Bridge to Home

Transcript

• 00:20Right.
• 00:23Yeah.
• 00:51Okay.
• 00:54Welcome, everyone. Here in Nanon.
• 00:57Just a few introductory
• 01:00slides. We're
• 01:01very excited to,
• 01:07Okay.
• 01:08I'll see a link for
• 01:09today.
• 01:17Okay. I'll be having events
• 01:18soon. It's the solution establishing
• 01:20retreat.
• 01:23As you know, one of
• 01:24the main,
• 01:25factors of that retreat is
• 01:27giving feedback on words and
• 01:28projects. You will be hearing
• 01:30from from us soon, to
• 01:32request,
• 01:33you to submit draft abstracts,
• 01:35project ideas, etcetera. The, the
• 01:38workshopping
• 01:39is the, the main take
• 01:40home
• 01:41of that of that event.
• 01:44Other retreats coming up.
• 01:47Other events coming up. RA
• 01:49update as pertaining to the
• 01:50primary care by Betsy Tsao.
• 01:53A week from today, Elena
• 01:54Byhoff will be a a
• 01:56visiting lecturer
• 01:57speaking about health policy to
• 01:59address hunger, all carrots, no
• 02:01sticks.
• 02:03She's a well funded researcher
• 02:05focusing on food insecurity,
• 02:07both her k and now
• 02:08an r o one grant
• 02:09on that topic. I think
• 02:10it'll be really interesting to,
• 02:13learn about her career path.
• 02:16Disclosures
• 02:17here.
• 02:18Oh,
• 02:20okay.
• 02:22You didn't miss much. Alright.
• 02:24Disclosures.
• 02:27Then
• 02:29I'll pass the baton to
• 02:30Brad.
• 02:34Thank you, Carrie.
• 02:35So I get the pleasure
• 02:36of introducing Ted
• 02:38today, at least for this.
• 02:40And,
• 02:41I know Patrick said he's
• 02:42not here for the talk.
• 02:42He's on his way to
• 02:43do a Zing professorship in
• 02:45Norway, which is very exciting.
• 02:47But I, so for those
• 02:49who don't know me, Brad
• 02:50Richards, I'm the exec director
• 02:51in the Yale Primary Care
• 02:52Program. Ted and I were
• 02:53the same year, he was
• 02:54the traditional I'm program, he
• 02:55was in YPC.
• 02:57But I'll do a little
• 02:58less formal than the intro
• 02:59this morning, because many of
• 03:00you have already heard it.
• 03:03But Ted,
• 03:04is now the senior vice
• 03:05president of ambulatory care and
• 03:06population health at New York
• 03:07Health and Hospitals. I think
• 03:08I got that. It's on
• 03:09there. Great. Nailing it. Which
• 03:11he's been in since twenty
• 03:12eighteen. But he has been
• 03:14has been a intermittent Yalie,
• 03:17for many years. He was
• 03:18here for undergrad,
• 03:20did,
• 03:21his,
• 03:21and then left, Yale for
• 03:23a while, went to USC
• 03:24for his for medical school,
• 03:26and then came back here
• 03:27for for residency before staying
• 03:29on to do, the clinical
• 03:30scholars program back in the
• 03:32day, RWJ Clinical Scholars Program.
• 03:36And then went and did
• 03:37some really neat stuff in
• 03:38Rhode Island, actually worked at
• 03:40CMMS
• 03:40as well before joining, taking
• 03:42this role where he's done
• 03:44a lot of pretty amazing
• 03:45things for those who got
• 03:46to hear about it this
• 03:47morning. And today, we're gonna
• 03:48hear about this new endeavor,
• 03:50Bridge to Home, which you
• 03:51caught a little bit about
• 03:52this morning that they're really
• 03:54just launching. So very excited,
• 03:56really excited to welcome Ted.
• 03:57I
• 03:58still get to, I look
• 03:59up to him in the,
• 04:00in some of my,
• 04:02the excitement around primary care
• 04:04innovation and change, and some
• 04:05of the work that they've
• 04:06done at New York Health
• 04:06Hospital, so I think is
• 04:07very inspirational as a model
• 04:09for a lot of other
• 04:10systems. So welcome Ted.
• 04:15Well, it's good to be,
• 04:16back home now. I, lived
• 04:18in, New Haven for eleven
• 04:20years, was at Yale for
• 04:21ten years,
• 04:23plus today. My wife still
• 04:24is here every single day.
• 04:26So we have a lot
• 04:27of connections. I think my
• 04:29wife's much more well known
• 04:30than I am because she's
• 04:30done surgery on, as of
• 04:32last night, about half the
• 04:33people there.
• 04:34So
• 04:35it's very good.
• 04:37So for today, I thought
• 04:38we'd do something a little
• 04:39bit different. In Grand Rounds,
• 04:41for those that joined,
• 04:43we, gave a I gave
• 04:44an overview of, a lot
• 04:46of the changes in New
• 04:47York City, a lot of
• 04:47the crises that we've managed.
• 04:49But we, one of the
• 04:50interesting things that we're doing
• 04:52now is we've just launched
• 04:53a new program.
• 04:54So, just in full disclosure,
• 04:56there is no research yet
• 04:57for the program. It is
• 04:58two weeks old. But I
• 04:59thought it could be cool
• 05:00to talk through what it's
• 05:01like to implement the program
• 05:02in real in real time,
• 05:04and how we wanna think
• 05:04about evaluations going forward. And
• 05:06I would say, actually, if
• 05:07anything, I'd love to learn
• 05:08from you all today,
• 05:10about any related work or
• 05:11research or how you'd approach,
• 05:13you know, implementing an evaluation
• 05:15evaluating a program like this.
• 05:16I'll tell you what we're
• 05:17doing in New York City,
• 05:18and I'd love to, have
• 05:19this be as interactive as
• 05:20possible. I only have, like,
• 05:22fifteen slides.
• 05:23So,
• 05:24please, you know, jump in,
• 05:26cut me off. I will
• 05:28have some, intentional pauses to
• 05:30to try to to try
• 05:31to give some space.
• 05:32So by way of quick
• 05:35background,
• 05:36I have no disclosures.
• 05:38So CME is looking good.
• 05:41So So for learning objectives,
• 05:43I wanna tell you guys
• 05:44about the, all of the
• 05:46health care services that we
• 05:47have for people experiencing homelessness
• 05:49in New York City every
• 05:50day.
• 05:52I wanna tell you about
• 05:52the new model that we
• 05:53have. And then as time
• 05:54allows, talk a little bit
• 05:55about how we're thinking about,
• 05:57evaluating and continuing to implement
• 05:59the program. Again, it's only
• 06:00a couple of weeks old
• 06:01now, but I think it
• 06:02holds a lot of potential
• 06:03and builds on, a lot
• 06:04of the work we've done
• 06:05in New York City and
• 06:06a lot of work that
• 06:06you may be more familiar
• 06:08with than I am about
• 06:09what others have done to
• 06:10address the issue of people,
• 06:11especially with severe mental illness
• 06:13that are sleeping on our
• 06:13streets every night.
• 06:16So by by quick way
• 06:17of numbers for who we
• 06:19are, New York City Health
• 06:20and Hospitals is a large,
• 06:23the largest city run public
• 06:24health care system in the
• 06:25country.
• 06:26We have eleven hospitals,
• 06:28thirty,
• 06:29community health centers,
• 06:30forty five thousand staff.
• 06:32My area is I'm in
• 06:33charge of ambulatory care, which
• 06:34is six million visits a
• 06:35year. We also have a
• 06:36hundred and sixty thousand admissions.
• 06:39We are a diverse place.
• 06:40You could see our locations
• 06:41on the, on the map
• 06:42there. Our patients are forty
• 06:44two percent Hispanic or Latinx,
• 06:46thirty one percent black or
• 06:47African American, thirty seven percent
• 06:49prefer to speak in a
• 06:50language other than English.
• 06:52Twenty eight percent of our
• 06:52patients are uninsured,
• 06:54which I would believe is
• 06:55probably higher than, patients at
• 06:57Yale.
• 06:58Thirty four percent Medicaid,
• 07:00and about a hundred and
• 07:01forty thousand are in a
• 07:02program I started that, is
• 07:03one of the things I'm
• 07:04proudest of in twenty nineteen.
• 07:05It's a universal access to
• 07:06care, a program called NYC
• 07:08care. This will be relevant
• 07:10as we talk about people
• 07:10experiencing homelessness as well. This
• 07:12program is an insurance like
• 07:13program that gives you a
• 07:15card. So Brad Richards' name
• 07:16would be on the card.
• 07:17Actually, I'll put my name
• 07:18on the card. Brad would
• 07:19be my doctor
• 07:20for sure.
• 07:22And,
• 07:23on the card would be
• 07:24a twenty four seven phone
• 07:25number to call for customer
• 07:27service, your individualized fee scale,
• 07:29based on your individual income.
• 07:31So two dollars or zero
• 07:32dollars for any medication visit,
• 07:33emergency department,
• 07:35visit, things like that.
• 07:37So we wanna try to
• 07:38be able to meet every
• 07:38any New Yorker where they
• 07:39are and offer them some
• 07:41sort of access to care,
• 07:42whether it's through Medicaid or
• 07:43through this program as a
• 07:45way to for it to
• 07:45engage them into care.
• 07:48As I go to and
• 07:49then,
• 07:50worthy note, we do in
• 07:51our system, of course, have,
• 07:53the compendium of, a variety
• 07:55of services,
• 07:56legal services. We have, a
• 07:57very large community health worker
• 07:59program. At Grand Aransas, I
• 08:00talked a little bit about
• 08:01how I I think we
• 08:01have the largest program in
• 08:02the country. When we started
• 08:03it, it was two hundred
• 08:04and fifty strong,
• 08:06drawing from our our on
• 08:07the ground contact tracers during
• 08:08COVID.
• 08:09We've studied it. It's made
• 08:10an incredible difference for chronic
• 08:11disease outcomes. Now we're looking
• 08:12at utilization.
• 08:13So we have a lot
• 08:14of assets in our tool
• 08:15belt. And specifically, part of
• 08:17the community health worker program,
• 08:19are community health workers for
• 08:21exclusively people experiencing homelessness.
• 08:23They are New Yorkers that
• 08:24have, shared lived experience, so
• 08:26themselves have been homeless,
• 08:28and are there now to
• 08:28help, people currently experiencing homelessness
• 08:31know how to navigate social
• 08:32benefits and, health care for
• 08:34themselves.
• 08:37So,
• 08:38one fun fact,
• 08:40that you probably didn't know
• 08:42is that, at New York
• 08:43City Health and Hospitals,
• 08:44we today
• 08:46in New York City provide
• 08:48well over carry a sixty
• 08:49percent, considered well over half,
• 08:51carry a grace.
• 08:53Well, statistically, well over half,
• 08:58of all behavioral health services
• 08:59in New York City.
