathy. The studies show that there is a large portion of this country that is at threatened homelessness and threatened housing insecurity. I've met people with doctoral degrees. I've met clergy members, I've met high-functioning people that have all fallen into homelessness through various paths, and so having that kindness and empathy is very fundamental in how to interact with a lot of these patients. These patients are already here. This is our issue. This is a health care issue and we can't shirk our duty here.

Speaker 4:

And I would just add I think that our care delivery pathways we have to be creative, we have to be thinking outside the box and thinking about how we can deliver care differently for patients. That includes how we train our caregivers and the experiences that our caregivers have and who you know may be traditionally expert. Quote unquote of a team, of a medical team like that, and we maybe we flip that on its head. You know, and everybody's kind of ideas and thoughts are really important.

Speaker 2:

You're impacting a lot of lives in this area and doing really good work in the process. I would have to assume you've got some amazing stories of differences you've made in patients' lives. Is there one that you could share with us?

Speaker 1:

There are so many that I can come to mind one being a family at the Hope Center, and the story kind of speaks to the humble nature of many of our patients. I was leaving the Hope Center after a clinical session. I had a gentleman stop me and ask me hey, can you refill my meds? I said, sure, give me a list, we'll get you up and to be seen. And from that very minor interaction spiraled up to understand his complex medical history, his six months in a hospital in Philadelphia, his 30 day prognosis and the absolute fear he had about his impending mortality and about how that affected his middle school daughter. And how that affected, you know, his partner, who had been living under the radar for years. His daughter was a middle schooler and she had been in the school for four years.

Speaker 1:

And you know, when we finally unraveled this, when we build enough trust with these patients, where they open up and share these, these um dehumanizing stories that they've been through, we're able to, you know, uh, partner with them. We're able to walk many of these journeys together. Um and the family made incredible strides. The, the gentleman's health really stabilized, um stabilized to the point where he exceeded this 30-day window. He was given and had very conflicting emotions about it that were ultimately very positive. But the family left the Hope Center into stable housing and continues to be housed to this day, over a year later, which speaks to the idea that what they needed was just a little bit of partnership, and it was a real pleasure to walk that journey with them.

Speaker 3:

You talk about partnership. This sounds a little bit like it needs to be a two-way street for not only you to be able to reach out and get them to also reach out to you as well. How do you do that?

Speaker 1:

One of the strategies that's been shown most successful in working with a disenfranchised group is the idea of goal-negotiated care, meaning a patient sets a goal for themselves which becomes the overall goal for the healthcare team in all of its domains the medical providers, the social worker, the nurse case managers, et cetera. The healthcare team in all of its domains the medical providers, the social worker, the nurse case managers, et cetera. Whatever that goal is, it's patient defined, meaning they have their buy-in to it. Many times, our role is to offer anything that we can do to help eliminate barriers in this regard and then set expectations for the patient to help themselves as well. Obviously, every goal, every step can be renegotiated. Pitfalls befall other pitfalls, but that is that's part of the journey that we have with each individual patient.

Speaker 4:

I would say like consistency also, like of us, of the medical team, of the multidisciplinary team. You know, to Ben's point, you know things happen and life happens to everybody. But knowing that we're going to be there at the time that we said we're going to be, and that you know, if it takes 10 tries to get this figured out or to come see us or for us to have a complete medical visit, that in our you know, in our medical opinion, like that's okay and I think that that helps people feel you know, there's not, there's no real downside to this. It's really like how you want to engage and how you want your care, and when you're ready, we're ready, and it kind of, you know, it kind of takes that pressure off, I think.

Speaker 2:

Where do you see this going? Where do you hope this program and the work that you're doing? Where do you hope that's going to be in the 5-10 years?

Speaker 4:

Yeah, I'm hopeful for continued like community partnerships so that we can really make sure that we're, you know, capturing the voice of the community and the needs of the community to be able to provide services in the way that patients are hopeful to have them. I think Friendship House is a great example. Also, there's a mobile van consortium through Delaware that's actually run through the University of Delaware and the Delaware Food Bank, and so this is an opportunity for various mobile vans in the state to come together to understand resource availability, to understand strategy and what's worked and, you know, to learn more. So I think, for all those reasons, our community partnerships are tremendously important and, again, because typically these organizations may know how to serve patients best, you know in things, again, that we're not expert in, but that we know our patients need. So I think that you know there's more, only more to learn and more partnerships to really come from that.

Speaker 1:

The dreamer in me knows that there is a. This is a field where, hopefully, none of us ever will have to work eventually. But, being more pragmatic, the growth here is of scale. It's of scale in both services, delivered locations, delivered patients that are able to be inputted into the system, and then ultimately building a larger network that includes stable housing, stable permanent housing, which requires a lot of state and federal buy-in, like you referenced. Ideally, we would have more people reaching out to the communities in need, entering communities in need, being invited to connect with patients. Patient engagement is always one of the hardest issues for this population, because the unhoused, rough sleeping population has learned to be invisible as a survival mechanism, and so being able to find these communities where they exist, show good intentions, show consistent good intentions, is really crucial to overall delivering care.

Speaker 4:

When you ask about growth of these programs and development of these programs, I think about our medical students and learners, really important. You know that we incorporate them in the work that we do and we continue to do so. You know we need, you know, clinicians and care team members to help grow this work as well. So that's one of our goals and missions is to continue to have experiences, clinical experiences for learners.

Speaker 3:

Ben and Ashley. Thank you both so much for your time today. This certainly is not the last time we will be discussing homelessness on this program. Thank you, my pleasure. We'll have more information on the programs we mentioned today, such as the Mobile Health Services, van and the New Castle County Hope Center, in the show notes for this episode.

Speaker 2:

And don't forget to subscribe to For the Love of Health on Apple Podcasts or Spotify. And you can watch the video version of For the Love of Health on Christiana Care's YouTube channel.

Speaker 3:

We'll be back in two weeks with another great conversation.

Speaker 2:

Until then, thanks again for joining us.

Speaker 3:

For the Love of health.

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