Reflections on a Local Global Health Elective

June 15, 2021

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00:00Thanks so much to everybody
00:02who's tuned in today.
00:03My name is Tracy Raven.
00:05I'm the director of the Office
00:06of Global Health and the
00:08Department of Internal Medicine.
00:10An as part of our Global
00:12Health week activities.
00:13An really excited today to be
00:14able to introduce two of our
00:16fantastic third year residents
00:18in the traditional program who
00:20are members of the global health
00:22and equity distinction pathway.
00:23Aiden Milner and Becky Osborne,
00:25both Becky and Aiden,
00:26had the opportunity this year
00:28to two pilot along with two
00:30other residents in the program.
00:32Highlighting a local global
00:33health elective experience,
00:34and I'm thrilled that they were
00:35willing to share this with with
00:37everybody here this afternoon,
00:39so I'm going to go ahead and turn
00:41the screen over to Becky and Aiden.
00:44Thanks so much, guys.
00:47Thanks Doctor Raven so I'm Becky
00:49for anyone that doesn't know me.
00:52So Aidan and I had this really cool
00:55opportunity over the last few months.
00:57Aidan did his local health
00:58elective in the fall,
01:00and I did mine in the winter,
01:02but this was during the time that
01:04we were both supposed to be on our
01:07international health electives,
01:08which were obviously cancelled because of,
01:10you, know, the global pandemic,
01:12but ended up being like one of the
01:14probably probably one of my favorite
01:16moments of residency was doing
01:17this local global health elective,
01:19and so we're super excited to talk about it.
01:22With everybody here just kind of
01:25run through some objectives of
01:27what we'll be talking about today.
01:29So we wanted to share some
01:31highlights of our elective.
01:33Also wanted to discuss how persons
01:36experiencing homelessness interact
01:37with the health care system
01:39identify some unique barriers,
01:41understand how principles of harm
01:43reduction are carried out in our New
01:46Haven community and then also to apply the
01:49principles of global health to local health.
01:52Talk about community,
01:53engagement, health disparities,
01:54interprofessional approach and
01:56social justice.
01:58So I first just wanted to touch kind of
02:01briefly on this concept of global health,
02:04being somewhat synonymous with local health.
02:09And by that I mean that you know you think
02:11about the core tenets of global health,
02:14some of which are public health,
02:15local community engagement,
02:17and these are really.
02:18Knowledge bases in skill sets that are
02:21transferable to our own community.
02:22I used to kind of think of global health
02:25being like public health somewhere else,
02:28but it's not.
02:29I mean,
02:29we have vulnerable populations everywhere.
02:31There are similar disparities
02:33in our own community here.
02:35I'm.
02:37And you know a lot of the public health
02:39challenges that are faced around the
02:41world are also faced here in in New Haven.
02:44And I want to put up this photo of the New
02:47Haven Green just to kind of highlight.
02:50A story so that when I when
02:52I first moved here,
02:54I moved from the Midwest and really
02:56didn't know too much about New Haven.
02:58An every morning I would bike down
03:00College Street and on my right would
03:02be this like beautiful Castle which was
03:04the Yale freshman dormitories and on
03:06my left would be the New Haven Green Man.
03:08I remember just biking down early in
03:11the morning to work and seeing like.
03:13Just this weird juxtaposition of
03:15this castle on my right and then
03:17people sleeping on the green.
03:18A lot of homeless people you know,
03:20staying living on the green.
03:23I think that there's just,
03:24you know,
03:25there's such a stark divide between
03:27the Yale community in the town and
03:29this elective really helped too.
03:30I'm sort of just exposed both 8
03:33and a 9/2 a lot more in New Haven.
03:37So our experience,
03:38our AG experience in New Haven was
03:40really diverse in both Aiden and I
03:42had a little bit separate or we had a
03:45slightly different experiences based
03:46on what we were interested in.
03:48I particularly wanted to do a little
03:50bit more with addiction aid and did a
03:53little bit more with the Street Medicine
03:55group and with incarcerated health.
03:57So we did St Medicine with Cornell,
03:59Scott Hill health.
04:00We did a methadone clinic at the
04:02New Haven Correctional Center and
04:04we'll talk about each of these.
04:06A little bit more in depth,
04:08but I did the addiction recovery
04:10clinic on the Nathan Smith even
04:12did the transitions clinic and
04:14then syringe services.
04:15The mobile health van as well as
04:18some online learning opportunities.
04:22Eating dinner? Yeah, I'll
04:23take it away. Can you guys hear me?
04:28Yeah, right OK so thanks Becky.
04:32Yeah, so for those of you that don't know me,
04:35I made in one of the third years
04:37in the traditional program.
04:39Is Becky mentioned I had a particular
04:41interest in understanding a little bit
04:43more about incarceration medicine,
04:45both pre and then while incarcerated and
04:47then also in the post incarceration period.
04:49As folks we enter the community.
04:52So it's kind of difficult to talk
04:53about medicine in the incarcerated
04:55setting without talking about substance
04:57use and specifically opioid use.
04:59We both had the opportunity to go to
05:01the New Haven Correctional Center.
05:04And work with Doctor Altys in
05:06his work with methadone,
05:08prescribing in the jail.
05:09So little bit of background about
05:12incarceration is relation to opioid.
05:14Use is really that the two are sort of
05:17intertwined and a lot of different ways,
05:20but up to 20% of incarcerated people
05:23meet the criteria for opioid use
05:25disorder and in the absence of any
05:28sort of treatment while incarcerated
05:30the risk for relapse.
05:32Appan community entry is just.
05:34Astounding.
05:34It's 85 to 90% within a year.
05:36And really the majority of that
05:38is within the first two weeks.
05:40And along with that opioid overdose
05:42is the leading direct cause of death
05:44in the two weeks that immediately
05:46follow re-entry into the community.
05:48So in despite you know,
05:49the strong evidence that I think
05:50a lot of us have learned.
05:52Either in our educational half days
05:54or in other parts of the hospital.
05:56Strong evidence for use of opioid
05:59agonist therapy less than 5%
06:00of people who are referred for
06:02opiate use disorder treatment in
06:04the criminal justice system.
06:05Receive it and then 1% of individuals
06:08in jails needing methadone receive it.
06:11So methadone programs have
06:13expanded very slowly,
06:14and they continue to very low coverage.
06:16Only about 30 to 50% of the prisons offer it,
06:19and then about 2.2 million people
06:21within the United States have the
06:24opioid use disorder and more than 50%,
06:26you know,
06:2650 to 70% will cycle through the criminal
06:29justice system at some point in.
06:31This provides a really remarkable
06:34opportunity to screen patients
06:35and then also treat patients.
06:38So so as I mentioned,
06:39we both got the opportunity
06:41to work with Doctor Altys,
06:43who does really pretty remarkable
06:45work in the New Haven Correctional
06:47Center and some of his goals is
06:49that this is a high turnover jail.
