Bridge to Home

Name: Bridge to Home
Uploaded: 2026-01-29T20:10:14.2Z
Duration: 1 h 50 s
Description: Theodore G Long, MD, MHS, LHD October 9, 2025 Yale GIM Research in Progress Meeting

January 29, 2026

Theodore G Long, MD, MHS, LHD

October 9, 2025

Yale GIM Research in Progress Meeting

About the speakers

Patrick G. O'Connor, MD, MPH, MACP
Dan Adams and Amanda Adams Professor of General Medicine; Chief, Section of General Internal Medicine; Head of Advisory House, Yan House, Office of Student Affairs

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ID: 13790
To Cite: DCA Citation Guide

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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.