• 09:01So that that's all comers
• 09:03regardless of insurance, regardless of
• 09:04anything else.
• 09:05So we already are in
• 09:07a position
• 09:08to make a difference for
• 09:09people in terms of providing
• 09:10behavioral health care just because
• 09:12of the footprint that we
• 09:13have. So as I talk
• 09:14about our new model, one
• 09:15thing to keep in mind
• 09:16is a reason why the
• 09:19a reason why this didn't
• 09:20exist before two weeks ago
• 09:21is nobody else could really
• 09:23do it.
• 09:24We have the majority of
• 09:26the psychiatrists,
• 09:27because we are providing the
• 09:28majority of behavioral health services.
• 09:31It's not just, you know,
• 09:33a generic visit I'm referring
• 09:34to here. We have a
• 09:35variety of services that we've
• 09:37built out over time, just
• 09:38to contextualize the overall, sort
• 09:40of medical footprint that we
• 09:41have in New York City.
• 09:42So we have inpatient care.
• 09:44We have extended care units
• 09:46where people patients can spend
• 09:47a couple of months after
• 09:49they've graduated from inpatient, sort
• 09:50of like a a mini
• 09:51step down, if you will.
• 09:53If they don't need inpatient
• 09:54level of care, but they'd
• 09:55be okay. It's,
• 09:57extended, you the extended care
• 09:58unit is still inpatient technically,
• 10:00but it's a step down
• 10:01from inpatient.
• 10:03We have forensic care. We
• 10:04have mobile crisis teams. So
• 10:05the teams that go around
• 10:06New York City and evaluate
• 10:08people, in crisis on the
• 10:09street, we run those teams.
• 10:12We have a virtual version,
• 10:13of behavioral health care,
• 10:15for people with urgent needs.
• 10:17So it's express care or
• 10:18urgent care on your phone,
• 10:19tablet, or laptop specifically for
• 10:21behavioral health.
• 10:23We built that out. It's
• 10:24been a popular program. It
• 10:25means any New Yorker, regardless
• 10:26of insurance, can log on
• 10:27and get behavioral health care
• 10:28urgently from their phone.
• 10:31We have,
• 10:32just in terms of the
• 10:33volume, almost, or over eight
• 10:35hundred thousand outpatient visits a
• 10:36year. We have, opioid treatment
• 10:38programs, addiction clinic services,
• 10:41partial hospitalization program. We have
• 10:43intensive outpatient programs, which also
• 10:45are where people, we meet
• 10:46people on the street for
• 10:47ongoing care,
• 10:48and then, of course, general,
• 10:50outpatient behavioral services.
• 10:51I say all of this
• 10:52to make the point that
• 10:53as we're thinking about implementing
• 10:55this new program here, we're
• 10:56not implementing a program
• 10:58in isolation of everything else.
• 11:00We already are in control
• 11:01of a a a pretty
• 11:02big chunk of all the
• 11:03behavioral services in New York
• 11:05City today, and we already
• 11:06have a diverse array of
• 11:07behavioral services that we're providing.
• 11:09So one of the things
• 11:10I think about day to
• 11:11day is we're implementing this
• 11:12new program, and you could
• 11:14think about with me here
• 11:14too, is how can we
• 11:16be tying these puzzle or
• 11:17putting these puzzle pieces together
• 11:18in different ways to ultimately
• 11:20achieve the goal that patients
• 11:21in need of behavioral health
• 11:22are getting it continuously. And
• 11:23we know today is not
• 11:24the case, Carrie.
• 11:31General primary care. What percent
• 11:33continue to have do you
• 11:34know those that like, what
• 11:36percent of the city's primary
• 11:38care is managed by health
• 11:40and hospitals or other types
• 11:41of care? We have four
• 11:42hundred and fifty nine thousand
• 11:43patients in paneled in primary
• 11:45care today. I think it's
• 11:45about a seventh or an
• 11:46eighth ballpark. Maybe it was
• 11:48slightly more than that, actually.
• 11:50Maybe maybe fifth, something like
• 11:51that. It's not sixty percent,
• 11:52though. Yeah. This is so
• 11:53widely skewed because there is
• 11:55no other
• 11:56private providers willing to do
• 11:57this. It's a it's
• 11:59a
• 12:01low, reimbursement for these types
• 12:03of services.
• 12:05So and there but there's
• 12:06a need for them. So
• 12:07as other systems have started
• 12:09to do less of these
• 12:09services, it also has meant
• 12:11that we've done more. So
• 12:12the state has opened more
• 12:13beds.
• 12:14When you hear that New
• 12:15York state is opening more,
• 12:16you know, inpatient psych beds,
• 12:17that's us doing that.
• 12:20Yeah. Doctor Justice.
• 12:22Give us a sense of
• 12:23what the distribution
• 12:25I mean, behavioral health covers
• 12:27a great deal
• 12:29of care. Yes. What are
• 12:31the major expenditures
• 12:33for for that?
• 12:34So the major parts so
• 12:36the I know this is
• 12:36hard because there's there's, like,
• 12:38a million different programs listed
• 12:39on there. The major expenditures
• 12:41are inpatient. That's the number
• 12:43one. And, again, we have,
• 12:45the largest proportional inpatient footprints.
• 12:48We all and, I would
• 12:49say behind that is,
• 12:51we have outpatient behavioral health
• 12:53clinics
• 12:54that, you know, can serve
• 12:56patients with any behavioral health
• 12:57needs. But one of the
• 12:58the changes that I've made
• 12:59in our system is I've
• 13:00really massively grown out collaborative
• 13:02care, which is part of
• 13:03outpatient behavioral health. Collaborative care
• 13:05is where you have social
• 13:06workers that are providing the
• 13:08direct care for depression and
• 13:09anxiety, and they all have
• 13:11their own individual panels, and
• 13:12they roll up to one
• 13:13attending psychiatrist.
• 13:15So it amplifies your behavioral
• 13:16health reach.
• 13:18But those are the main
• 13:19areas. And then in our
• 13:19behavioral health clinics, we also
• 13:21offer,
• 13:21opioid addiction services, things like
• 13:23that.
• 13:24The, it's an interesting question,
• 13:26though, because we also do
• 13:27think about, you know, like,
• 13:28should we have more mobile
• 13:29units? You know, how is
• 13:30that gonna look,
• 13:32and things like that. And
• 13:33then when I get to,
• 13:34talk a little more about
• 13:34the program, I think that's
• 13:35one of the questions on
• 13:36our mind is, you know,
• 13:37what is that balance of
• 13:39where we're providing care? At
• 13:41the end of the day,
• 13:41there are a lot of
• 13:42New Yorkers that are going
• 13:43without that are on the
• 13:44streets. How do we engage
• 13:45them? What do they need?
• 13:46Do they need a mobile
• 13:47unit? Do they need to
• 13:47be brought to the hospital?
• 13:49These are questions that we're
• 13:50trying to to parse out
• 13:51with the new program.
• 13:55Okay.
• 13:57So, mother, just background.
• 13:59This is New York City
• 14:00data,
• 14:01and but I'm sure there's
• 14:02a lot of, you know,
• 14:03strands that you can draw
• 14:04to to you guys at
• 14:06other places too.
• 14:07So nearly fifty percent of
• 14:08behavioral health patients at our
• 14:10system,
• 14:12would,
• 14:13are are addressing are experiencing
• 14:14homelessness in the Bridgestone program,
• 14:16which is the name of
• 14:16the new program,
• 14:18would be targeted
• 14:19at that population.
• 14:20So, a lot of in
• 14:21other words, a lot of
• 14:22patients,
• 14:23that are that have behavioral
• 14:24health issues have experienced homelessness,
• 14:26meaning gone some number of
• 14:28days in the past year,
• 14:29with housing insecurity.
• 14:31And some of them have
• 14:32been in our shelter system.
• 14:33Some of them have been
• 14:33in the street, things like
• 14:34that.
• 14:36In terms of numbers, in
• 14:37twenty twenty four, in our
• 14:39system alone,
• 14:40seventy one thousand
• 14:42patients were homeless or marginally
• 14:44housed.
• 14:45So I know it's New
• 14:46York City numbers, so everything
• 14:47everything seemed bigger. But that's
• 14:49a big number.
• 14:50It I'll the point of
• 14:51reference I would give you
• 14:52in comparison to that is
• 14:53the totality of our New
• 14:54York City shelter system today,
• 14:56I think, is
• 14:57forty five thousand or so.
• 15:00People are staying in shelters.
• 15:02So more than the people
• 15:03in shelters, because people come
• 15:04in and out of experiencing
• 15:06homelessness. What's true is we
• 15:07tend to see them all,
• 15:08even if they're not currently
• 15:10in shelter.
• 15:11And then to contextualize that
• 15:12number a little bit more
• 15:13too, it's not in the
• 15:15slide.
• 15:15So if you have seventy
• 15:17one thousand plus people in
• 15:19New York City experiencing homelessness
• 15:21in a year, some number
• 15:22of them currently be in
• 15:23shelter.
• 15:24Some number of them will
• 15:25currently be sleeping on the
• 15:26street.
• 15:27That's the population that that,
• 15:29is in desperate need of
• 15:30intervention.
• 15:31That number, we think, is
• 15:32about thirty five hundred.
• 15:34So tonight, there's about thirty
• 15:36five hundred New Yorkers that
• 15:37are going to sleep
• 15:39on the street. Interestingly,
• 15:41this is and this is,
• 15:42I don't know if this
• 15:43is a New York City
• 15:44thing or if this is
• 15:45more generally done. We know
• 15:46who they are.
• 15:48We have great intelligence
• 15:49about what people's bot names,
• 15:51where they tend to sleep.
• 15:52We have community outreach teams
• 15:54that get to know them,
• 15:56and and if, a sort
• 15:57of interesting fact that, that
• 15:59underlie or that, you know,
• 16:00validates that our pop quiz.
• 16:03Not too bright.
• 16:04What percentage
• 16:06of people experiencing homelessness,
• 16:08generally speaking, in New York
• 16:10City have insurance?
• 16:16There's no right or wrong
• 16:16answer. Actually,
• 16:19I heard a five percent.
• 16:20Can I go do I
• 16:21hear a ten? Do I
• 16:22hear a ten?
• 16:23Are you
• 16:24Seventy five percent is pretty
• 16:26much right. Yep. But that
• 16:27includes government insurance. Yes. Oh,
• 16:29yeah. It it's almost all
• 16:30Medicaid.
• 16:31But the, seventy five percent
• 16:33is pretty much dead on.
• 16:34So the interesting the
• 16:36the reason for that is
• 16:37a simple explanation,
• 16:38as you already know. It's
• 16:40that, people experiencing homelessness always
• 16:42touch the hospital system. So
• 16:44when they come to the
• 16:44hospital, we're really good about
• 16:45when you're in the emergency
• 16:46department or admitted. We you
• 16:48have emergency Medicaid or straight
• 16:49Medicaid or Medicaid managed care,
• 16:51whatever it is.