06:52So just for clarity,
06:53jail in prison or two different things.
06:56So jail really involves people who
06:58are not yet sentence or pre trial.
07:00So specifically this is a jail,
07:02so it involves a really high turnover.
07:05People can be there weeks to months
07:07rather than serving longer sentences.
07:09When patients come in off the street,
07:12or if they've been arrested, they don't.
07:14They haven't been.
07:15Some people haven't been started
07:17on treatment.
07:17Others have been obtaining opioids
07:19or methadone from the street,
07:21and they will either go into
07:23detox or they can
07:24go into treatment.
07:25So the goal of this program that
07:27they have there is to really rapidly
07:30identify people as they enter Jalen
07:32before they have time to withdraw.
07:34Be started on methadone.
07:35This has been sort of a long process
07:38that Doctor LT's been fighting for and.
07:41They've been scaling it up over the last.
07:43You know, over the last couple of years,
07:46and initially we're only allowed
07:48to see up to 30 patients,
07:50and now they're seeing over 90.
07:52They continually continue to expand,
07:53continue to identify patients,
07:55and continue to get treatment.
07:59So some of the reflections.
08:01So this is, you know,
08:02as I mentioned in the first slide,
08:05there's a really significant prevalence
08:06of opioid use disorder with throughout
08:08the criminal justice system,
08:10and we really had a really
08:12unique experience of starting
08:13patients on methadone in jail.
08:15A lot of inmates,
08:16most inmates have not had any regular
08:18health care prior to interacting
08:20with Doctor LT's in the group there,
08:22and they have not really ever discussed
08:25their addiction with the physician.
08:27So you know,
08:28unfortunately this to tie it
08:30into what a lot of US deal
08:32with in the outpatient setting.
08:34I kind of heard multiple multiple
08:35stories during my time there of patients
08:38who unfortunately source started on
08:39opioids in the outpatient setting,
08:41either after a surgery or some kind of
08:43pain an they were abruptly stopped.
08:46At some point.
08:47You know someone's been on
08:48opioids for too long.
08:50There's haven't been plugged in with
08:51pain clinic or just for whatever reason
08:54that opioids are stopped abruptly.
08:55So patients in order to avoid
08:57withdrawal or when they start
08:59experiencing symptoms of withdrawal.
09:01They'll go to obtain either illicit
09:03opioids or start using heroin
09:04prior to any sort of treatment.
09:06So again, this a lot of people will come in,
09:09and they'll have used opioids
09:11in the outpatient setting,
09:12and then they won't have been plugged
09:15in with a provider an you know won't
09:17be on a stable dose of methadone,
09:20or they'll be using other illicit
09:22opioids or heroin and will
09:24go through withdrawal period.
09:25So in one of the really important
09:27things that I think to take away from
09:29all of this is that it's really,
09:31you know,
09:31opioid use disorder and treating it.
09:33Especially in you know when it comes
09:35into jails and in the hospital as well.
09:37There's a lot of stigma around it,
09:39but it's really just like any
09:40other medical condition.
09:41You know,
09:41Doctor LTS really liking it a
09:43lot to diabetes,
09:44and you wouldn't let a diabetic enter jail
09:46and not get the right dose of insulin.
09:48You know that would be.
09:49That would be a terrible thing to do,
09:51so they need to really get on methadone
09:53quickly and be at a good stable dose.
09:55And it's really critical.
09:57Especially as it going through their
09:59time in jail to maintain therapy and
10:02after they re-enter the community.
10:04As I mentioned,
10:05a lot of people will will relapse
10:07within the first year.
10:09You know up to 80% plus patients
10:11will relapse within the first year
10:13a lot within the first two weeks,
10:15so being on a really stable dose an
10:18appropriate dose is really important
10:20to maintain therapy after community reentry.
10:22And we know there's been a lot
10:24of published on this topic,
10:26but specifically in doctoral
10:27thesis project practice.
10:28What he tries to work,
10:30too is after patients are able to
10:32get to a a dose of 80 milligrams
10:36or higher that really.
10:37Helps their likelihood of maintaining
10:39treatment after they leave the
10:41hospital after they leave
10:42the justice system up to,
10:44you know, within the first year,
10:46especially to I think it's
10:48you know a good significant
10:50portion of patients continuing
10:51treatment after they leave jail.
10:53If they're on 80 milligrams or higher.
10:58And sort of overlapping the two.
11:00So both while incarcerated and then
11:02the post incarceration period after
11:03re-entry is kind of ties into some of
11:05the experiences that I specifically
11:06had in the Nathan Smith clinic.
11:08I know Betty and Becky and I were both there,
11:11but I work with Doctor Mayer who's also done
11:14a lot of work in the criminal legal system,
11:16and she's seen a lot of patience.
11:20In her prior work with patients who were
11:23incarcerated and she now works at the Nathan
11:26Smith clinic where a lot of her panel have.
11:29Both opioid use disorder as well as
11:32have a history of incarceration as well
11:34as our patients living with HIV AIDS,
11:37and you know, it's a really remarkable
11:39clinic model that they have there
11:41where infectious disease physicians
11:43work as their primary care physicians,
11:45but they really have a really integrated
11:48system that involves psychiatry.
11:49Behavioral health.
11:50Because of the significant prevalence of
11:52PTSD and depression in this population.
11:55And they'll do treatment for
11:57substance use disorders,
11:58including Suboxone initiation,
12:00as well as counseling right there on site.
12:05OK, and then shifting gears a little bit,
12:08I'm going to start talking about our
12:10experience with the street medicine folks.
12:12We both spend a lot of time with this
12:15team and just kind of a little bit of
12:17background on what street medicine means.
12:20So these are programs that have been
12:22heavily expanded over the last several
12:24years and many large cities in America.
12:26But essentially St Medicine programs
12:28are set up to provide medical care
12:30for unsheltered people in those with
12:32poor access to health care and the
12:34whole idea of St Medicine is really
12:36meeting people where they are.
12:38It's going, you know?
12:39These are.
12:40Extremely vulnerable people and you know,
12:42they often don't aren't able to
12:44get into a primary care doctor.
12:46They often utilized the emergency
12:48room as their primary care,
12:50and it's really just going out to where
12:52these folks are meeting them and building
12:55these relationships and overtime.
12:56It really emphasizes this serious
12:58investment in the Community because,
13:00you know, often takes years.
13:03A lot of time to build up these
13:05relationships to have a trusting
13:07relationship with these patients.
13:10So in terms of kind of where where we
13:12went with the street medicine crew,
13:14we were all over the place.
13:17We're so just kind of talk
13:19through some of these, you know,
13:21places that we we had visited.
13:22We did some outreach on the
13:24green where we would go with the
13:27Cornell Scott Hill Health team,
13:28which I guess I'll briefly just
13:30can't tell you who the team is.
13:33It's that the street medicine
13:34team is composed of there.
13:36There's two different APR ends,
13:38an infill that lead the team.
