Moving with Boston Health Care for the Homeless Program
The new home for BHCHP's Barbara McInnis House is a place of healing, trust, and hope
When was the last time your hospital moved all of its patients and equipment across town to a brand new building? That's exactly what Boston Health Care for the Homeless Program (BHCHP) did in July when they relocated their inpatient medical respite program, the Barbara McInnis House, from a 94-bed nursing home in Jamaica Plain to BHCHP's new home at Jean Yawkey Place in Boston's South End.
Barbara McInnis House, now expanded to 104 beds, is the first—and still largest—medical respite program for homeless people in the U.S. The multidisciplinary staff provides medical, recuperative, rehabilitative, palliative, and hospice care for 2,000 people annually, all under one roof. The program at BMIH is also the primary referral source for Boston hospitals when they discharge homeless people who need sub-acute care for complex medical or psychiatric conditions.
Jean Yawkey Place is a state-of-the-art facility with medical and dental clinics and mental-health services on the first floor. McInnis House occupies two upper floors. During an interview, James O'Connell, MD, founder and president of BHCHP, gestures out the window to show the strategic location of Jean Yawkey Place: Across the street is Boston Medical Center's Emergency Department. Right next door is the Boston Public Health Commission's Woods Mullen Shelter, where up to 500 people line up every night. O'Connell says, "We are in the perfect location, symbolically perched between academic medical care and the homeless community."
On the day of the move, Joanne Guarino, a homeless woman who had been a patient at McInnis House for three months, graciously allowed On Call to accompany her to the new location. This is the story of her day. It's also a story about what motivates the nurses who provide care for Joanne and thousands of others who are currently homeless.
Carrying on a tradition of help for the homeless
Joanne is 52, smart, articulate, and self-aware. A fall from a motorcycle in November left her with a deep, infected wound on her right thigh. After surgery, she was referred to McInnis House and then to a rehabilitation hospital. That was followed by months of living in shelters and more surgeries.
She says she tried to avoid infection, but that was hard. "I was living in a shelter and trying to bandage and tape up my leg in the bathroom," Joanne recalls. "The bandages and tape would fall on the floor or in the toilet." Finally, three months ago, she was admitted to McInnis House.
Joanne says she's looking forward to the new facility. At the same time, she hopes it isn't going to lose the intimacy and the chance for personal relationships that the complex in Jamaica Plain fostered. "Sure, it's crowded," Joanne says. "But while we're having breakfast, my nurse practitioner stops in the kitchen to grab a cup of coffee, and I can ask her questions."
BHCHP's McInnis House is named for Barbara McInnis, a public health nurse and tuberculosis specialist who devoted her career to caring for the homeless. McInnis is a legend on the streets and at BHCHP. "The staff at McInnis House," says Joanne, "have carried on Barbara's message and work perfectly. When you come here, the nurse practitioner gives you a complete physical and work-up. They discover many problems you didn't even know you had."
Comprehensive care for complicated problems
In her first two weeks at BMIH, Joanne had 18 appointments with professionals in the BHCHP system and with outside providers, including surgeons, physical therapists, an optician, a podiatrist, and a dentist. Now the proud owner of new eyeglasses, dentures, and her "sweet ride" — a blue rolling walker — Joanne's acute medical problems have improved considerably.
- Some patients are discharged to a rest home, rehab facility, of group home, but many more are discharged to the street and shelters.
In addition, like most homeless people, Joanne still deals with multiple chronic conditions such as rheumatoid arthritis, gastrointestinal problems, and depression, all of which have been brought under better control at BMIH. Homeless for a year this time, Joanne says, "It's very depressing to live like this." She explains that many homeless people resort to alcohol and drugs, in part to protect themselves from feeling too much or remembering the traumas that led to being homeless. Joanne herself has been clean and sober for several years now and is active in Alcoholics Anonymous.
While more housing has become available nationally, the number of homeless people keeps growing. Some patients are discharged to a rest home, rehab facility, of group home, but many more are discharged to the street and shelters.
Joanne says she stays motivated to strive for a better life because she feels like a teacher now. She's been sharing her experiences with other women to help them recognize the impact of past abuse and trauma on their current lives. She also advocates for more transitional programs to teach life skills to long-term homeless people to give them a better chance of succeeding in permanent housing.
Joanne works with a case manager and social worker to apply for benefits and permanent housing. "The social workers give you an extra push," she says, "to make phone calls when you get discouraged."
Jean Yawkey Place — a dream come true
The day of the big move is the culmination of four years of planning and fundraising to bring all of BHCHP's core programs under one roof and to be able to expand services to provide care to the more than 10,000 homeless people BHCHP helped last year.
When the medical vans transporting 90 patients to the new facility arrive at Jean Yawkey Place, nurses and nurse practitioners from all of BHCHP's programs join the regular staff to seamlessly settle patients. They attend to a seizure aura, glucose monitoring before lunch, vital-signs checks, and unpacking hundreds of medications for the next scheduled dose.