• 16:52We're really good at enrolling
• 16:53you, and we know that
• 16:54you come because we know
• 16:56that that generally by the
• 16:57time you when you when
• 16:57you come in, you already
• 16:58have insurance.
• 17:00But to me, it's almost
• 17:00like it's a it's a
• 17:02it's a great thing. Everybody,
• 17:04health insurance is a human
• 17:05right, but the problem is,
• 17:07you know, with that many
• 17:09people having insurance but still
• 17:10sleeping on the street, it's
• 17:11like we know we're trying
• 17:12to help them, but we're
• 17:13failing because they're still going
• 17:15back to the street. It's
• 17:16great when they come to
• 17:17us. They have already filled
• 17:18out the the paperwork's done,
• 17:19but they're still on the
• 17:20street.
• 17:23So on average,
• 17:25I actually zoom out here.
• 17:26Our patients experiencing homelessness with
• 17:28our data go to the
• 17:29emergency department three to three
• 17:31to four times more often,
• 17:33than other patients do and
• 17:34are admitted five times more
• 17:36often than other patients.
• 17:38So there's a tremendous amount
• 17:39of need here.
• 17:41And but I think this
• 17:42the asset we have going
• 17:43into this is, we generally
• 17:45know about what our denominator
• 17:47is. And in a lot
• 17:48of cases, we even know
• 17:49who you are, where you
• 17:50tend to sleep, and you're
• 17:51already insured. So it's like
• 17:52it was like a with
• 17:54a little more optimism, there's
• 17:55a setup for us to
• 17:55be able to have an
• 17:56intervention. Yeah. Steve Holt.
• 17:58What
• 18:02report,
• 18:03of of the population in
• 18:04New York is undocumented and
• 18:06not a candidate for New
• 18:07York Medicaid?
• 18:08So good question. We think
• 18:09it's about that difference.
• 18:11So we think that, generally
• 18:13speaking, everybody experiencing homelessness will
• 18:15come to the emergency room.
• 18:16If it's about seventy five
• 18:17percent that are insured, probably
• 18:19about a quarter. It's, you
• 18:20know, it may be less.
• 18:21I mean, it's probably a
• 18:22little bit less than that.
• 18:23It's probably more, like, you
• 18:24know,
• 18:25fifteen percent, something like that,
• 18:27because there's some number of
• 18:28people that, fortunately for them,
• 18:29didn't go to the emergency
• 18:30room. But, it's, yeah, so
• 18:31probably around that range.
• 18:34To your, implicit point there,
• 18:36we want everybody to have
• 18:38access to care. So whether
• 18:40for that population that wouldn't
• 18:41qualify for Medicaid, we will
• 18:43enroll them in NYC care.
• 18:45And I've had patients in
• 18:46my my panel in the
• 18:47Bronx,
• 18:48where I'm in clinic every
• 18:49Friday, who are experiencing homelessness
• 18:51and who are in NYC
• 18:52care. So I know it
• 18:53definitely happens,
• 18:54because they don't qualify for
• 18:55Medicaid.
• 18:57Yeah. Gary. So when you're
• 18:59I know you're gonna get
• 19:00to it. So feel free
• 19:01to answer the question. No.
• 19:02I I I'm loving it.
• 19:06Yep. We're heading towards trying
• 19:07to do something to Yep.
• 19:08Yep. Yep.
• 19:10To what degree
• 19:12do false constraints
• 19:14enter of the intervention,
• 19:16enter your thinking. Meaning,
• 19:19does something have to be
• 19:20cost savings for you, say,
• 19:22for you to implement to
• 19:23do? Because I see, like,
• 19:24there are longer hospital stays,
• 19:26more times going to the
• 19:27ER. Is the idea, like,
• 19:28okay. We're we can save
• 19:31nine million dollars, whatever, if
• 19:33if we get as many
• 19:34more people off the streets,
• 19:36and therefore, that'll be cost
• 19:37saving. Or are we thinking
• 19:39this has to be cost
• 19:40effective? Like, it's worth an
• 19:41investment to do Right.
• 19:43How how do you think
• 19:44about that? More the latter,
• 19:46but I would say not
• 19:47yet. So in other words,
• 19:48the the to flip the
• 19:49the the frame there,
• 19:51everybody in my program that
• 19:53I'm gonna tell you more
• 19:54about could be in a
• 19:55DHS
• 19:56department of homeless services, not
• 19:58federal DHS,
• 20:00New York City shelter tonight.
• 20:02Hundred percent could be.
• 20:03So that would be money
• 20:04that DHS would be spending,
• 20:06city money DHS would be
• 20:07spending where there is no,
• 20:08of course, recoupon,
• 20:09you know, shelter spending.
• 20:11So the way I think
• 20:12we're initially viewing this is
• 20:14this is a different way
• 20:15to spend money on the
• 20:16same population.
• 20:18It's gonna be more expensive
• 20:19for sure. And that's where
• 20:20over time, we're gonna we're
• 20:21gonna have to look at
• 20:22that's where the evaluation piece
• 20:24will come into it. How
• 20:25do we wanna define cost
• 20:26effectiveness? Is it just they
• 20:27didn't need to go to
• 20:28DHS? Is it fewer people
• 20:29sleeping on the streets? You
• 20:30know, what what are the
• 20:31outcomes that we care about?
• 20:32But, initially,
• 20:34we've been able to get
• 20:35the city to give us
• 20:36funding for two sites for
• 20:38two years, basically.
• 20:40Each site is about seven
• 20:41million dollars a year. Again,
• 20:43New York City money
• 20:46is doable.
• 20:48So but if this does
• 20:49work, then I think, you
• 20:50know, we'll get more into
• 20:51the realm of, okay,
• 20:53seven million dollars for each
• 20:55site. How many sites do
• 20:56we need? How many sites
• 20:58what what savings does that
• 20:59look like to DHS?
• 21:01And what savings does that
• 21:02look like to MetroPlus, the
• 21:04health insurance company that we
• 21:05own? That's why it's important
• 21:06to remember with, you know,
• 21:08about seventy five percent of
• 21:09people being insured, many of
• 21:11them are insured by the
• 21:12health insurance company that my
• 21:13system owns.
• 21:15So if we do a
• 21:16better job, that's just that,
• 21:17help MetroPlus will save money,
• 21:19and that will be risk
• 21:20surplus for our system. So
• 21:21how do you wanna balance
• 21:22out savings we might have
• 21:23with money DHS might have
• 21:24spent? That's the balance point
• 21:26we'll have to find.
• 21:27So yeah.
• 21:29Alright.
• 21:32So, we announced this program.
• 21:34We announced it in twenty
• 21:35in January twenty twenty five.
• 21:38And, then we said we
• 21:39were going to launch it
• 21:40as quickly as we could.
• 21:41Just a quick interesting,
• 21:43backstory to this for, for
• 21:45those that from they were
• 21:46grand rounds this morning.
• 21:48We, as a health system,
• 21:50have gone well beyond the
• 21:51four walls of our clinics
• 21:52in terms of what we
• 21:53do for New York City
• 21:54day to day. The reason
• 21:55we are doing this at
• 21:57all is because we,
• 21:59my team back in the
• 22:00day now in twenty twenty,
• 22:01set up the COVID hotels.
• 22:02We learned how to manage
• 22:04hotels for people,
• 22:05with, the issues of isolation
• 22:07and quarantine. We then set
• 22:08up the totality,
• 22:10designed and implemented all of
• 22:11the city's humanitarian centers, not
• 22:12just for medical care, for
• 22:14everything.
• 22:15During the asylum seeker crisis,
• 22:16I had a hundred and
• 22:17forty thousand people staying at
• 22:18my sites that stayed at
• 22:19my sites.
• 22:20And we built that brick
• 22:21by brick, including case management
• 22:23to help people get work
• 22:23authorization, medical needs. We administer
• 22:25two hundred thousand vaccines,
• 22:27did, innumerable health screenings, including
• 22:29chest x-ray upon entry for
• 22:31active TB. So we did
• 22:32a ton of work about
• 22:33how to build a new
• 22:34type of site, taking into
• 22:35account the needs of a
• 22:36population.
• 22:37And we basically volunteered to
• 22:38do this and said, hey.
• 22:39You know, this is an
• 22:40idea that had been circulating
• 22:42for a while among the
• 22:43psychiatry experts.
• 22:44But we're gonna get it
• 22:45done. And, we're gonna figure
• 22:47out how to do it
• 22:47quickly. And that's why we
• 22:48we did the ribbon cutting
• 22:49two weeks ago. So things
• 22:51are moving very fast now.
• 22:52But we wanna see as
• 22:53things move fast, you know,
• 22:54how this works and the
• 22:55impact we have. And just
• 22:57to put you a day
• 22:58in the life of, like,
• 22:58what my day to day
• 22:59is,
• 23:00it's not gonna be perfect
• 23:01on day one or or
• 23:02week two or, you know,
• 23:02whatever whatever it is now.
• 23:04These these programs evolve and
• 23:06adapt over time.
• 23:08The same way that, you
• 23:09know, when we set up
• 23:10the sites for asylum seekers,
• 23:11we didn't know that they
• 23:12would need case management to
• 23:13help them to get work
• 23:14authorization.
• 23:15But that became a cornerstone
• 23:16of our approach, you know,
• 23:17months in. So with this
• 23:19here, I'll tell you what
• 23:20we're currently thinking. I'm a
• 23:20show you our our whole
• 23:22staffing model. But just keep
• 23:23in mind, this is I'm
• 23:24not coming here to say
• 23:25this is perfect and final.
• 23:26I know it's gonna change
• 23:27and probably change a lot,
• 23:28but that's sort of the
• 23:29the fun of all this.
• 23:33So, generally, the model here,
• 23:35these are the principles behind
• 23:37it.
• 23:38I'm actually gonna take a
• 23:40there's another slide. The next
• 23:41one too, I'm gonna combine
• 23:42these together just to, to
• 23:43zoom out for a second
• 23:44and talk about the problem
• 23:45we're trying to solve here.
• 23:46And I'd be curious after
• 23:47I share this if this
• 23:48resonates, you know, with what
• 23:50you guys see here day
• 23:51to day or whether it
• 23:52seems very different in New
• 23:53Haven.
• 23:54But in New York City,
• 23:55what happens is
• 23:57we have,
• 23:58a good intelligence on how
• 24:00many people are sleeping outside.
• 24:01We have community outreach teams
• 24:02that go out day to
• 24:03day.
• 24:04They can bring patients to
• 24:05the or people to the
• 24:06hospital to become patients. That's
• 24:08That's when we enroll them
• 24:09in insurance.