13:40And then there's also a group
13:41of social workers and nurses,
13:43and any given time.
13:44There's usually 1A PRN,
13:46one nurse and one social
13:48worker who are going out.
13:50To host these kind of just St clinics,
13:52essentially where most people in
13:54the community know them and they
13:56also wear jackets that say Cornell,
13:58Scott Hill Health,
13:59St Outreach team and and
14:00people recognize them,
14:01know them and know where they
14:03said they have set times like
14:05you know will be on the green at
14:08Thursday at 4:00 PM and so people.
14:10It's almost a clinic where people no
14:12one to show up and have expectations
14:15of when they can get medical care.
14:17So we went to the green.
14:19We also went to encampments
14:21in East Rock Park so.
14:22And I've I've hiked up used rocks so many
14:25times and never knew that these existed.
14:27I just I never looked but kind
14:29of behind the like soccer fields
14:31or baseball fields by the river.
14:33If you if you walk down there,
14:35there's many encampments that
14:37are set up where there was one
14:39or two people living there.
14:40When we actually visited in the winter.
14:43But in the summer is a lot
14:45more people do stay there.
14:47There's also an area in Fairhaven
14:49where there's a McDonald's.
14:51They actually before COVID.
14:52They were actually like doing
14:54clinic in the McDonald's sometimes,
14:56but they set up in the parking
14:59lot and specifically they set up
15:01on like Friday mornings at 6:00
15:03AM or something very early.
15:06A lot of times they see sex workers
15:09in this parking lot and people
15:11know exactly where to meet them.
15:14We also went to some of the hotels,
15:17so during COVID they shut down the
15:19previous shelters and opened up hotels.
15:22There were at least two hotels
15:24that were sort of down by like
15:26Long Wharf that had opened up,
15:28which I'll talk about a bit later.
15:31We also went to soup kitchens,
15:33several in downtown New Haven.
15:36A motel in Westville was one location
15:38I went to we we essentially just
15:40heard from word of mouth that
15:42there was a sex worker that had
15:44been beat up by some guy and she
15:46and her boyfriend were in pretty
15:48bad shape and they were staying in
15:50this motel and so we actually we.
15:52We found the name of the motel
15:54and went out and met them and
15:56did this like very comprehensive,
15:58urgent visit.
15:59Primary care visit in their motel room which
16:02was a really cool experience.
16:03Warming shelters I had opened up during
16:05the winter and then midnight runs all
16:07at 8 and talk about a little bit.
16:10Yeah, so midnight runs.
16:12Is this really interesting?
16:13That's done pretty much every
16:15other Friday evening between like
16:177:30 or 10:30 eleven o'clock.
16:18Really, whenever they're done,
16:19which takes place really
16:21at all these locations.
16:22But at night.
16:23So a lot of times it's as big as
16:25Becky mentioned that the team
16:27knows where to find their their
16:29clients and their patients,
16:31but sometimes it's not easy to
16:33find people during the daytime.
16:35Sometimes it's easier to find them
16:37at night or also to address specific
16:39things that come up at night so.
16:42I had the opportunity to
16:44go on one Midnight Run,
16:45which was effectively a walk
16:47around several of the more highly
16:49trafficked blocks of Fairhaven,
16:51just to see if anyone needed it.
16:54Had any medical concerns,
16:55you know,
16:56handing out clean needles and syringes.
17:00Really just seeing if anyone needed anything.
17:02It actually seemed to be a pretty calm night,
17:04but a lot of times it seems like
17:06there's a lot of things that people need
17:08and there's a lot of people out at that time,
17:11even honestly more so than there was during
17:13the day when those are pretty cold evening,
17:15and we we also went back to try and
17:17find a couple of a couple of people who
17:19we were unable to find during the day,
17:22went to their homes to see
17:23if they were there, but.
17:26The remarkable experience to
17:27be able to go around at night.
17:29It's kind of puts a different spin on things,
17:31but we really go around to a lot
17:32of the same locations with a big
17:34focus on Fairhaven to see if there's
17:36anything that we can help with.
17:39I'm just going to answer
17:40just saw the chat question.
17:42Sorry Andrew, I saw your question
17:43about why there's under address,
17:45mental opioid use disorder in
17:46the criminal justice system.
17:47From what I read,
17:48some of this was like a review from 2008.
17:51They had served a lot of the directores of
17:53prisons and the number one issue was cost.
17:55I think that a lot of people is
17:57just it's expensive to put in place.
17:59A methadone clinic and also they
18:01have to get some sort of specific.
18:04Like I don't know that there is some sort
18:06of legal loopholes or clinic certification.
18:09I'm not the right person to ask about this,
18:12but in order to actually
18:13establish the methadone clinic,
18:14it's not the same thing.
18:16It's just like setting up a, you know,
18:18a diabetes or endocrine clinic in a prison.
18:20It's a lot more tricky, and so I think
18:23because it's very difficult people just.
18:25Don't do it as much.
18:27I don't know.
18:27Even if you had any other insight
18:29that was kind of my understanding
18:31from the same thing.
18:32I do notice that Doctor Altise is here.
18:34I'm not sure if used.
18:36Able to speak further to that,
18:38or if you're.
18:41Yeah, no I
18:42would. I would be happy to you all.
18:45Have done a really wonderful presentation
18:47and just want to say that it's sort
18:51of a multi level complex issue.
18:53There are issues with one,
18:54whether the institutions even
18:56believe it's part of their mandate,
18:58so it's not just cost.
19:00Methadone is probably like $0.06
19:02a day in terms of a medication,
19:05but there are some impediments
19:07that can be overcome.
19:08There's has because of the great need
19:11in the overdose potential after release.
19:13As places are starting to develop
19:16these programs there coming
19:17up with different models,
19:18there's the what I call the intrinsic
19:21model where they actually homegrow the
19:23methadone program within the prison
19:25that requires all those licensing and
19:27other sorts of regulatory things.
19:29Becky that you're talking about,
19:31so the paperwork and all of
19:33those other sorts of things.
19:34There's the,
19:35there's the model where people
19:37bring in the methadone,
19:38which is the model that is currently
19:41in the Connecticut system,
19:42so they've got.
19:43External providers who actually
19:45bring in the medication,
19:46then there's the logistics of actually
19:49carrying a controlled substances
19:50through the doors and stuff like that,
19:52and then that model is evolving
19:54to where the external person is
19:56actually building within prison
19:57methadone clinics so that those
19:59are licensed independent clinics
20:00which just happened last week.
20:02So you all didn't get to see that,
20:05and so there are those sorts of
20:07what I call system level barriers.
20:09There are barriers with regard
20:10to staff staff think that you're
20:12treating one addiction trading
20:14one addiction for another.
20:16So they have impeded it.
20:17Make make some cases made it absolutely
20:19impossible to run the programs,
20:21kept people from being able
20:22to move within the prison,
20:23setting the feeling of that you know
20:25people are undeserving an the idea
20:27that you punish people appropriately
20:28by making them go through withdrawals.