When she comes in the door, Joanne's attention is grabbed by the soaring atrium and outdoor deck. Light cascades through the windows over the flowing banners that say "A place for healing…hope…trust." In the recreation room are a large pool table, a flat-screen TV, books, and games. There are also nooks for quiet reflection. When she gets to her room, Joanne is awed by its spaciousness. There are five beds and a locked storage space. Each patient has a private television set with headphones.
From the staff perspective, the most visible difference in the new facility is that all the furnishings are new and the medical equipment is the same as that in a top hospital. There are even two negative-pressure rooms for patients with tuberculosis. The sense of equality, worthiness, and belonging instill a feeling of pride in staff that spreads to the patients. As one nurse remarks, "It's like driving a Model T Ford, then jumping into a Cadillac!"
The specialty of healthcare for the homeless
Caring for homeless people is a unique nursing specialty that requires distinct skills and a gift for understanding.& It also brings distinct challenges, lessons, and rewards. Nurses choose to build their careers at McInnis House for several reasons.
Suzanne Armstrong, NP, says the opportunity to build relationships with patients over time and to practice collaboratively with physicians drew her to the setting. When Armstrong examines patients during a daily medical visit she follows the acute and chronic problems associated with diabetes, heart disease, lung disease, HIV, cancer, recent surgery, substance abuse, and mental illness.
Carolyn Sturm-Regarato, RN, BSN, joined the staff when she graduated from Simmons College last year. Now she is helping to redesign the orientation for new graduates. During a school rotation at St. Francis House day shelter in Boston, Sturm-Regarato discovered she liked the engaging conversations and teaching inherent in the nurse's role. She also found the atmosphere less stressful than that of a hospital setting.
That's not to say the workload is less than that on a hospital unit. Each nurse carries an assignment of 13 to 18 semi-independent patients for whom she does treatments, gives medications, teaches, coordinates appointments, and addresses safety issues.
Kathleen George, RN, came to McInnis House because she wanted to practice nursing focused on some aspect of social justice and to better understand issues of poverty, mental illness, and homelessness. George says the respite aspect of the McInnis House mission means patients are getting a break from shelters and from the rigors of caring for their illness on the street. "They get some relief and rest, and then get back on track," George explains. The staff first deals with the top layer of medical issues that led to admission. They then move on to discover the other layers.& George says, "While patients are here, we can provide something tangible and good right now. McInnis House is a context in which to help and give."
To work effectively with homeless people, nurses need top-notch assessment and communication skills, empathy, compassion, a sense of humor, and a nonjudgmental attitude.
All of the nurses speak of the "privilege" of caring for homeless people who come to trust them and let them into their complicated lives. They also describe the act of washing a person's feet as one of their most meaningful contributions. The patients speak with gratitude of having their feet washed as one of the best gifts one person can give to another.
Lessons learned with experience
Sturm-Regarato says the other nurses have taught her to offer what the patient is ready and willing to accept. Many patients are readmitted, and some of them gradually try a detox and substance-abuse program. She says it may take years to accept a sober life, but each encounter with sobriety in a supportive setting can have an impact.
- The respite aspect of the McInnis House mission means patients are getting a break from shelters and from the rigors of caring for their illness on the street.
After one year at McInnis House, Sturm-Regarato is more aware of the amount of abuse many homeless men and women have suffered at a young age. She points out that many people land on the street because they have a severe mental illness and our society is lacking in comprehensive supports.
Armstrong says her biggest learning experience has been how to make the patient's self-care and medications less complex so they are more likely to work on the street. "It's nice to have people clean and sober while they are here and their condition comes under better control," she says. But the harsh realities of homelessness have to determine the discharge plan. For example, a person with diabetes can manage his blood glucose well when three nutritious meals and insulin are provided. But, Armstrong says, "It's a challenge to manage sugars when you don't know when you will eat next and have no choice over the food." In addition, medications are frequently stolen by others who plan to sell them on the street.
According to Armstrong, the nurses learn to accept that things are not going to be perfect. She teaches her patients to ask, "What's the one medication I should always take, and what's the one medication I should not take if I am drinking?"
Most of all, Armstrong says she has learned that homeless men and women are just like everybody else. The main difference is that they lack the network of support systems we have in our everyday lives.
The never-ending need
Sarah Ciambrone, director of McInnis House, says, "One of our biggest challenges — despite our good fortune — is that we still can't meet the needs of the people of Boston." She adds, "Hospitals are frustrated with the wait for a bed, and so many homeless people have such complex medical needs." Still, the existence of McInnis House is a step in the right direction.
One week after the move, Joanne was discharged to the street to await housing in Cambridge. To thank the staff for their care and extra effort during the move, Joanne designed a card for all the patients to sign. The message read, "Thank you for believing in us."
Editor's note: This is the second in an ongoing On Call series of articles examining the issues around healthcare and homelessness. The first article, "Envelopes of Care," about caring for homeless families in Boston, appeared in April. The next article in the series will focus on the Mercy Medical Center's Health Care for the Homeless (HCH) program in Springfield, Massachusetts.
Janet M. Cromer is a freelance writer and regular contributor to On Call. She is a recipient of the 2008 Will Solimene Award for Excellence in Medical Communication. She received the award — her second — for her three-part series on medical humanities in Boston-area hospitals that appeared last year in On Call.