• 24:10We do probably the best
• 24:12job in their relative approach
• 24:13here of starting or restarting
• 24:15you on antipsychotic
• 24:16medication. If you have severe
• 24:17mental illness, so schizoaffective, schizophrenia,
• 24:20or, you know, decompensated bipolar,
• 24:22were really, really good at
• 24:23putting you on a medication
• 24:24that work for you. You'll
• 24:25get to the point where
• 24:25you have linear linear thinking,
• 24:26clarity of thought. You won't
• 24:28need to be in the
• 24:28hospital anymore,
• 24:29but then it falls off.
• 24:30And that's the problem we're
• 24:31trying to solve here.
• 24:33Especially for people with serious
• 24:34mental illness,
• 24:36when you're started on the
• 24:37right long acting injectable or
• 24:39whatever it is, we don't
• 24:40have a good plan for
• 24:41you when you're ready to
• 24:42leave the hospital. It's great
• 24:44if you can go home
• 24:44with, with Carrie, if Carrie
• 24:45has a good family support
• 24:46system. And actually, it's a
• 24:47good the best example is
• 24:48you take care of your
• 24:49own family members. But, you
• 24:51know, from spending time with
• 24:52this population of people,
• 24:54they, with schizophrenia, will tell
• 24:55you they don't have family
• 24:56support. So they literally don't
• 24:58have a place to go,
• 24:59and they go back to
• 25:00the street, and there is
• 25:01no answer for that.
• 25:03Out of curiosity, just take
• 25:04a pause there. Is that
• 25:05a similar problem to how
• 25:07you perceive things here?
• 25:10I I mean, I I
• 25:11imagine it's a problem for
• 25:12everybody.
• 25:14So but it's just it's
• 25:15very, yeah, it's very pronounced
• 25:16in New York City. I
• 25:16think also because it's,
• 25:18it's it's become a political
• 25:19issue too. I mean, you
• 25:20can't walk down the street
• 25:21in New York City and
• 25:22not so you oftentimes see
• 25:23somebody sleeping on the street.
• 25:24So whether you're a billionaire
• 25:26or, you know,
• 25:28or not,
• 25:29You know, you're you're going
• 25:30to see people sleeping on
• 25:31the street in our city.
• 25:32So, it's a very visible
• 25:33issue.
• 25:35But, anyways, so as we
• 25:36designed the set the the
• 25:37program here, that was the
• 25:38key problem we wanted to
• 25:39solve was,
• 25:41that there had not been
• 25:42an approach that's worked for
• 25:43people with severe mental illness,
• 25:45and we wanted to start
• 25:46with the population that we
• 25:47thought we could have the
• 25:48best bridge to, those that
• 25:50had been inpatient, start on
• 25:51the right medications, ready to
• 25:53go, but don't have anywhere
• 25:54to go. So we said
• 25:55we're gonna do things differently.
• 25:57So instead of, creating another
• 25:59shelter system, we're going to,
• 26:01give you a private room.
• 26:02In New York City, if
• 26:04you have,
• 26:05if you go to a
• 26:05mental health shelter or any
• 26:06shelter and you're an adult,
• 26:07so let's say, you're not
• 26:08gonna get a private room.
• 26:09You're gonna be in a
• 26:10semi congregate setting. You're gonna
• 26:12be with, you know, fifteen,
• 26:13sixteen other people, maybe eight
• 26:15people. And, that's that is
• 26:16what shelter that's our shelter
• 26:18shelter system works. In this,
• 26:19we wanna say immediately, we're
• 26:21gonna do things a little
• 26:22bit differently there. We're going
• 26:23to give everybody a private
• 26:24room with a private fridge,
• 26:26private TV,
• 26:28and, their own room key.
• 26:29It's not inpatient. There's no
• 26:30curfew. You can leave or
• 26:31come when you want. We're
• 26:33gonna have you scan a
• 26:33QR code in your badge.
• 26:35It's gonna look like this.
• 26:37In and out every time
• 26:38you come in or out
• 26:38of the building so we
• 26:39will know exactly where you
• 26:40are. If you haven't come
• 26:41out of your room for
• 26:42fifteen hours, we're gonna knock
• 26:44on Brad's door. If you've,
• 26:45been gone for twenty four
• 26:46hours, we're going to activate
• 26:47the community team to see
• 26:48if we know where you
• 26:49are. So we're gonna be
• 26:50looking after people very closely,
• 26:51but it's not it's, but
• 26:52you can come and go
• 26:53as much as you want.
• 26:54It's not, this is intended
• 26:55to be a home like
• 26:56setting for doing your laundry.
• 26:58We have a contract with
• 26:59the local laundromat.
• 27:00We'll pay for it, but
• 27:01you gotta do it. So
• 27:02pick up your medications. We
• 27:03want you to go to
• 27:04the pharmacy. We will walk
• 27:05you there, but we want
• 27:06you to go. So we
• 27:07want this to try to
• 27:08be as much of a
• 27:09a bridge to making you,
• 27:10be successful managing yourself on
• 27:12your own when you're ready
• 27:13to leave the program, which
• 27:14we think will be about
• 27:15a one year stay.
• 27:17The second point, in addition
• 27:18to creating a home like
• 27:19environment, is, it's gonna have
• 27:21a very strong
• 27:22behavioral health and psychiatric component
• 27:24to it. And, you know,
• 27:26I I just wanna say
• 27:27this point because I don't
• 27:27wanna make it seem like
• 27:28I'm we're we're we've we
• 27:30feel like, you know, that,
• 27:31everybody's tried this and has
• 27:32failed in the past. Nobody's
• 27:34tried this before in New
• 27:34York City for a very
• 27:36simple reason. Nobody else can
• 27:38do this.
• 27:39You can't,
• 27:40our DHS system doesn't have
• 27:42psychiatrists.
• 27:42It's not their fault. They're
• 27:44a homeless shelter system.
• 27:46So we I've basically deploy
• 27:48not basically have have deployed
• 27:49the Bellevue psychiatry team. They're
• 27:51managing clinical care on-site.
• 27:53They're going to have a
• 27:54psychiatrist, twenty four seven nurses,
• 27:56social workers, community health workers
• 27:58with lived experience,
• 28:00peers also with lived experience.
• 28:01And we're not even gonna
• 28:02have security guards. We're gonna
• 28:03have special a special type
• 28:04of guard called a patient
• 28:05care technician that has experience
• 28:07with deescalating,
• 28:09events that are happening among
• 28:10people with,
• 28:11you know, that are in
• 28:12crisis with severe mental illness.
• 28:14So it's a very intensive
• 28:15medical model.
• 28:17And, again, we're gonna see
• 28:18if that's what people need.
• 28:19Maybe but, you know, next
• 28:21week, we might not need
• 28:21twenty four seven nursing coverage.
• 28:23Like, it is we're going
• 28:24into this with the intention
• 28:25of being flexible,
• 28:26but we want to, really
• 28:28try to, at the end
• 28:28of the day, make sure
• 28:30that everybody stays on their
• 28:31medication. I would just be
• 28:33very blunt and argue that
• 28:34if a schizophrenic patient falls
• 28:35off their medication, they have
• 28:36no chance.
• 28:38So our job is to
• 28:39make sure we do we're
• 28:39moving heaven and earth to
• 28:41have them stay on the
• 28:41medications that they started and
• 28:43prove they're able to take
• 28:44in the hospital.
• 28:46So that's the general premise
• 28:48behind the model.
• 28:50As I went over this,
• 28:51I'd a second ago too.
• 28:54But, again, the the main
• 28:55the the the focus initially
• 28:56for the model is going
• 28:57to be on patients that
• 28:58are ready to leave the
• 28:59hospital. They,
• 29:00start on the right medication.
• 29:01They're ready to, they don't
• 29:03need to be in the
• 29:04hospital anymore, but there currently
• 29:05is nowhere for them to
• 29:08go. Oh, and then sorry.
• 29:09This actually I have the
• 29:09whole slide in this. Great.
• 29:11Very important thing.
• 29:13As you're with us for
• 29:14a year oh, yeah. Please.
• 29:15You may be about to
• 29:16talk about this on this
• 29:17slide, but on the previous
• 29:18slide, you showed,
• 29:20that there is an application
• 29:21process, which makes sense. You
• 29:23wanna, you know, meet needs
• 29:24that are
• 29:26whatever your,
• 29:27need criteria are. Yep. Based
• 29:29on
• 29:30the population that you know
• 29:31a lot about,
• 29:32what kind of capacity do
• 29:33you think you're going to
• 29:34have, and how quickly will
• 29:36you reach a point where
• 29:37someone
• 29:38qualifies and you've got nowhere
• 29:39to put them? What what
• 29:40are you gonna do in
• 29:41that
• 29:42circumstance? Yeah. Great question. So,
• 29:44each site initially is going
• 29:46to be about fifty people.
• 29:47So these aren't huge sites.
• 29:49You know, it's it really
• 29:50is trying to prove the
• 29:51concept that it can work.
• 29:53I will tell you in
• 29:54the last two weeks since
• 29:55opening our first site,
• 29:57interestingly, we are on pace,
• 29:59but not, not ahead of
• 30:01pace about filling the site
• 30:03up. It's still sort of
• 30:04an open question. I'm gonna
• 30:05I have a slide later
• 30:06on about the exact eligibility
• 30:08we have. That's the type
• 30:09of thing to your point.
• 30:10Like, we we know we're
• 30:11gonna have to change it.
• 30:11You know? Maybe we're being
• 30:12too strict. Maybe we're being
• 30:13too, you know, too flexible
• 30:15initially.
• 30:16But that's the type of
• 30:17thing where we want to,
• 30:18make sure that we're serving
• 30:19as many people as possible,
• 30:20but being targeted enough that
• 30:21we understand what we've what
• 30:23we've done.
• 30:24So
• 30:26alright.
• 30:28This is the important point
• 30:29that I, should've talked about
• 30:30a couple slides ago too.
• 30:32So you're gonna be in
• 30:33a in a home like
• 30:34environment. Come go as you
• 30:35like, but we're gonna know.
• 30:36We're We're gonna offer you
• 30:37all of the clinical care
• 30:38that the Bellevue psychiatry team,
• 30:39with their centuries of experience,
• 30:41can think of,
• 30:42and we're going to get
• 30:43you into permanent housing. So
• 30:45we're that's why I mentioned
• 30:46about a year earlier. That's
• 30:47the amount of time that
• 30:48we think would be a
• 30:49safe bet to get you
• 30:50into permanent housing in New
• 30:51York City. It can be
• 30:53done in a few months.
• 30:54By the way, we're also
• 30:55not gonna kick you out.
• 30:55We're gonna offer you permanent
• 30:56housing before you leave.
• 30:58But generally speaking, we think
• 30:59that the one year barometer
• 31:00will be a good place
• 31:01to start. You know, maybe
• 31:03we're wrong, maybe it'll be
• 31:03longer or shorter. We'll we'll
• 31:05learn that as we go.