20:30So there are multiple levels.
20:32And then there's the patients
20:33themselves who are fearful of coming
20:35into the program and trying to figure
20:37out what's going to happen to me if
20:39I don't get a linkage sort of program,
20:41or if I have to move from prison to prison.
20:44So there are multiple multi
20:46level factors that go into,
20:47but you're presenting a really.
20:49A wonderful overview of what's happening,
20:51but there's a lot going on there.
20:55Thank you. Give
20:56it super helpful. Somebody else had
20:58asked what is in place for these
21:01patients to receive medications.
21:03It's a big issue.
21:05You know that the team does carry some,
21:08just like over the counter meds with them.
21:11They also are able to carry like Narcan,
21:14ceftriaxone. What else toradol
21:19shots did they have very limited?
21:23You know amount of medications with them,
21:25but it's so they also do carry
21:27a laptop with access to epic,
21:29and they often just, you know,
21:31call in medications to a pharmacy
21:33that's across the street.
21:34Or you know the nearest pharmacy.
21:36But it's a big issue of getting
21:39these patients medications.
21:40You
21:40might you might see on some of
21:42your patients that you admit there
21:44may be notes from the medical
21:47outreach team by either Phil or an,
21:49and those are those are notes
21:51from the Street Medicine team.
21:52But yeah, it's a tough situation.
21:56I guess I can talk about Tent City.
22:00So we were able to go to this
22:03really remarkable place in New
22:05Haven that we did not know existed
22:07before this before this elective,
22:09which is called Tent City,
22:11which is actually a really remarkable
22:14little community of homeless,
22:15homeless people who function in
22:17this community of resource sharing,
22:19security and support.
22:20So they have this really remarkable.
22:24Community where they have a set
22:26number of Members you know they built
22:28members in and out and they really
22:31work together to share resources.
22:33And they have this pretty cool like
22:36solar panel setup that they are able to
22:38work into making into a phone charger.
22:41You know they have a whole like kitchen area.
22:44They have this whole space of tents.
22:48And so it's just a really.
22:50It's kind of famous within
22:51within that sphere,
22:52so it was really interesting
22:54for us to be able to see.
22:56And there was when I went there,
22:58there was only a couple of people there, but.
23:02All work together,
23:02both for everyone's health as well.
23:04You know they share him warmers
23:05and things like that,
23:06so it's a very cool thing to see.
23:12And then just kind of talking through,
23:14you know, some are our reflections
23:16and thoughts about doing this.
23:18You know St medicine elective.
23:21It really just underscored how massive
23:22the need is for mental health services.
23:25There is now a street psychiatry
23:26team with the Yale psychiatrist who
23:28is wonderful and does a lot of good,
23:31but there's. You know, so,
23:34so many of these patients have significant
23:36mental health problems and it's it's just,
23:39you know, a very underserved community.
23:41We also talked a lot about how New Haven
23:44really underestimated the homeless
23:46population, especially when it came to COVID.
23:51They essentially were asked or
23:53had to decide how many homeless.
23:57Folks, were, you know,
23:58going to be needing shelter during
24:00the winter in order to know how many
24:02hotel rooms took to book and they had
24:05estimated about 100 hotel rooms that
24:07would be needed when there's like
24:09certainly more than 400 people who are
24:11living on the streets or or have been
24:13homeless in the last year in New Haven.
24:15And so we ran into this a lot where
24:18there are keeping people who were
24:20unable to get into the hotels.
24:22People have been kicked out of
24:25the hotels for having, you know.
24:28Have I don't know.
24:30They have extremely strict drug
24:31policy is and also like.
24:33If anybody had gotten into any
24:35sort of arguments with a roommate
24:36and there were a lot of politics
24:38within the hotels themselves and
24:40also just really underscored how
24:42important interprofessional teams
24:43are in terms of just relying on the
24:45social workers and the nurses for
24:47the outreach and coordination for
24:49getting people to their appointments.
24:51I mean, they, they were just phenomenal,
24:53and they know the community so well
24:55and it was just a delay working,
24:58working with them very closely.
25:00I'm and then you know things.
25:02I just don't think about and terms of what
25:05what people need and what people you know,
25:08appreciate or socks underwear
25:09ensures in hand warmers.
25:10Somebody had told me when I was on
25:13the selected that they always keep
25:15insurers and hand warmers in their
25:17car in their glove box at all times.
25:20So when they see somebody on
25:22the street you know who's.
25:24Posted up on the corner they always
25:26have something to give them,
25:27which I thought was a really great idea
25:29and I started keeping hand warmers and
25:31I think it's you know it's very simple.
25:33Easy thing you can do that
25:35is very much appreciated.
25:39These are just a few photos that
25:41I found on line of the street
25:43medicine team and sort of what
25:44their clinics end up looking like.
25:46This was at a soup kitchen that was
25:49downtown where they set up a set of a tent,
25:52but usually the team is just is
25:54just out on the street and this
25:56is Phil who's the who's the APR
25:58and it does a lot of the work.
26:03Alright, so also the opportunity to work with
26:06Doctor Puglisi in our transitions clinic,
26:09which is a network of clinics,
26:11but they have they have one here and now.
26:14The same building as the
26:16NH PCC and it's really.
26:18It's an enhanced primary care for
26:20people released from incarceration.
26:22And again it's part of this
26:24national network and really,
26:25the model here is,
26:27it's a multidisciplinary approach with
26:29integrated legal services as well as
26:31a dedicated community health worker.
26:33Which there are there were two
26:36that we primarily worked with.
26:38In this I had a lot of opportunities because
26:40they're their reach is much more so than
26:43just within the clinic building itself.
26:45It's really in terms of getting
26:47people from halfway houses into the
26:48clinic and then outside the clinic.
26:50Also in community engagement.
26:51So I was able to go to Walter
26:54Brooks halfway House,
26:55which is a men's halfway house.
26:57Just down the street from the hospital.
27:00I went there with Jerry Smart,
27:01who's one of these one of
27:03the community health workers?
27:04And really the goal of his halfway
27:06houses to facilitate stable housing for
27:08their clients as well as employment.
27:10And it also serves as a great entry
27:12point into Transitions Clinic.
27:14So we went there and just looked,
27:16you know,
27:16talked with the folks who work there and
27:19ask if there's any new people have joined.
27:21It was really interesting time
27:22because there wasn't a whole lot of
27:25movement just because there wasn't.
27:26It was during Kovit and there's.
27:28Not an opportunity really for people
27:30to get stable housing and the halfway
27:32house itself was only at wasn't.
27:34Was that like 70% or so capacity.
27:36Just because they had to have
27:37the right amount of distancing.
27:39So there wasn't as much movement
27:41into and out of the halfway
27:42houses there are at other times,
27:44so there wasn't a lot of opportunity
27:46for us to sort of accrue any new
27:48members of the transitions clinic,
27:50and it really left to a kind
27:52of a sort of a not a halt,
27:54but like a little bit of a
27:56slowing in the ability for.
