From the HIV epidemic to the rise of multi-drug resistant TB and the opioid crisis, those caring for people experiencing houselessness and housing insecurity saw the rise of each of these epidemics in their patient populations long before the rest of us.  The devastating impact of the COVID-19 pandemic was particularly harsh for those in shelters or unhoused. Some say that caring for those experiencing houselessness reveals the fractures in our healthcare system earlier and more clearly than healthcare in other settings.  Join us for the first of 2 episodes with 2 experts on caring for this population, Dr. James O’Connell, MD, MACP (Boston Healthcare for the Homeless) and Dr. Rachel Solotaroff, MD, FACP (Central City Concern- Portland, Oregon). In our discussion of the obstacles faced by these patients and the opportunities to learn from them, Drs. O’Connell and Solotaroff describe the root causes of houselessness, the best terms to use when addressing people experiencing houselessness, and some of the challenges in delivering healthcare to these patients.

Click here to obtain CME/MOC credit for listening to the episode!

Show Notes
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Learning Objectives
  1. Define houselessness/homelessness and housing insecurity.
  2. Explore and define root causes of the crisis of houselessness in the U.S.
  3. Understand the challenges to access and provision of healthcare to houseless folks.

[00:00] Welcome and Introductions[0:00-1:58] Welcome and Introductions
  • Introduction of our co-hosts, guests, and episode topic
 
[1:58-6:13] Introduction to Guests: Dr. Jim O’Connell and Dr. Rachel Solotaroff
  • Dr. Jim O’Connell
    • President of Boston Health Care for the Homeless Program
    • Assistant Professor of Medicine at Harvard Medical School
    • Established the nation's first medical respite program
    • Serves on the Governor’s Council of the ACP Massachusetts chapter
    • Received MACP honorary achievement
    • Author of Stories From the Shadows: Reflections of a Street Doctor
  • Dr. Rachel Solotaroff
    • Served as Central City Concern’s President and CEO
    • Served as Medical Director of the Charlottesville Free Clinic in Charlottesville, VA and the Old Town Clinic in Portland, OR
    • Designed and implemented a social medicine curriculum for OHSU internal medicine residents
 
[6:13-12:02] “Be the Change” Segment
  • Dr. Jim O’Connell
    • Started working with patients experiencing houselessness unexpectedly 
    • His Chief of Medicine and the Vice President of Massachusetts General Hospital recruited him to work on integrating the care of homeless people into the mainstream of Boston's healthcare system
    • Has been involved in this work ever since then
  • Dr. Rachel Solotaroff
    • Dreamt of becoming a rural family practice doctor in Maine
    • After moving to Portland, a mentor introduced her to an academic partnership that involved OHSU and Central City Concern
    • This resulted in her creating a social medicine curriculum at OHSU
    • Felt a sense of community working at Central City Concern, similar to the sense of community she sought to find as her goal of becoming a small town family practice doctor
 
[12:02-18:35] Different Terminology for Houseless Patients
  • Dr. Jim O’Connell
    • Back in the 1980s, it was acceptable at the time to use the term “the homeless”
    • For instance, organizations that were created to advocate for the homeless used the term in their name (ex.: National Coalition for the Homeless) 
    • Over time, the stigmatization of homelessness and racial issues in classism resulted in an issue of addressing people without disparaging them and their experiences 
    • Some homeless people find the term “homeless” acceptable 
      • For instance, the Consumer Board of the Boston Health Care for the Homeless Program, which consists of homeless people, believe removing the noun “homeless” from the program’s name will make it difficult for people to know what the program is 
    • Currently, it’s appropriate to use the phrase “persons experiencing homelessness”, or PEH 
    • Many homeless folks disagree with the term “PEH” because they feel as though it glorifies the experience of homelessness
    • Ultimately, there’s no right term that’s acceptable to everyone
    • However, what matters lies in using words that show we appreciate the dignity and courage of the people we serve 
  • Dr. Rachel Solotaroff
    • Concrete definitions regarding homelessness (from the U.S. Department of Housing and Urban Development) 
      • Chronic homelessness - when a person lives in a place not meant for human habitation, a safe haven, or emergency shelter for at least 12 months consecutively or on four separate occasions in the past three years, as long as those three combined occasions equal at least 12 months
      • Rent-burdened - more than 30% of an individual's income goes toward their rent
      • Extremely rent-burdened - more than 50% of an individual's or a household's income goes toward rent
 
[18:35-25:29] Root Causes of Houselessness
  •  Dr. Rachel Solotaroff
    •  Root causes of houselessness can fall into 2 categories
      • Structural factors
        • Absence of affordable housing, absence of meaningful wage employment, structural racism and discrimination, interaction with the criminal justice system
        • These factors are the root causes of vastly disproportionate numbers of BIPOC communities who are houseless
      • Individual experiences
        • Mental illness, substance use disorder, being in the foster care system as a child, trauma (particularly traumatic brain injury)
    • The drivers of houselessness are complex and root causes from different categories can influence each other
    • As structural root causes become more pronounced, it takes fewer individual root causes to drive someone into houselessness
  • Dr. Jim O’Connell
    • Houselessness is a complex societal problem 
    • Think of homelessness as a prism that we hold up to society and what gets refracted are the weaknesses in each of the main sectors of our society
    • Providing good health care to people who are homeless isn’t sufficient to solve the problem of homelessness. It’s important to address all the complex factors at play and continue to support them once they're in housing
 
[25:29-32:56] Providing Houseless People Help with the Social Determinants of Health
  •  Dr. Rachel Solotaroff 
    • Central City Concern aims to help people experiencing homelessess to build health, housing, economic resiliency, and social connectedness
    • Central City Concern employs a housing choice model that recognizes that there’s no right type of housing for everyone
    • Central City Concern also practices a supported employment model and clubhouse model, and is trained in helping people get onto social security and its benefits
    • Self-actualization in Maslow’s hierarchy of needs
      • “How am I giving back to the community?”
      • Can take many different forms 
      • “Flip the Script” program at Central City Concern
        • Black and African-American men and women exiting incarceration are assisted with employment and housing
      • Self-actualization is a beautiful part of the journey to ending homelessness
  • Dr. Jim O’Connell
    • There’s a fundamental struggle with helping patients with needs whose solution are outside of our domain
    • There’s an issue with continuity of care and providing specialty care to houseless populations
    • Taking care of homeless people will teach us the weaknesses in our healthcare system
 
[32:56-33:37] Closing

[33:37-34:19] Outro
 
Guests: James O'Connell MD MACP Boston Healthcare for the Homeless; Rachael Solotaroff MD, FACP Central City Concern PDX​
Co-Hosts: Dr. Marianne Parshley, Dr. Elisa Choi
Executive Producer: Dr. Tammy Lin 
Co-Executive Producers: Dr. Pooja Jaeel, Dr. Tiffany Leung
Senior Producers: Dr. Maggie Kozman, Dr. DJ Gaines
Editor/Assistant Producer: Clara Baek 
Production Assistants: Nilgoun Farhadi, Leyna Nguyen 


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Disclaimer: The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with. 

The DEI Shift podcast is proudly sponsored by the American College of Physicians Southern California Region III Chapter.  

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Contact us: [email protected], @thedeishift, thedeishift.com 

Disclaimer

.The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with.