• 31:06These are just the steps
• 31:07for permanent housing. It is
• 31:09it is complicated, but of
• 31:10note,
• 31:11you know,
• 31:13your,
• 31:14mental health report and things
• 31:15like that, which we can
• 31:16do on-site, which can sometimes
• 31:17be a barrier for off-site.
• 31:18It's just nice to put
• 31:19everything under one umbrella. So
• 31:20our social work team will
• 31:21be armed with everything they
• 31:22need to get you into
• 31:23permanent housing, which is which
• 31:25is unique and something that
• 31:26we've struggled with.
• 31:28Yeah. Are you guys handling
• 31:29substance use disorder treatment, or
• 31:31is that different population?
• 31:34A lot of overlap. Great
• 31:35question.
• 31:36So,
• 31:38our,
• 31:39criteria does not include substance
• 31:41use. Meaning,
• 31:42if you have a substance
• 31:44use disorder, we welcome you,
• 31:45and we'll provide any care
• 31:46that you need. If you
• 31:47don't, that's great too.
• 31:49But we're, if for the
• 31:50initial launch here,
• 31:52we're not including that as
• 31:53a inclusion or exclusion criteria
• 31:55planning just to treat you.
• 31:56To your, you know, next
• 31:57question, in the future, would
• 31:59we wanna include patients that
• 32:00may exclusively have substance use
• 32:02disorder?
• 32:03Totally thinking about it. We
• 32:04just wanted to try to,
• 32:05you know, have some definition
• 32:06to start with and then
• 32:07see where things went.
• 32:08So they're if they're gonna
• 32:09be put on methadone or
• 32:10buprenorphine, that's just managed in
• 32:12the same way anybody else
• 32:13who's housed in some other
• 32:14place. Well, so it's, I
• 32:16I, actually, to put a
• 32:18little more precision on it,
• 32:19it's managed the same way
• 32:21that if you went to
• 32:22Bellevue's
• 32:22substance use clinic,
• 32:24because it is literally the
• 32:26same team.
• 32:27So any resource that they
• 32:28would have there will have
• 32:29at the site.
• 32:30So it's it's different from,
• 32:32like, if you were going
• 32:33to if, say, you're treating
• 32:34somebody on on the street
• 32:34or in a shelter or
• 32:35something like that. Like, we're
• 32:36gonna have a lot more
• 32:37capabilities to offer, what Bellevue
• 32:39would offer. We're taking a
• 32:41harm reduction approach.
• 32:42So, you know, it's not
• 32:43we're not going to it's
• 32:45not a,
• 32:46a a violation if you're
• 32:47using,
• 32:48substances on-site.
• 32:49There's no pharmacy on-site. Correct.
• 32:51Well, with the there's no
• 32:53pharmacy on-site. Yeah. That is
• 32:54for the regulars for people
• 32:55listening, absolutely right. We we
• 32:57do
• 33:00we do have a fridge,
• 33:01which is legal,
• 33:02with, long long acting injectables
• 33:04in it. So by prescription,
• 33:05we can administer those,
• 33:08which also is pretty unique.
• 33:09I that's gotta be the
• 33:10only site that has a
• 33:11fridge as long as I
• 33:11can injectables in the city.
• 33:12So Mostly antipsychotics.
• 33:14Mostly antipsychotics. Yeah. Exactly. Exactly.
• 33:16Exactly. But maybe more for
• 33:17substance use going forward. Yeah.
• 33:19Yeah. Yeah. Sorry. You mentioned,
• 33:21a lot of,
• 33:22opportunities to build up, like,
• 33:25life skills that should hopefully
• 33:26help them Yep. Successful
• 33:28after they graduate from the
• 33:30bridge and they're in, long
• 33:31term housing.
• 33:33Are there any, like, vocational
• 33:34training programs or, other programs
• 33:36to help with, like, reengagement
• 33:39with family members and and
• 33:40relationships they may have lost
• 33:41in the past? Yeah. Great
• 33:43question.
• 33:44So, the short answer is
• 33:45we're, doing as much as
• 33:46we can think of right
• 33:47now. I think that's an
• 33:48area where we're gonna actively
• 33:49learn, though. So right off
• 33:51the bat, we're having occupational
• 33:52therapy, which is really great.
• 33:54We're having group therapy with
• 33:56social work,
• 33:57so to bring have some
• 33:58camaraderie and talk about re
• 33:59you know, what it means
• 34:00to reengage family members' connections
• 34:02in that way. We're working
• 34:03with local community based organizations.
• 34:05There are, some organizations
• 34:07like Fountain House, for example,
• 34:09that provides services to people
• 34:11experiencing homelessness, but you can't
• 34:12stay there. It's actually a
• 34:14block away. So we're trying
• 34:15to leverage the community as
• 34:17much as we can.
• 34:19But I think we're gonna
• 34:20learn over time, like, do
• 34:22we need more straight vocational?
• 34:23Like, what are the job
• 34:24opportunities for somebody that's actually
• 34:27been stable with schizophrenia for
• 34:28a year? I and I
• 34:29would argue that there there
• 34:31are the right jobs for
• 34:31them for sure if we're
• 34:32able to keep them on
• 34:33their medications.
• 34:35But I think that's the
• 34:35piece where we're gonna sort
• 34:36of see where things go,
• 34:37and probably see what works
• 34:38best and build more of
• 34:39that.
• 34:40Yeah.
• 34:41What physical space did you
• 34:43use, or were there, like,
• 34:43zoning or regulatory challenges there?
• 34:46Or the answer to are
• 34:48there were there regulatory challenges
• 34:49is uniformly, yes.
• 34:52So we are in a
• 34:53hotel.
• 34:54Basically, we,
• 34:56bought out the hotel via
• 34:57a lease. So we,
• 34:59control the totality of the
• 35:00hotel. So we have the
• 35:02check-in area that we're used
• 35:03to checking to the hotel
• 35:04is now where we have
• 35:05scanned your the QR code
• 35:06on your badge and now.
• 35:08And, from a regulatory perspective,
• 35:10we are an article thirty
• 35:11one satellite clinic. I'm sorry.
• 35:13New New York's, New York
• 35:15terminology.
• 35:16We are a satellite clinic
• 35:17at Bellevue,
• 35:18which is great because then
• 35:19that also means we get
• 35:20the all the Bellevue services
• 35:22there.
• 35:23Yeah. What proportion of the
• 35:25clients are likely to be
• 35:26HIV positive? I have no
• 35:27idea.
• 35:32We will, get experience with
• 35:33that, I'm sure. But that's
• 35:34a good question. Was there
• 35:34something you're thinking about for
• 35:35that? Like services or Right.
• 35:37I mean, there's Yeah. Yeah.
• 35:38Burden of care that they're
• 35:40gonna need,
• 35:41and and just keeping track
• 35:42of those medications as well.
• 35:44Yeah. Yeah. Well, I think
• 35:45keeping track of the medic
• 35:46of their medications in general
• 35:47is gonna be a challenge.
• 35:48And I think,
• 35:50I'll keep saying we're gonna
• 35:51learn a lot about how
• 35:52to do that. I mean,
• 35:52initially, again, while we don't
• 35:54have a pharmacy, you're gonna
• 35:55be picking up your own
• 35:56medications. You know, if you're
• 35:57on a lot of medications,
• 35:58I just to say it
• 35:59simply, it's gonna be harder.
• 36:01And, you know, we're we
• 36:03don't wanna be
• 36:05totally looking over your shoulder
• 36:06to to say, did you
• 36:07take this pill, this pill,
• 36:08this pill? We wanna make
• 36:09sure you pick them up,
• 36:10but we want you to
• 36:11take them on your own
• 36:12unless it's long acting injectable.
• 36:13So I think that's part
• 36:14of the balance we're gonna
• 36:15see about how that works.
• 36:17Worst case, if people aren't
• 36:19taking their medications, we're gonna
• 36:20have to recalibrate.
• 36:23Yeah. Brad. I was just
• 36:25thinking about,
• 36:26how you guys are thinking
• 36:27about success of the program
• 36:28and what that looks like,
• 36:29and then also thinking about
• 36:31financial stability and
• 36:32how do
• 36:33you pull in all the
• 36:34pieces because Yep. There's a
• 36:36lot that you could include,
• 36:37but there may be barriers
• 36:38to things like how do
• 36:39you include potential of reducing
• 36:41recidivism is somewhat Mhmm. Frustrated
• 36:42because that obviously could reduce
• 36:44costs to the city broadly.
• 36:45Mhmm. Mhmm.
• 36:47But that data is often
• 36:48really hard to access and
• 36:50And delayed. Yeah. So just
• 36:51curious to hear about that.
• 36:53Yeah. Yeah. If you'll give
• 36:54me a minute,
• 36:55in a couple slides,
• 36:57that's where I want feedback.
• 36:59We have, I think, what
• 37:00I would consider sort of
• 37:00the obvious outcomes that we're
• 37:02thinking of looking at, but
• 37:03that is, where we could
• 37:04do some help.
• 37:06Alright. So
• 37:09okay. So here is our
• 37:10full staffing model. I talk
• 37:11I've talked about a lot,
• 37:12some of this already, but
• 37:13just to walk through it.
• 37:15It is rare and unique,
• 37:16at least in New York
• 37:17City, to have a psychiatrist
• 37:19that's seated on-site around the
• 37:21clock,
• 37:22which we do. His name
• 37:23is Chris. He's excellent.
• 37:25We have social workers, peers,
• 37:27nurses, occupational therapists,
• 37:29community health workers are didn't
• 37:31make the cut for the
• 37:32slide, it looks like, but
• 37:32we have them there.
• 37:34Psychiatry technicians are the security
• 37:36guards for,
• 37:38that are they have specialized
• 37:39training in de escalation.
• 37:41So, you know, this is
• 37:42our is our best,
• 37:43you know, the best,
• 37:45model we could put together
• 37:46here for staffing.
• 37:48Not gonna be perfect. We're
• 37:48gonna learn a lot. I'll
• 37:50take a pause here, though.
• 37:51I'm curious if if there's
• 37:52any immediate,
• 37:53thoughts or reactions that folks
• 37:54have.
• 37:56You have one psychiatrist who's
• 37:58there all the time? Correct.
• 38:00But it's not the same
• 38:01person. Surely they have breaks.
• 38:05Chris does not live at
• 38:06the site.
• 38:07But we so, he's there,
• 38:09like, nine to five, Monday
• 38:10through Friday. And when he's
• 38:11not there, it's the same
• 38:12as with any Bellevue patient.
• 38:14The rest of the Bellevue
• 38:15team covers.
• 38:16So it's nice because, like,
• 38:17we get a dedicated person
• 38:18that gets to know everybody.
• 38:20But if something happens at
• 38:21two in the morning, it's
• 38:22Bellevue team covering,
• 38:24which they're good at.