27:58For these people to get,
28:00you know appropriate care,
28:01but I also was able to work
28:04in the clinic itself here.
28:05And was able to see a sort of a
28:08standard intake which goes through.
28:10As I mentioned,
28:11this multiple disciplinary approach.
28:12So first Jerry would talk with the
28:14patient and look for any critical issues,
28:16including any need for identification
28:17or any assistance with clothing.
28:19And it was both in this and with work
28:21with some of the other groups that
28:23aren't really mentioned in this presentation,
28:25that one of the biggest things
28:27that we can do for people,
28:29especially home homeless individuals
28:30when they if they come to us in clinic.
28:33A lot of times they need a doctor's
28:35note that says that they are
28:37who they say they are.
28:39Just to verify their identity so that
28:40they can get an actual identification,
28:42and one of the people that we
28:44saw in clinic that they did need
28:46that and it's just as simple
28:48as as you writing a letter.
28:50Sort of, you know,
28:51not there's no specific format to it,
28:53just saying that you know you saw
28:55this person and they are in fact
28:58they are who their name says they are
29:00so they can go and get an ID which
29:02really holds up a lot of critical
29:05elements including stable housing.
29:07So, but after that,
29:08that sort of intake.
29:09There's also a structured intake
29:11by the integrated pro bono legal
29:13team who assist patient with
29:15any pressing legal matters.
29:16Sort of helps to establish any
29:18barriers to employment and any sort of
29:21barriers to housing that may be ongoing.
29:23And then there's the medical visit,
29:25which I'll talk about a little bit
29:27more in depth on the next slide,
29:30but also along with this,
29:31as we talked about,
29:32there's the really deep connection
29:34between the incarcerated and post
29:36incarceration community, an opioid use.
29:37So it a lot of times it involves discussion
29:39and consideration of Suboxone initiation,
29:42which they can do,
29:43and then again,
29:44as Becky mentioned, you know,
29:46it's really important behavioral health,
29:47and you know the core abilities
29:49that patients have for my mental
29:51health standpoint is really key,
29:53and so there's a lot of referrals.
29:55Behavioral health specialists.
29:58Yes, Christina there is a mechanism,
30:00so you can just shoot a message.
30:02Honestly, the doctor,
30:03Puglisi or to Jerry Smart as well.
30:05I actually had a patient at the
30:07PCC who I thought would be really
30:09appropriate for this and I just
30:12sent a message to Doctor Puglisi.
30:14This is when we were back at the
30:16other clinic and then they can work
30:18with Jerry to get them to get them
30:20plugged in with the transitions clinic.
30:23And so I was able to do that.
30:25I actually don't think that this
30:27individual followed up, but.
30:28It was, uh,
30:29they worked very **** ** and getting
30:31them to come and see them in clinic.
30:33So it's just as simple as that.
30:37So as I mentioned, some of my thoughts
30:39on the transitions clinic, you know.
30:42Again, it really is this incredible
30:43multidisciplinary approach,
30:44both from Transitions Clinic as well.
30:46As we mentioned with the Street Medicine
30:48team, it really requires a lot of efforts
30:51from multiple different avenues, so.
30:52Patients leaving incarceration have high
30:54rates of not only opioid use disorder,
30:57but also a lot of chronic and
30:59communicable diseases, including hep C.
31:01HIV, as I sort of alluded to with the
31:03work in the Nathan Smith Nathan Smith
31:06Clinic and there is a significant price
31:08prevalence of mental health and mental
31:10illness and again about you know,
31:1265 plus percent will have some history
31:15of substance use this initial history
31:17as opposed to when we would usually
31:19do you know a new patient visit
31:21where we really drill in on the.
31:24Their blood pressure and their
31:25diabetes and things like that.
31:27Really.
31:28The intake here really focused on a
31:30lot of emotional and psychological
31:32questions along as along with drilling
31:35into physical trauma as well as
31:37emotional trauma and sexual as well.
31:39And it also involves a really
31:41detailed overview of their substance,
31:43use history,
31:44and it's really how all of these
31:46different factors affected their lives,
31:48interacted with their time spent,
31:50incarcerated and surgically sort of
31:52very poignantly pointed out this.
31:54Incarceration is really treated as
31:56a time dependent exposure in terms
31:59of development of substance use
32:01disorders as well as PTSD, depression,
32:04a lot of mental health concerns.
32:07And then also had the opportunity
32:08to work with some of the community
32:11outreach that is done through
32:13the Transitions Clinic umbrella.
32:14And this was specifically as it was.
32:17You know, around October, November,
32:19we worked with the Community,
32:20COVID ambassadors were also,
32:22you know,
32:23patients of the transitions clinic and we
32:25would meet with them weekly on the green
32:28and talk about various aspects of COVID.
32:31Whether it's you know the importance
32:33of masking the importance of quarantine
32:35of testing, where to get tested?
32:37When vaccine started to become,
32:39you know,
32:40started to come into the news a bit
32:42more during the ends of their trials
32:45and the approval of the vaccines.
32:47We also talked about the vaccines
32:49and the importance of vaccines and
32:51sort of addressing vaccine hesitancy
32:53within the Community and what we
32:55did was meet every week with these
32:57community COVID ambassadors and sort
32:59of educate and empower them and also
33:02reimburse them for their time and
33:04sort of have them then go out into the
33:07community and spread this information.
33:08Their own local communities to try and
33:11increase the education within the community.
33:13About COVID from multiple different aspects.
33:16So it's really remarkable that you
33:18know that both the way that they bring
33:20patients into transitions clinic,
33:21what they do while they're there,
33:22and then also how they reach out
33:24to the to the community.
33:29And another up to that we had that
33:32I had was to work with the Community
33:34Healthcare van, which was wonderful.
33:36So I don't know if any of you have
33:38had experience with this ban.
33:40Any other residents on the call.
33:42But I knew about it and I had no idea really
33:44what services they are able to provide.
33:47So this is a van that goes around New
33:50Haven and parks the days I was with that it
33:53was parked down in the Hill neighborhood.
33:56And essentially it just functioned
33:57as a walking clinic.
33:58It was somewhat limited because of COVID.
34:00We were doing flu shots that day,
34:02but also saw a couple urgent visits
34:04and we Park Park the van and then
34:07two of the social workers that work
34:09on the van were able to go out and
34:11just chat with people on the street,
34:13convince them to get a flu shot,
34:15talk with people who then came on
34:17and you know got their flu shot.
34:19Have their questions answered.
34:21They also do mother baby visits after
34:23people are believed the hospital
34:24for people that have a hard time
34:27getting to their appointments.
34:28And it was just.
34:29It was a really wonderful experience.
34:31This is really to who runs
34:34the syringe services van,
34:35which I wish I had a photograph
34:38'cause it's amazing.
34:39So really,
34:40to really to drives this white
34:42unmarked van that.
