A young woman who appeared to be pregnant came to the soup kitchen daily. She seemed catatonic. She would not state her name. Staff recognized signs of schizophrenia and suspected that she might be pregnant. For many months she averted her eyes as she ate and indicated no interest in talking to anyone, except the woman who served the soup. Every day medical providers spoke to her gently, inquiring if they might help her while she sat rigidly guarded, isolated and withdrawn. She did not respond to the Health Care for the Homeless (HCH) medical staff, yet returned to the soup kitchen daily.
After six months of extreme withdrawal and persistent gentle daily outreach by the medical staff, she uttered these words to the woman who served the soup: “Take me to the hospital.” With that, the HCH team coordinated her transfer to the hospital, accompanied by the HCH nurse and the woman who served the soup. At the hospital, she was evaluated, voluntarily admitted to the psychiatric unit, and was found to be eight months pregnant. After admission, the medications helped her stabilize psychiatrically, she revealed her name, and accepted prenatal care. The HCH team, in collaboration with the psychiatric and obstetrical teams, assisted Adelle as she chose to offer her child for adoption. After delivery of a healthy newborn, arrangements were finalized, and her son was placed with his adoptive family. She was later able to arrange weekly visits with her son.
This outcome was transformative for Adelle and the HCH team. “We were new at this at that time. We witnessed something first hand and thought, this is important … it’s critical that we combine medical care with mental health care; and we thought, this works…persistent, gentle outreach, presence and patience. You never know when something will click; you never know when your message will be heard; and you never give up hope that your offerings of help will be accepted.”
Providing persistent, gentle extensions of friendliness to welcome people in need of services has worked for Marianne Savarese since she first practiced community health care 30 years ago. Her street outreach work began in 1979, before the first Health Care for the Homeless project was developed. She worked under the direction of Philip W. Brickner, MD at St. Vincent’s Hospital Department of Community Medicine in New York City. The team practiced the principles that are Heath Care for the Homeless as we know it today.
As the Director of Manchester, New Hampshire’s Health Care for the Homeless program since 1994, Marianne ensures that her HCH team works in close collaboration with the PATH clinician at The Mental Health Center of Greater Manchester. Together, the HCH Nurse and PATH mental health clinician make up a street team with a range of clinical skills that ensure effective assessments and access to care. This street team conducts outreach together on a regular basis, and remains in contact in between outreach activities.
Of her early years in nursing, Marianne explains, “We learned what we needed to do by following the lead of our patients and addressing their needs as they presented them. At the time, the term ‘homeless’ was not yet widely adopted. We would meet someone in need on the street, accept them where they were at, listen to their story, determine what was to be done, and then do it. Our patients were our teachers; they showed us the way and truly shaped the program. Offering simple medical and nursing care during street outreach served as initial engagement tools; such measures seemed less threatening, more familiar and easier to accept for those who suffered chronic, persistent mental illness,” says Marianne.
She recalls early morning outreach to a New York City bar to check blood pressures of patrons who were engaged in prostitution before they reported to work. “There is something about medial care that is primal and basic. We accepted patients in any (and all) states of inebriation; if offered an extended arm or rolled up sleeve, we would check a blood pressure; no one was turned away.” After building relationships on the street, some people were willing to go to hospital-based clinics when ready to address more significant health issues.
Establishing deliberate partnerships between local HCH programs and PATH programs promotes integration of care and lends a supportive team context for outreach workers who often go it alone. Coupling an HCH or local community health center nurse, physician, or mid-level provider with the PATH clinician combines the essential elements of an integrated street outreach team without starting a whole new program. These community agency collaborations foster a persistent, gentle PATH outreach on the streets.
“Persistent, gentle, and integrated,” what other ways would you describe outreach? Click “add a comment” below to share your thoughts.
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