• 38:26Yeah.
• 38:27Are they engaged in a
• 38:29specific primary care setting, or
• 38:30do they have access to
• 38:31primary care throughout this the
• 38:33city from
• 38:34from prior hospitalizations
• 38:36and relationships and such? Great
• 38:38question. And, I the in
• 38:39two slides, I'm gonna get
• 38:40to some of the other,
• 38:41the primary care component of
• 38:43all of this. But in
• 38:43a nutshell,
• 38:45we have special clinics for
• 38:46people experiencing homelessness that I'm
• 38:48very proud of, and I
• 38:48have a little bit of
• 38:49data to share about them
• 38:49too.
• 38:50My goal is to have
• 38:51every single person in this
• 38:52program go to those clinics
• 38:54when they're there and then
• 38:55afterwards permanently.
• 38:56Put it nice and simple
• 38:57like that.
• 39:00Yeah. Yeah.
• 39:02Oh, question from the Zoom.
• 39:03Alright.
• 39:06Hi, Dave.
• 39:07Hey, Ted. Sorry I'm not
• 39:09there in person, but
• 39:10great great progress.
• 39:12I love this. I'm just
• 39:13I may have missed this
• 39:13because I came a little
• 39:14late, but it's easy.
• 39:15Dave, it's been a bit.
• 39:16I can't see you. Is
• 39:18Sam Semperis,
• 39:19from Pathways to Housing helping
• 39:21at all advising? Seems like
• 39:22their project based housing facilities
• 39:24can be very instructive.
• 39:28Housing.
• 39:29Housing. Housing. Helping. It seems
• 39:30like project based housing facilities
• 39:30can be instructive.
• 39:33I'm not sure. Dave, if
• 39:34you wanna shoot, what?
• 39:36My email. It's ted dot
• 39:38long at n y c
• 39:40h h c dot org.
• 39:41Maybe we can,
• 39:42Dave, I have your email.
• 39:43So we'll we'll we'll we'll
• 39:44find a way. Quit being
• 39:46bashful.
• 39:49That would be nice if
• 39:50you could be on the
• 39:50screen. Yeah.
• 39:52Yes. Okay. Yeah. This mic's
• 39:54not working. Oh, sorry.
• 39:57Curious about the different options
• 39:59with regard to this forty
• 40:01hour a week psychiatric
• 40:03psychiatrist stuff. Mhmm. And do
• 40:04you have psychiatrists Yep. Having,
• 40:06like, a psychiatric social worker?
• 40:08Like, I'm just what were
• 40:09the what went into the
• 40:11decision about
• 40:13that? We have both.
• 40:16So, I mean, to to
• 40:17your point, though, so in
• 40:18the future, do we need
• 40:19to have one full time
• 40:21psychiatrist per site?
• 40:23Probably not, but we don't
• 40:24know. Maybe the balance is
• 40:25one per two sites.
• 40:28Maybe the balance is a
• 40:29different part time arrangement, something
• 40:30like that. So this I
• 40:31think to your to your
• 40:32right, Kara, I should have
• 40:33been clear about this. This
• 40:34is more of,
• 40:36the full court press approach.
• 40:38I think this this is
• 40:39everything we could we could
• 40:40think of,
• 40:42that would be help potentially
• 40:43helpful. But we may add
• 40:45more on or we may
• 40:45peel some layers back. Like,
• 40:47for example,
• 40:48I asked my team to
• 40:48have nurses there twenty four
• 40:49seven when the site launches.
• 40:51Is that necessary? No. We
• 40:52all know it's not gonna
• 40:53be necessary long term, but
• 40:54I wanna see what happens.
• 40:56I wanna learn as we
• 40:57go. So I think, you
• 40:58know, this is sort of
• 40:58the maximum, if you will.
• 41:03Alright. So,
• 41:05eligibility, I'll go quickly through
• 41:06this because there's only three
• 41:07more, like, three more slides.
• 41:09But I wanna get to
• 41:10the, to Brad's question about
• 41:11outcomes.
• 41:12So for eligibility,
• 41:14single adult men identifying people
• 41:16identifying as male, eighteen years
• 41:18or older,
• 41:19completed inpatient stabilization, as I
• 41:21said. Have to have SMI,
• 41:22of course.
• 41:24We want,
• 41:25you to come from our
• 41:26behavioral health department.
• 41:29In the future, we may
• 41:30broaden that or we may
• 41:31say to other
• 41:33inpatient psych units, they could
• 41:34transfer somebody to us to
• 41:35evaluate and then send to
• 41:36the program, but we don't
• 41:36want to start to with
• 41:37the simplest approach.
• 41:39You have to be experiencing
• 41:40homelessness.
• 41:41You have to have had,
• 41:42you know, multiple engagements, so
• 41:43we're sure that you need
• 41:44these services.
• 41:46You need to be able
• 41:47able to perform your ADLs.
• 41:49And, importantly, you need to
• 41:50agree to participate. This is
• 41:51not a mandatory program.
• 41:53We want this to be
• 41:54a program people want to
• 41:55be a part of. It's
• 41:55actually sort of funny. We,
• 41:57we have a brochure that
• 41:58is for patients to try
• 42:00to, you know, sell you
• 42:01on the program. Yeah.
• 42:03I think one of the
• 42:04the really nice
• 42:05benefits of choosing kind of
• 42:06like a hotel structure
• 42:08is that you've I assume
• 42:10it's probably a bit more
• 42:11modern than some of the
• 42:12existing Yeah. Yeah. Yeah. Totally.
• 42:14Probably have accessible suites,
• 42:16that are an option Yep.
• 42:17Independent
• 42:18with ADLs, but of course,
• 42:20somebody might be using mobility
• 42:21equipment. Yeah. Exactly.
• 42:23So what is the capacity
• 42:24in the particular buildings you've
• 42:25chosen look like for people
• 42:27who either come in using
• 42:28something like a walker or
• 42:29a wheelchair or through a
• 42:30future medical event, you know,
• 42:32short term, now they're gonna
• 42:33need a a tub transfer
• 42:34bench. Like, can you can
• 42:35they stay?
• 42:36Yep. So, in short, and
• 42:38that's in those situations, we
• 42:40would likely find a way.
• 42:41For people with some accessibility
• 42:42issues,
• 42:43we I think it's,
• 42:45like, ten percent of the
• 42:46maybe more than ten percent.
• 42:47Maybe it's ten percent. Something
• 42:48like that of the rooms
• 42:49are accessible. So we should
• 42:50be good on that front.
• 42:51And then, I mean, the
• 42:52nice part about, again, taking
• 42:54a page out of why
• 42:55has nobody done this before,
• 42:57those are hard questions. We're
• 42:58a health care we're a
• 42:59hospital system. We have all
• 43:00you know, we can find
• 43:01the the answer to anything
• 43:02medical. So it's a big
• 43:03advantage we have compared to
• 43:05another city agency that doesn't
• 43:06have, you know, the back
• 43:07end of Bellevue Hospital a
• 43:08few blocks away. So
• 43:13alright. So,
• 43:15the this is a schematic
• 43:17that sort of shows where
• 43:18we are now. Another population
• 43:19that we're interested in serving
• 43:20going forward are those that
• 43:21are justice involved,
• 43:23that are experiencing homelessness as
• 43:24well.
• 43:25But right now, it's a
• 43:26tumultuous place.
• 43:28The this, I wanted to
• 43:29spend a second on here
• 43:30just to make the point.
• 43:31This is around the primary
• 43:32care point,
• 43:33about how things are today.
• 43:35So,
• 43:36we have the behavioral health
• 43:37services that I talked about
• 43:38a couple of slides ago,
• 43:40but we have a strong
• 43:41primary care footprint and opportunity
• 43:43here as part of this.
• 43:44And I just wanted to
• 43:45to give a little bit
• 43:46more detail there.
• 43:47So all of this is,
• 43:49for those from Grand Rounds,
• 43:50all of this is fairly
• 43:51new. Like, we built out
• 43:52these different programs,
• 43:54you know, over time. But,
• 43:56we not only have, if
• 43:58you are a person experiencing
• 43:59homelessness, specialized clinics, including at
• 44:01Bellevue, which are open access.
• 44:04You know, if you're a
• 44:05person experiencing homelessness, you're not
• 44:06gonna make it on the
• 44:07minute of your appointment. So
• 44:08we say, you know, just
• 44:09come when you like. We
• 44:10have integrated behavioral health in
• 44:12these clinics. We have,
• 44:14social work support. We have
• 44:15community health workers that are
• 44:16specifically there for to help
• 44:18people experiencing homelessness.
• 44:20These clinics are very effective,
• 44:21and I'll just jump ahead
• 44:23one slide to come then
• 44:24come back. This is where
• 44:25and I shared this grand
• 44:26rounds too where this data
• 44:27comes from. So these clinics
• 44:29that we've designed, which are
• 44:30primary care clinics,
• 44:31if you step foot into
• 44:32them, you have a fifty
• 44:34seven percent reduction in in
• 44:35a risk of going to
• 44:36the ED and a sixty
• 44:37seven percent reduction in risk
• 44:38of being admitted.
• 44:40So these numbers, by the
• 44:41way, are not unique to
• 44:42New York City. Good interventions
• 44:44for people experiencing homelessness in
• 44:45other cities have found, I
• 44:47would say, similar numbers. But
• 44:48these are awesome. I mean,
• 44:49imagine if we could do
• 44:50this for everybody experiencing homelessness
• 44:52in New York City. I
• 44:52mean, then you've really changed
• 44:53the world. So, you know,
• 44:55our hope is that
• 44:57these will provide sort of
• 44:58a benchmark of what we
• 44:59hope to accomplish with these
• 45:00new sites.
• 45:01And maybe we'll even do
• 45:02a little bit better in
• 45:03that. This is just if
• 45:04you enter into into medical
• 45:05care with us. Imagine if
• 45:06we also had housing onto
• 45:08this. Housing has an independent
• 45:09effect on your risk of,
• 45:10or, on reducing your risk
• 45:12of, being admitted to the
• 45:13hospital or going to the
• 45:14ED. So, these clinics exist.
• 45:16They're effective. They provide the
• 45:18base, sort of intellectual basis
• 45:20for the new program,
• 45:21but, also, we still access
• 45:23them. So
• 45:24I want to have all
• 45:25of the patients that are
• 45:26coming to our program go
• 45:27to these clinics. I built
• 45:29them out,
• 45:30a lot over the last,
• 45:31you know, eight years. We
• 45:32have, you know, five times
• 45:34as many as we did
• 45:35eight years ago.
• 45:36And,
• 45:37when people leave too, we
• 45:38want them to be comfortable
• 45:39continuing to get care. So
• 45:41if you're used to getting
• 45:42care in this model at
• 45:43Bellevue, we want you to
• 45:44continue to go to Bellevue
• 45:45with the doctor you trust.