34:44One of the doors opens up and it
34:46just has this like incredibly,
34:48beautifully organized.
34:50I always containers with like
34:52syringes and needles and condoms,
34:54and these fentanyl test strips
34:55and just like it's this really
34:57wonderful resource.
34:58And he he he gets these text messages from
35:01people in the community that will say like,
35:04hey can you come basically like
35:06making small orders asking like hey,
35:08can you come drop off?
35:10You know 1520 syringes or
35:12needles and he drives around?
35:13He's able to do that and has just
35:16done like a tremendous job with
35:18harm reduction in the community.
35:20This is I don't know if these are the
35:22actual fentanyl test strips that they use.
35:25These are just ones that I found online,
35:27but it's a concept that I didn't know
35:29even existed and it's very cool where
35:31people are able to test their product
35:33to see if there's fentanyl in it.
35:35In order to gauge how much to use.
35:38And also he was saying that drug
35:40dealers will use this to know
35:41whether or not you know,
35:43especially people of you who want to
35:45avoid selling fentanyl in order to
35:46protect their clientele will often use
35:48this to determine whether or not the product.
35:50They've purchased has fentanyl in it.
35:56So along with all these.
35:59These activities that we did in person,
36:00we also had the opportunity for some,
36:02some online learning and I'll
36:04highlight a couple of them here.
36:06One that we both took part in was
36:08this clinical Tropical Medicine
36:10and global health curriculum
36:11that's done through the Universe,
36:13University of Minnesota.
36:14An what it offers is it offers the
36:17opportunity to get a certificate
36:19of completion for clinical Tropical
36:21Medicine and global health.
36:23That involves doing these seven
36:25online courses in an in person course
36:27that in total totality is like 200
36:29plus hours worth of course material.
36:31But what we focus on for this is
36:33we each were able to do one one of
36:35them online courses that they have,
36:37so you wouldn't be doing all seven of them,
36:40but you would be doing one of them.
36:42As you can see here.
36:44There I've listed out this is just
36:46from their website that you know the
36:49seven different options that you have.
36:51I did public health.
36:52I'm not sure which one.
36:54What you worked with?
36:55Becky,
36:55but parasites, so it's OK. So there
36:57you go so you can do whatever you want.
37:01So you can do it, you know,
37:03complete at your own time.
37:04There are a ton of modules within it,
37:06a lot of information,
37:07really useful stuff.
37:08Not a lot of statistics and things as well,
37:11but really a lot of a lot of
37:13great things to go through.
37:14And then I also listen to a few
37:16lectures that were posted on the
37:18yellows do for global health.
37:19It's a really sort of everyone
37:21can just go to this.
37:22It's why I just looked up by GH and they
37:25post a lot of events that they have into,
37:27including guest speakers and lectures
37:29and things like that I heard.
37:31Doctor Fouchy give a give a talk on
37:33COVID back on it back in October,
37:35November that was hosted by Yale.
37:37I think they've had John Kerry
37:38come and talk as well,
37:40so there are a lot of really awesome
37:42opportunities and it's just as
37:43simple as going to the website
37:44and registering for anything.
37:50And then I was able to do a few days
37:52at the A RC addiction recovery clinic
37:55which is over at the at the PCC,
37:58but no Longworth building so this
38:00is something that the YPC residents
38:01have had much more experience with.
38:04I don't, I don't think that many
38:06traditional residents have really
38:07rotated or spent much time in the clinic,
38:10but it was a really wonderful experience.
38:12So it's staffed by YPC.
38:13An addiction to faculty.
38:15And it's a clinic is able to
38:17provide frequent visits for patients
38:19with substance use and.
38:21What I said primarily it was treatment
38:22for opioid use disorder and alcohol
38:24use disorder and just notably it.
38:26It's not a methadone clinic,
38:27you know patients that are still on
38:30methadone still usually go to APT.
38:32But it was nice in that you know I
38:35learned a lot from the addiction.
38:38I worked with an addiction medicine
38:40fellow there and got to see how
38:42she counsels patients.
38:43And I was really surprised by you.
38:46Know she tells all of her patients who
38:48use any substances that they buy off
38:51the street from cocaine to opiates obviously,
38:54and also even even like pressed pills
38:56that everything is laced with fentanyl.
38:59Now like they're seeing just
39:01so much fentanyl lacing.
39:03And so she did a really amazing
39:05job warning the patient.
39:06Or you know,
39:07just educating patients on the fact
39:08that even if you're using cocaine,
39:10that you buy off the street and you
39:12haven't used cocaine in 10 years,
39:14you know there.
39:15There's still a good chance of that.
39:17Cocaine could be laced with
39:19fentanyl here in New Haven.
39:20And just to note something
39:21that I always forget about.
39:23And I don't think I knew as an intern.
39:25But fentanyl does not show up on a standard.
39:28You talk that you send from the hospital,
39:30you have to specifically send
39:32urine fentanyl for it to show up.
39:37And then how to refer?
39:38So if anybody is looking to refer
39:40their patients to this clinic,
39:42which I think is just like
39:44an incredible resource,
39:45you know I, my clinic at the VA.
39:47And so I'm in a little different position,
39:50but I I know that we don't
39:52often have timed to vote.
39:53These patients are automatically
39:55complicated and you don't have
39:561520 minutes to sit down and really
39:58talk about someone's use disorder.
40:00This clinic is just like a
40:01really great resource for that.
40:03And so here is where you can message to.
40:06For your patient,
40:07or Steve Holt is also the
40:08director of the clinic.
40:13And then even talked about
40:14this a little bit earlier.
40:15But just like some opportunities that
40:17we had within community engagement,
40:19I know Aiden was able to go
40:21to the green and you know,
40:22talk about vaccinations and COVID etc.
40:24But I was also able to
40:26watch the Hill documentary,
40:27which I know several of you watched.
40:29I'm sure with the traditional
40:31program that put on, you know,
40:32a screening night for the hill,
40:34but that was for anyone that didn't watch it.
40:37You know this is a story about a
40:39neighborhood in the Hill neighborhood.
40:41There was a street.
40:42That was just adjacent to the hospital,
40:44essentially where they bulldozed and evicted.
40:46I don't know. 4040 homes.
40:48I can't remember the number,
40:49but it in order to build a new school and
40:53just all the politics that went behind it.
40:57It was very eye opening and a
40:59very interesting film to watch.
41:00We also just had time.
41:02You know,
41:02there were several days where there weren't.
41:04I was with the street Medicine team
41:06and maybe there wasn't a lot going
41:08on or people didn't have medical
41:10concerns and we just walked around
41:11Fairhaven or walked around different
41:13neighborhoods and just chatted
41:14with people caught up with people,
41:16asked how their kids are doing, and.
41:19It was a very nice experience
41:21because you know,
41:22I think that throughout residency
41:24we never really have the time
41:26to just sit down and like,
41:27listen to someone story.
41:29You know, we think we do,
41:30but in the back of your head
41:32you're always thinking,
41:34Oh my God,
41:35I have a discharge summary to
41:37write or I have to check on.
41:39You know this person's labs or
41:40there are so many more conflicting
41:42issues going on in the hospital.
41:44But this was just a really,
41:46really nice experience to just.
41:48Almost be a Med student and just
41:51kind of just sit back and absorb
41:53everything like a sponge and just,
41:56you know,
41:56be able to listen to people an it was.
42:00It was very refreshing.
42:03So in the last like couple minutes we have,
42:06we just wanted to talk through a case.
42:09This is a made up case,
42:11but it's something similar to I think.
42:13I think many of us would have,
42:15you know,
42:16similar patients when you're
42:18on fitkin or Verde etc so.
42:20This is a 45 year old gentleman who is
42:23history of opioid use and Ivy drug use.
42:25He was admitted after an accidental
42:27over accidental overdose.
42:28He was in Ark and intimated in the
42:30field and then admitted for a Narcan
42:33drip and withdrawal on examine.
42:34They make you use node to have a
42:37black eschar in his right first toe,
42:39without Cellulitis overlying in the X.
42:41Ray showed early osteomyelitis,
42:43so you konsult I deem they're asking
42:45for a bone biopsy and they did not
42:48yet start her money into biotics.
42:50And then he gets transferred to
42:52fit in at 5:25 PM and you contact
42:54social work right before they leave,
42:56and they say he's living with friends
42:59or staying on the green overnight.
43:02And then around 9:00 PM you're getting
43:04other admissions and this patient
43:05is now asking to leave the hospital
43:08and you're not totally sure if they
43:10have capacity because you're not
43:12sure if they're still withdrawing
43:13or you know what what's going on.
43:15You have psych.
43:17Go evaluate your internal psychiatry
43:18intern and she goes and evaluates and
43:21has the attending psychiatrist come with
43:23her and said the patient has capacity.
43:25So I guess her question here is just
43:27what are your biggest concerns with this
43:29patient and with patients like this.
43:39It's OK, it's OK. I know it's
43:41kind of late in the presentation.
43:43I think your concern would be that
43:45they're just going to go right
43:47back to the green and use again
43:48because they're so uncomfortable.
43:50Perhaps in their withdrawal.
43:54Yeah, exactly, I think that that is.
43:56That is like the key is just
43:59really thinking like why are they
44:01leaving and what can you do?
44:03To address why they want to
44:05leave and if any of that has
44:07to do with their withdrawal,
44:09are you under treating their
44:10withdrawal or are they having just
44:12severe cravings and desire to use
44:14and you haven't considered you know,
44:16starting them on treatment for this?
44:18Is it a complex social situation?
44:21You know, are they worried about?
44:24Paying a bill?
44:25Or are they worried about getting home
44:27in order to do something you know things
44:30just to really think about into address.
44:32And I think we just sort of wanted to leave
44:35you with a couple of pearls in terms of,
44:38you know when you think about patients
44:40like this who want to leave the hospital.
44:42Just what can you do in order to really
44:45make it as safe a discharge as you can,
44:48and it feels really
44:50challenging often because.
44:51You know,
44:52and it never feels like
44:53a very safe discharge.
44:55But there are things that you can do that
44:57can reduce the harm of their leaving early,
45:00so harm reduction practices.
45:01These are practices that seek to reduce
45:03adverse health consequences that
45:04could come from unhealthy behaviors,
45:06but assuming that patient will likely
45:08continue these behaviors and so things
45:09you can do along the lines of harm
45:11reduction is prescribed Narcan and you
45:13can show the patient how to use Narcan.
45:17You know one thing that I find very helpful.
45:20I saw recently that an ID note had left.
45:22You know, this is the patient
45:24that was similar situation.
45:25The patient had been,
45:26you know,
45:27saying that they want to leave.
45:29They are requesting to leave
45:30and obviously you know it.
45:32You don't necessarily want to
45:33put a patient with osteo on PO
45:35antibiotics and you'd rather have Ivy.
45:37But if they're going to leave,
45:39you know it's always useful to ask ID
45:41like hey, if if they have to leave,
45:44what is a PEO option and then
45:45also getting addiction medicine
45:47involved sooner than later.
45:48Is is always very key.
45:52Something very helpful is to get
45:53their meds to beds and so like
45:56like somebody had asked earlier,
45:57you know how do these
45:59patients get medications it?
46:00It's really hard.
46:01You know when you discharge somebody
46:03from the hospital who is not living
46:05in stable housing or is homeless
46:07and you give them the prescriptions
46:09to go to a CVS you know a mile away
46:11to pick up their albuterol inhaler.
46:14Like what are the odds that they're
46:16going to be able to do that?
46:18There are so many other more
46:20pressing issues for them.
46:21In their life that that that's a very
46:24difficult thing to ask somebody.
46:25And so the same reveals apothecary that
46:27I think it's under Epic as the wine,
46:30age, age, apothecary forget.
46:31But if you prescribe your
46:33medications to that apothecary,
46:34you can call the night before
46:36and have them brought over.
46:39Looking at the chat meds to beds, yeah.
46:43And so you know, getting those anime.
46:45I've done it the same day,
46:47but I think it's often easier
46:48if you can do it the day before.
46:51But it is.
46:51It is very helpful to be able
46:53to get those medications to the
46:55patient's bed before they leave.
46:56Think if you do it the
46:58same day they can usually get it to the
47:01patient's bedside in about 2 ish hours.
47:03If you. If you do it the same day.
47:07Nice. And then they will also
47:11do I bring in the chat that they
47:13also do supplies and glucometers?
47:15Yeah, that's that's great to know.
47:18And then, in terms of discharging somebody,
47:20who is your, you know someone to the street
47:22or somebody who has unstable housing.
47:25So you can always tell them that they can
47:28always follow up at liberty safe haven.
47:30That's on State Street on Monday mornings.
47:32An anagram is the contact there, and you
47:35can always shoot her a message, an epic.
47:39In the social worker should really be.
47:43You know your closest ally
47:45in these situations,
47:46and you can always inquire
47:48about medical respite programs.
47:49There are some programs that offer temporary
47:51housing for patients that have medical.
47:53Medical issues were leaving the hospital.
47:57You know that incentive to possibly
47:59get into a medical respite program
48:01could be raising a sick patient
48:02would stay in the hospital as well,
48:04and then Sarah Jacobs is one of the social
48:06workers here at Yale who works really
48:08closely with the street Medicine team.
48:10And so.
48:12For any questions or concerns
48:14about these patients,
48:15she would be a really great resource to have.
48:20It didn't do anything else to add,
48:22I think. No, yeah, well,
48:25we just wanted to say thank you so
48:27much to Doctor Shannon Dr Raven for
48:30putting together this collective.
48:31It was like we said earlier.
48:33I mean it was a wonderful experience
48:36and I think we both learned a lot.