• 45:47So these clinics are a
• 45:48really important part.
• 45:49Also,
• 45:51for people,
• 45:52let's say we lose track
• 45:53of you for a couple
• 45:54of days. We have other
• 45:55resources too. So we have
• 45:57our show program or street
• 45:58health outreach and wellness.
• 46:00This is the program that
• 46:01I'd started in twenty twenty
• 46:02one, to help people experiencing
• 46:04homelessness and living on the
• 46:05street to get vaccinated by
• 46:06saying, how can we help
• 46:07you first? Delivering wound care,
• 46:09medications,
• 46:10getting into housing, clothes, whatever
• 46:12you need. We gave it
• 46:13to you in the moment
• 46:14then vaccinated you.
• 46:15Worked so well that this
• 46:16program is able is actually
• 46:18now baselined in New York
• 46:19City's budgets.
• 46:20And we can use the
• 46:21program to help this program
• 46:22to we can use the
• 46:23show program to support the
• 46:24bridge to home program too.
• 46:26We're actually gonna show you
• 46:26a show I'll show you
• 46:27a minute a couple of
• 46:28blocks away. Yeah. Steve.
• 46:30So is there any relationship
• 46:31with medical legal partnerships,
• 46:33the police
• 46:35systems, so that if people
• 46:36get picked up for whatever
• 46:37and they're in a holding
• 46:38cell and they're gonna
• 46:39miss important meds, is there
• 46:41any
• 46:41opportunity to intervene and create
• 46:43a relationship and get these
• 46:44folks back out to you
• 46:46sooner?
• 46:47Yeah. Really good question. I
• 46:48think that's something we should,
• 46:50we're working on now, but
• 46:51we need to
• 46:53both put more thought into
• 46:54it, but also see, you
• 46:55know, see how things go.
• 46:56We've, briefed and met with
• 46:57the local police department.
• 46:59So they're aware of the
• 47:00program. They're aware of the
• 47:01needs, and they certainly know
• 47:02how to
• 47:03their first question is how
• 47:04do we reach you?
• 47:05So they know.
• 47:07So I think that'll be
• 47:08helpful too. Because, again, I
• 47:10think the use case of
• 47:11somebody, let's say, goes back
• 47:13to sleeping on the street
• 47:14two blocks away from the
• 47:15program. We may not even
• 47:16know that at the program.
• 47:17We may just know that
• 47:18they're gone. So maybe it's
• 47:20the Department of Homeless Services
• 47:21outreach team that finds them.
• 47:23Maybe it's the show program
• 47:24that finds them. Maybe it's
• 47:25the police that find them.
• 47:26All roads, we want to
• 47:27lead back to the program,
• 47:28though. So I think that'll
• 47:29be something where interagency collaboration
• 47:31will see how things go.
• 47:33Medical legal specifically,
• 47:34we are in in a
• 47:35good place there. We have,
• 47:37a substantial and effective contract
• 47:39with NILAG, which is definitely
• 47:40New York New York specific,
• 47:42so it stands for New
• 47:43York.
• 47:44But basically,
• 47:45an excellent legal team,
• 47:47that, any of our patients
• 47:48can access.
• 47:50So but to Steve's point,
• 47:52I mean, I think one
• 47:52of the things that we
• 47:53wanna see how things go
• 47:54here is,
• 47:55well, p where this is
• 47:56the program's not going to
• 47:57work for everybody. But as
• 47:59people are experiencing the program,
• 48:00like, how can we see
• 48:01what we can do to
• 48:02help people to stay in
• 48:03the program? And that's where
• 48:04I think we're gonna have
• 48:05a lot more learning to
• 48:06do. The show unit, like
• 48:07I said, we're positioning one
• 48:09right next to the program.
• 48:10They have roving teams with
• 48:11backpacks on, so we're gonna
• 48:12have some, you know, intelligence
• 48:14and opportunity to to intervene
• 48:15should people walk, you know,
• 48:16far away and then not
• 48:17come back.
• 48:18We also have,
• 48:20worthy of note, our own
• 48:21ambulance system.
• 48:22And, this is all in
• 48:23the same EMR. So let's
• 48:25say you are a patient
• 48:26with schizophrenia.
• 48:28You're on your meds, but
• 48:29it's not enough. That will
• 48:30happen.
• 48:31We will transport you to
• 48:32Bellevue. We'll document it in
• 48:33Epic, and the Bellevue team
• 48:35will pull up your record
• 48:35in Epic and see exactly
• 48:37what happened.
• 48:38So, we hope for patients
• 48:39that need to go, hopefully,
• 48:40for not too long back
• 48:41to the hospital, they'll then
• 48:43be able to come back
• 48:43to us with seamless care
• 48:45and seamless communication.
• 48:46So, again,
• 48:48you know, falls, is the
• 48:49the same page out of
• 48:50the book of, part of
• 48:51the reason this sort of
• 48:52thing wasn't done before is
• 48:54I mean, that's really hard
• 48:56to do, especially if you're
• 48:57another city agency.
• 48:59We happen to everything will
• 49:00be on Epic, so we
• 49:01have the advantage of, you
• 49:02know, a very good communication.
• 49:06We also have mobile teams
• 49:07in addition to the show
• 49:08program that can engage you
• 49:09on the street. So we
• 49:10have a lot of resources,
• 49:11and we're gonna see how
• 49:12it goes here.
• 49:14Let me just take a
• 49:15pause here. I I know
• 49:16it's sort of, the schematic
• 49:17maybe,
• 49:18is complicated, but it's it
• 49:20also, I know, is complicated
• 49:21all the array of services
• 49:23we have even through my
• 49:24organization in New York City.
• 49:26But any questions about sort
• 49:27of the array of, service
• 49:29options for people?
• 49:34Okay. Then we're gonna get
• 49:35to the last part here.
• 49:37This program's launched. We're very
• 49:38excited.
• 49:39Last slide.
• 49:41So we've put as much
• 49:42thought into this issue as
• 49:44you can see on the
• 49:44slide,
• 49:46which is less than Brad's
• 49:47question.
• 49:48So we are, overtime going
• 49:50to be able to evaluate
• 49:51all this.
• 49:52This is just what we're
• 49:53initially thinking about,
• 49:55but we'd love to spend
• 49:56a couple of minutes,
• 49:57to hear what folks think.
• 49:59Yeah. Yeah. Please.
• 50:02Initial methods question. So your
• 50:04outcomes here are all kind
• 50:06of, like, decreased or reduced.
• 50:08What is your comparison group
• 50:09gonna be? Because this is
• 50:11a question. A voluntary program.
• 50:13So Right.
• 50:15Right. I will actually,
• 50:16welcome thoughts. I mean, it
• 50:17could be,
• 50:19against peep the denominator could
• 50:21be all people in the
• 50:21hospital that could be eligible.
• 50:22It could be all people
• 50:24including those that are ineligible.
• 50:25Could be just those that
• 50:26step foot in the sites.
• 50:27We haven't,
• 50:29do
• 50:30what? Compensity match would be
• 50:32would be a great option.
• 50:33We could use some help
• 50:34with that, actually, if anybody's
• 50:35interested.
• 50:37Yeah. There's nobody assigned to
• 50:38research this, by the way.
• 50:40It's hard to launch it.
• 50:41Yeah.
• 50:43Yes. That's something I want.
• 50:44They might just be different
• 50:45than people Mhmm. Mhmm. I
• 50:47am eligible, but I don't
• 50:49wanna go to this place.
• 50:50So ten Excellent point. Yeah.
• 50:52Bunch of people who do
• 50:53opioid policy related research at
• 50:55the School of Public Health.
• 50:56Some of them might be
• 50:57quite interested in trying trying
• 50:58to help you design the
• 50:59fluency matched. And I'm quite
• 51:00interested in the in the
• 51:01intro introduction.
• 51:03Jason?
• 51:05You don't have any I
• 51:06don't think so. It's I've
• 51:07been gone for decades.
• 51:11One site right now. Correct.
• 51:14How many sites went over
• 51:15there for
• 51:17So we've been funded for
• 51:18two. So it's a but
• 51:19the funding we've received so
• 51:21far is still sort of
• 51:22at, like, the the the
• 51:23level of proof of, proof
• 51:24of concept.
• 51:26Out of all the sites
• 51:27in within New York health
• 51:28and and hospitals, it's like
• 51:31a hundred sites or something.
• 51:32Yeah. Yeah. It's more it's
• 51:33about fifty now. But yeah.
• 51:34So this is this is
• 51:35just happening at one site.
• 51:36So you've got Correct. Other
• 51:37places are control groups in
• 51:39a way because it's this
• 51:40you have similar homeless populations
• 51:41in all these different areas,
• 51:43and you're just comparing that
• 51:45this this place where an
• 51:46innovation is happening with all
• 51:47the other ones where it's
• 51:48not happening yet. That's true.
• 51:49And, today, I think the
• 51:50number is, like, we have
• 51:51eleven hundred or so people
• 51:53admitted, on inpatient psych across
• 51:55my eleven hospitals.
• 51:57I think the problem is
• 51:58the voluntary
• 51:59aspect of the program. People
• 52:00self select. They're not the
• 52:01same as just the general
• 52:03population of people requiring that.
• 52:05I'd say you're comparing how
• 52:07one population of people at
• 52:09one site does with a
• 52:09new innovation compared with all
• 52:11the other
• 52:12sites whether it's voluntary or
• 52:13not voluntary. You're showing that
• 52:15just having this available
• 52:17changes the
• 52:18proportion of people who are
• 52:19homeless or not homeless or
• 52:21But the question is, does
• 52:22it really change it or
• 52:23were they just different people
• 52:24to begin with?
• 52:27Essentially, you put people on
• 52:28a waitlist.
• 52:29Mhmm.
• 52:31Essentially,
• 52:32you get to fifty, continue
• 52:35screening folks and seeing if
• 52:37they'd be willing to. And
• 52:37then,
• 52:38you know, not just randomize
• 52:40people completely, but say, like,
• 52:41okay. It's a natural experiment.
• 52:42We don't have any space.
• 52:43What happens to you in
• 52:45the in the, you know,
• 52:45period of time where you
• 52:46don't have it? Obviously, you
• 52:47have to figure out you
• 52:48take those folks off the
• 52:49wait list if they're unstable.
• 52:51Right. And then
• 52:53Yeah. Controls.
• 52:55How so?
• 52:56These are peep you said
• 52:57you have a lot of
• 52:58data on these people already.
• 52:59Yeah. We do.
• 53:00So you have somebody who
• 53:02has Yeah. The utilization patterns.
• 53:04Prior year or prior two
• 53:05years, and then you look
• 53:06at what their pattern is
• 53:07after you're in a Yeah.
• 53:08Yeah.
• 53:09Yeah. That's true. And that
• 53:10that's the the method I
• 53:11believe that we chose for
• 53:12the data I presented here.
• 53:15When so you, were part
• 53:17of the eligible population if
• 53:18you step foot into the
• 53:19clinic. So you're sort of
• 53:20are your own control. The
• 53:21individuals are their own control.
• 53:22Correct.
• 53:23Yeah. I believe this is
• 53:24them being their own control.
• 53:26So we could do the
• 53:27same thing.
• 53:28Overdose rates too.
• 53:30Yeah. Yeah. Yeah. But I
• 53:31think also to to to
• 53:33Steve's point, as we one
• 53:34of the challenges would be
• 53:35as we expand or change
• 53:36eligibility, that that'll be another
• 53:38thing that'll make it harder
• 53:39to to research as we
• 53:40think about, like, substance use.
• 53:41But,
• 53:43I think it's sort of
• 53:44that balance point of, like,
• 53:45the real world implementation.
• 53:46Like,
• 53:47that, I I said a
• 53:49bunch of times we I
• 53:50know things are gonna change,
• 53:51which makes it harder to
• 53:52study. But maybe keeping you
• 53:53as your own control group,
• 53:55you know, counsel some of
• 53:56that.
• 53:57I think it does a
• 53:57lot. I mean, obviously, that
• 53:59especially because as people age,
• 54:01their probability of being homeless
• 54:02goes down.
• 54:04Right?
• 54:05Yeah. Yeah. Yeah.
• 54:07So anything device
• 54:09away from you showing it.
• 54:11That's true. Mhmm. Yeah, Brad.
• 54:13I mean, I'm just thinking
• 54:14that not just the I
• 54:16think that I imagine these
• 54:17outcomes are the easier ones
• 54:19for you guys to to
• 54:20monitor, and I think that's,
• 54:21like,
• 54:22how hard is to think
• 54:22about either recidivism or engagement
• 54:24with other law enforcement entities
• 54:27that, again, I know it's
• 54:28not a little bit of
• 54:29the partial umbrella of this
• 54:30No. No. No. But that's
• 54:31a great point. Yeah. I
• 54:32think you're ultimately gonna have
• 54:33to make the case that
• 54:35you need more money to
• 54:35do this broadly.
• 54:37Can I mean, this is
• 54:38kind of a super hard
• 54:39to get integrated data, but
• 54:41I don't know how hard
• 54:41that is in your world
• 54:42to say, let's pull data
• 54:44from the corrections and from,
• 54:46you know, departments of the
• 54:47police, etcetera?
• 54:49Well, actually, so to do,
• 54:51to do one better there,
• 54:52we have,
• 54:54a memorandum of understanding for
• 54:56data sharing with the Department
• 54:57of Home Services.
• 54:58So we actually like, one
• 54:59of the, the one of
• 55:01the outcomes I'd be interested
• 55:02in, personally would be, you
• 55:03know, if you walk down
• 55:04the street, are you less
• 55:05likely to see somebody sleeping
• 55:06there? In other words, if
• 55:07there's thirty five hundred people
• 55:08tonight, they'll be sleeping outside.
• 55:10And, the number is two
• 55:11thousand, you know, a couple
• 55:13years from now, that'll be
• 55:14that that would be a
• 55:15pretty pretty good outcome. But
• 55:17I think we we actually
• 55:18probably could study that a
• 55:19little more intellectually,
• 55:21if we were able to
• 55:22get the right data,
• 55:23you know.
• 55:24It's it's it's own special.
• 55:26It's yeah. But I think
• 55:26I think that would be
• 55:27doable. It's a DHS in
• 55:28New York City goes on
• 55:29something called the CARES system,
• 55:31but we've been able to
• 55:31work with them on that.
• 55:32And I think our MOU
• 55:33might apply. So good point.
• 55:36Yeah.
• 55:37Have you made any presentations
• 55:38to School of Public Health?
• 55:40No. We we launched just
• 55:41two weeks ago.
• 55:43If you don't know about
• 55:44the work that you're doing.
• 55:45No. Because they're extremely interested
• 55:47now in, you know, science
• 55:49science to society is the
• 55:51whole theme that they're Yeah.
• 55:52Megan Reagan is extremely interested
• 55:54in this stuff. Yeah.
• 55:55My point is just that
• 55:56they might be able to
• 55:57provide you with some free
• 55:58analysis. Yeah. Yeah. I I
• 55:59know. I saw I knew
• 56:01I knew where you were
• 56:01going with that. Let's talk
• 56:03after this. That that sounds
• 56:04great.
• 56:07Alright. I know we're right
• 56:07at time, and if Yeah.
• 56:08I was gonna say last
• 56:09couple of questions and we'll
• 56:10wrap up. We have a
• 56:11online.
• 56:17Yeah. I have a question,
• 56:18but it's not directly related
• 56:20to this particular project. Yeah.
• 56:22You're doctor Hughes, you're allowed
• 56:23to ask if
• 56:24he wants.
• 56:27So
• 56:28you you did a good
• 56:29job describing
• 56:31how you developed a lot
• 56:32of these initiatives.
• 56:34You listened to people, you
• 56:35talked,
• 56:36you
• 56:37Mhmm. And
• 56:40so I'm interested
• 56:41in how we duplicate
• 56:43you without
• 56:47physicians in training, medical students
• 56:49follow you around? I mean
• 56:52Air biz, welcome New York
• 56:53City.
• 56:56Can you can you
• 56:59think of any instances
• 57:03you you introduced learned
• 57:07of techniques of listening, visiting,
• 57:10and being patient and taking
• 57:12time.
• 57:13There's lots of people, lots
• 57:14of physicians that have gone
• 57:16into leadership that never learned
• 57:18any of that.
• 57:19And I'm just curious
• 57:22if there is some if
• 57:23there's some series of steps
• 57:25that we Mhmm. For
• 57:28the training of future
• 57:30leaders in public health.
• 57:32Well, I think, I mean,
• 57:34just to, you know, I
• 57:35agree with your premise. I
• 57:37mean, I I I take
• 57:38it to the the point
• 57:39where Steve stepped away.
• 57:41I was talking to Steve
• 57:42about this. I I my,
• 57:44job and role, I don't
• 57:45view myself as having to
• 57:46come up with good ideas.
• 57:47I just have to be
• 57:47able to implement the good
• 57:48ideas that people have. You
• 57:50have to but you have
• 57:50to listen to You have
• 57:51to listen. Yeah. Exactly. Half
• 57:52it's listening, half it's implementing.
• 57:54And I think, yeah, my
• 57:56one thing I would say
• 57:57is, just spending time with
• 57:58frontline doctors. I mean, medical
• 57:59students I don't know if
• 58:00you could do, like, a
• 58:01survey or to spend time
• 58:02with people and hear, you
• 58:03know, qualitatively what the key
• 58:05issues are for people.
• 58:06I visit every site in
• 58:07our system, and that's how
• 58:08I knew what I need
• 58:09to do to fix access
• 58:10to primary care. Couldn't have
• 58:11done it otherwise. It wasn't
• 58:12my ideas. It was everybody
• 58:13else's ideas. And I think,
• 58:14you know, it's, just in
• 58:16terms of, like, validating experiences,
• 58:18I think the the most
• 58:19extreme one I can think
• 58:20of, which, actually, they could
• 58:22accompany these, mobile units if
• 58:24they wanted to. But I've
• 58:25I'm a
• 58:26one hundred percent believer in
• 58:28needing to have the people
• 58:29affected by an intervention be
• 58:30the ones to lead it
• 58:31and to design it and
• 58:32to co run it with
• 58:32us. And the extreme example
• 58:34did you hear the grand
• 58:35rounds where I talked about
• 58:36MPOX?
• 58:37Just for those that didn't,
• 58:38I I to me, it
• 58:39was still a funny story
• 58:40because I remember the community
• 58:41said we couldn't we would
• 58:42never do this. So we
• 58:42took it as a challenge,
• 58:43and we definitely did do
• 58:44it.
• 58:45During MPOX,
• 58:47we, the Department of Health
• 58:48set up, some mass vaccination
• 58:50sites across the city, but
• 58:51there was still a population
• 58:52of people that was, you
• 58:53know, disengaged, disenfranchised from health
• 58:55care that were engaging in
• 58:56higher risk behaviors going to
• 58:58commercial sex venues.
• 58:59And I remember I talked
• 59:00to a bunch of, you
• 59:01know, community leaders, and they
• 59:02told me these are the
• 59:03places you need to go,
• 59:04but you're not gonna go
• 59:05there.
• 59:06And I took the challenge,
• 59:07and we literally went there.
• 59:08So I brought my mobile
• 59:09units to commercial sex venues,
• 59:11unmarked them, and it was
• 59:13so popular,
• 59:14that we vaccinated
• 59:16sixty per up to sixty
• 59:17percent of people going into
• 59:18the site, and then one
• 59:19of the sites even named
• 59:20their commercial sex venue after
• 59:22my vaccine units.
• 59:25Just totally true story.
• 59:27True story. Sounds great. But
• 59:30I had a lot of
• 59:30sense.
• 59:33What predisposed
• 59:34you to be
• 59:35out
• 59:37there in identifying the people?
• 59:39Because lots of people never
• 59:41learn that.
• 59:42Yeah. Yeah. I have to
• 59:44think about that, Jack. That's
• 59:45a really good question.
• 59:47But I definitely have the
• 59:48conviction that's the only way
• 59:49to make real change.
• 59:50Ted, you did the clinical
• 59:51scholars program at a time.
• 59:53True. Thanks, Carrie.
• 59:55Research was a major I
• 59:56I can say this since
• 59:57I'm not
• 59:58not him.
• 60:00You know,
• 01:00:03the fellowship. Right? Yeah. And
• 01:00:04I think also,
• 01:00:06qualitative research really affected me
• 01:00:08too, just learning the methods
• 01:00:09and principles behind it. That
• 01:00:10was the first paper Carrie
• 01:00:12knows I ever published as
• 01:00:13a qualitative paper.
• 01:00:14You know, I just talked
• 01:00:15to everybody that was read,
• 01:00:16made a lot at Yale
• 01:00:17New Haven and, you know,
• 01:00:18developed some hypotheses about what
• 01:00:19was going on.
• 01:00:21So, you know, maybe there's
• 01:00:22different ways to get, to
• 01:00:24to see the value over,
• 01:00:26to get engaged in, you
• 01:00:27know, the practice of listening.
• 01:00:28But,
• 01:00:29you know, definitely, like, once
• 01:00:31I started to experience it,
• 01:00:32I was completely sold.
• 01:00:34So maybe it's just how
• 01:00:35do you experience it. Anyways.
• 01:00:38Alright.
• 01:00:40Well, thank you all everybody
• 01:00:41just to say that to
• 01:00:42close us out here. It's
• 01:00:43our honor to be back
• 01:00:44back home here. I know
• 01:00:44it's been a decade, so
• 01:00:45let's not let it be
• 01:00:46another decade.