48:42But thank you so much,
48:43Becky and Aiden for this fantastic
48:45presentation, I think, well,
48:46I think you've done a phenomenal job
48:48of sort of describing the experience.
48:50I think Sheila and I both enjoyed
48:53opportunities to debrief with you
48:54and the other residents doing the
48:56electives on a weekly basis and to
48:58really hear in real time about what
49:00you were learning and how impactful
49:02so many of these experiences were.
49:04And wondering just in the last
49:06couple of minutes,
49:07if you guys would mind commenting,
49:08you know, we we.
49:10Framed this as a local global health
49:12elective to take the place of the
49:14international health electives that
49:16you guys were both supposed to be on
49:18and just hearing what you've shared.
49:20You know,
49:21I think something that's very similar
49:22to what I hear from residents coming
49:25back from from our international
49:26partners sites are these themes
49:28around having an opportunity to really
49:30understand the context of what's
49:32going on for the patients you know?
49:34Arriving in a new medical culture,
49:36a new social culture,
49:37an really sort of having this
49:39chance to try to understand things,
49:41and having that.
49:42Sort of trigger thoughts on how
49:44they might change their practice
49:46going forward and I'm just wondering
49:48if either of you would be able to
49:50comment on sort of that parallel
49:52between sort of what you had hoped
49:54to get out of an international
49:56experience and sort of how how
49:58this experience met or didn't
50:00meet some of those expectations.
50:03Yeah, so I think I'm speaking to that.
50:06The you know when you go when we were both
50:08hoping to go to an international location,
50:11I think you may look forward
50:13to experiencing new cultures,
50:14new communities and really learning from
50:16them and sort of broadening your view
50:19on medicine along with health care and.
50:22No, through the different
50:23experiences that we had,
50:24whether it's with incarceration,
50:25medicine or if the street medicine team,
50:27it really is a completely new
50:29environment as far as you know what
50:31we're used to participating in,
50:32whether it's our clinic here or you know,
50:34especially on the inpatient side,
50:36you really are just in your little bubble,
50:38I guess, and you don't really see the broader
50:40scope of everything going on around you.
50:42And I think both of our eyes were really
50:45opened by all the experiences that we had.
50:47I know is Becky mentioned, you know,
50:49I also keep hand warmers in my car now.
50:52At all times,
50:53and I think that the allowed
50:54the lessons that we learned by,
50:56you know,
50:57going around with the street Medicine
50:59team and seeing what kind of things
51:01they try and do in terms of harm
51:03reduction and trying to get plugged
51:05in with people and trying to keep,
51:07you know,
51:08keep on top of become allies with with
51:10their patients is something that we don't.
51:12A lot of times think about when
51:14we're on the inpatient side,
51:16and especially when trying
51:17to discharge people.
51:18Both of us were really struck by a
51:20couple of stories of people who are
51:23discharged from the hospital and.
51:24You know,
51:25of course they didn't go to the pharmacy
51:27that they prescribe the meds too.
51:29Of course they didn't pick
51:30anything up like that's.
51:31They prescribe them to this pharmacy,
51:33but we know that they know this
51:34person hangs out on this corner and
51:36this pharmacy is closest to that.
51:38So a lot of really unique
51:40experiences that we had,
51:41and I think it is,
51:42you know you really liking it to it being,
51:44you know,
51:45a really sort of a different culture
51:47in different community that you don't
51:48really get to interact with all the time.
51:53Yeah, I agree with everything
51:56that you said I. I was once really
51:59struck by Philip said to me.
52:01He was like it's like we
52:03were standing outside of the.
52:05One of the soup kitchens and people
52:06were all eating and kind of chatting
52:08and then eventually before right
52:10before they were about to leave
52:11would come over and be like, oh Phil.
52:13I have this horrible Abscess on my back.
52:15Or, you know, they would wait until
52:16the end to really address the medical
52:18problems and he was talking about,
52:20like Maslow's hierarchy of needs.
52:21And he was saying, like you know,
52:23people need in order for them to
52:25address their medical problems.
52:26They need to.
52:26They first need to address their own safety,
52:28their own.
52:29You know they have to eat.
52:30They have to have housing and
52:32a lot of times you know those
52:34priorities come first before they
52:35even care about their health and so.
52:37Which makes sense and I I think that really.
52:40Changed the way I often think about.
52:41Sometimes you know, I think,
52:42like Oh my God, how could you let this?
52:46You know, go on for so long.
52:48You know you've had this infection.
52:50You've had this, you know.
52:51We've had this problem for so long,
52:53and it's so easy to forget about
52:55the fact that, like that's,
52:57that's one of their absolute lowest
52:58priorities when people don't
53:00have any stable housing,
53:01it is reiterated how just housing is.
53:03I mean housing is health and it's
53:05it's critical to good health care.
53:09Thanks so much to both of you and
53:11I think I mean even in this last
53:13piece you've just highlighted some
53:15really concrete takeaways that
53:16anybody can implement in your time.
53:18Working on the inpatient wards
53:19just even sort of asking patients
53:21about which pharmacy you know,
53:23the one that's in the computer might not
53:25necessarily be the one that makes the
53:27most sense to be sending their meds too,
53:29and certainly even thinking about whether
53:31they can afford whatever copay or afford
53:33to pick up the medication before you
53:35send them out to really important pieces.
53:37And as Sheila put in the chat.
53:39You know, every week when we would talk
53:41with you guys we were so jealous that of
53:43all the experiences that you were having,
53:44I think we told you this over and
53:46over again that you know these were
53:47all experiences and colleagues that
53:49you had the opportunity to work with,
53:50that we have been wanting
53:51to work with for years.
53:53So so glad to be able to pull this
53:55together for residents to experience.
53:56I'm so I think I don't see any
53:59other questions in the chat so
54:01maybe will end just a minute early.
54:03I want to just put up a quick quick slide
54:06two to promote our global health day
54:09activities for next week for tomorrow.
54:11Rather said tomorrow is Global Health
54:13Day in the Department of Medicine.
54:15We have some really exciting things planned.
54:18Doctor Askar Rastegar is going to be
54:20giving grand rounds tomorrow at 8:30
54:22talking about building human resources
54:24for health and his personal journey
54:26will have a fantastic panel discussion.
54:28At noon this is a QR code to sign on.
54:32I know that both sets of chiefs
54:34are going to be organizing this
54:36in for groups on both campuses,
54:38but I'm really excited about
54:40our panel discussion at noon.
54:42Talking about colleagues around
54:43the medical campus who are engaged
54:45in global health capacity building
54:47efforts now and then.
54:48Tomorrow night we'll have our fifth annual
54:50refugee Health education conference.
54:52It's a shorter version.
54:53It's just an hour and a half this year,
54:56but focusing on sort of COVID updates.
54:59Related to physical and mental
55:00health of refugees.
55:01So I hope that folks on the call
55:03will be able to join us for those.
55:05So thanks so much again to Becky
55:07and Aidan for presenting and to
55:08all of you for joining us.
55:10Have a great rest of your day.