01/16/2013 - Making it Count:  Reflections on Boston’s Annual Homeless Census

More than 350 volunteers left Boston City Hall on the crisp, cold early winter night to fan out across the city streets and conduct the annual homeless census—a 33-year tradition.  USICH Regional Coordinator Bob Pulster and I were part of the team lead by Boston Emergency Shelter Commission Director Jim Greene.  Under the directive of Boston Mayor Thomas M. Menino, Jim had emphasized that the volunteers participating in the count had a primary goal to assist and help those who were unsheltered.  We were charged to help them connect to immediate resources like shelter, health care, food, blankets, and clothing.  Counting alone would not be sufficient -- we also were to engage and outreach.  If someone needed help, we were to wait with that person until one of the outreach vans arrived and a good connection was made.  Our job was to make sure the linkage actually happened. 

Pictured right, also participating in the count L-R: Dr. Barbara Ferrer, Director of the Boston Public Health Commission; Barbara Poppe, USICH Executive Director; Barbara Fields, HUD Regional Administrator - Region I; Arthur Jemison, Deputy Undersecretary, Massachusetts Department of Housing and Community Development.

I observed Jim and another volunteer interact with two women, one in her 50s, the other in her early 20s and pregnant. Among the volunteers on Mayor Menino’s team was Dr. Paula Johnson, a noted primary care physician, the head of the Connors Center for Women’s Health at Brigham and Women’s Hospital, and board chair of the Boston Public Health Commission. Jim beckoned Dr. Johnson over, and she spoke softly, and more privately, with the young woman about her pregnancy, homelessness and related risks.  The rest of the group stood back to give them some space and a level of privacy. When Dr. Johnson urged the young woman to consider accepting a ride to shelter, she wavered, asking for time to think it over. Greene assured her that an outreach van would be back to check in with her during the night. 

A few blocks later we came upon a couple under a comforter in a corner with chain link fence on two sides.  On the other side of the fence was a stalled construction site. Jim introduced himself and me to Don and Tammy (not their real names). Don spoke for the both, saying they were fine and didn't need any assistance.  Jim crouched down and kept talking.  I observed Tammy and after a moment asked she was feeling all right.  Reluctantly, she said she'd been in the emergency room earlier that day at a community hospital north of Boston. I asked if she'd like to see a doctor. Don said she was fine but said it was up to Tammy if she wanted a doctor to come check her out.  Jim offered sandwiches, socks, gloves, hats, and blankets; Don accepted all for the two of them. I kept engaging with Tammy until finally she said seeing a doctor would be good as she was feeling worse. Jim contacted Dr. Jim O'Connell with the Boston Health Care for the Homeless Program (BHCHP) and made arrangements for the Pine Street Inn outreach van to pick him up from the T station. I offered that Bob and I could stay with Don and Tammy to await Dr. Jim's arrival.

Photo right: Jim Greene and Barbara Poppe interact with two individuals experiencing homelessness on Boston's streets

While we waited, Don told us he had diabetes that required insulin but he had not been able to get a prescription filled.  He said they both received SSI and had been moving from place to place across Massachusetts.  Don pressed us that if we were making him stay up, we should buy them a cup of coffee so Bob headed out to McDonald's.  Don also pressed that the lack of public restrooms was one of the biggest problems and asked that we get the city to make them available on a 24-hour basis. The outreach van arrived and we got an update that Dr. O'Connell would arrive soon.

At this point I was getting stiff from sitting on the sidewalk, but was excited to see Dr. O'Connell in action. I have admired his work for many years and we’ve had conversations at conferences and other settings, but to see him in action on the streets of Boston was going to be an unexpected bonus to this trip.

Dr. O'Connell, accompanied by a 3rd year medical student, arrived and began talking with Don and Tammy.  He checked Tammy’s vital signs and did a mini-physical exam.  I encouraged Tammy to share the papers she’d received when she left the hospital ER earlier in the day. The medical student reviewed the paperwork and used his iPhone to pull up Tammy’s medical records and review the results of her blood work.  Dr. O’Connell encouraged them both to seek follow up care and made offers of shelter. The latter was declined as Don and Tammy did not want to be separated, but promises were made to follow up with the clinic the next day.  Don was also seeking funds to pay for a train ticket to another community where they had arranged for an apartment with a friend.  A promise of funds to cover the tickets was also made. 

Feeling that we’d done the best that we could to make a good connection for Tammy and Don, we departed, leaving them to sleep on the sidewalk with warmer blankets, hats, and gloves, and with the opportunity to get some of their needs met the next day.  It was a long way from a complete solution, but nonetheless, I was grateful that the good folks of Boston saw fit to offer them some relief, medical attention, and a pathway out of their situation.  This approach is decidedly better than “just counting” them to meet a federal funding requirement. The engagement serves as a stark reminder of the gaps in all communities – the gap in shelter for couples without children, the lack of access to sanitary facilities for those unsheltered, and the gap between income and the cost of housing.

Postscript from Jim Greene, Director of Boston Emergency Shelter Commission:

The next day Tammy and Don followed through and were seen at the walk-in clinic at the hospital. They received extensive attention and health care work-up from Dr. O’Connell and will certainly be followed up if they choose to stay in the area.  BHCHP also provided some assistance for them to return to the North Shore and on to their stated destination, but Tammy and Don appear to have either chosen to delay the trip or perhaps they re-purposed those funds for some other need or priority. We all know how easy it can be, despite the best-laid plan, for homeless adults living transient lives to take a left turn at Albuquerque. Or Houston, or Boston.

The response of Jim O’Connell and his colleagues at Massachusetts General Hospital is a great example of providing high quality care to homeless people in need. With the community hospital an affiliate of Partners, they were able to do an assessment that would be the envy of anyone in need of medical care. BHCHP also verified the transience of Tammy and Don: they were new to Boston Health Care for the Homeless. BHCHP has a vast storehouse of electronic medical records that covers well over fifteen years of homeless patients, yet this couple was new to the system. 

As is our history here, Mayor Menino expects action in response to homeless people in need. Boston’s Interagency Street Outreach Network had already engaged with this couple. Agencies involved include the HUD-funded Outreach Project in the daytime, the Pine Street Inn’s state-funded Outreach Van and the privately-funded Business Improvement District (BID) Community liaison. Each agency had already approached and begun to engage Tammy and Don when I reached them. More importantly, these providers were in communication with each other and coordinating their efforts.

In many ways, this interagency collaboration exemplifies exactly the integration of Federal, State and local partnerships that Barbara Poppe spoke about in her remarks to our census volunteers; while the lack of a straight path back to the North Shore and the complex relational dynamics around Tammy’s well-being reflect all that is so challenging about assisting homeless people in need. We’ll keep trying, and with colder winter weather looming, Tammy and Don may change their minds.

During the night of the Boston Point-in-Time count, 10 individuals accepted transportation to shelter: six were transported by staff volunteers of the Boston’s Homeless Services Bureau. Four others came later that night, transported by Pine Street’s Outreach Van. Among them was the 20 year old pregnant woman, who expressed gratitude that Dr. Johnson had urged her to make her own health and safety a greater priority for the sake of her baby’s health. That wise and compassionate counsel made better sense as the night wore on and she accepted that shelter and care made more sense than another night on the streets.

Boston's commitment to making the street count a vehicle to assist, as well as assess, homeless people in need, was summed up by Dr. Barbara Ferrer, Executive Director of the Boston Public Health Commission.  Speaking on behalf of Mayor Menino, Dr. Ferrer reminded our census volunteers that, “tonight’s count is so important because we have an opportunity not only to influence a national policy debate, we have a chance to help address the immediate needs of people out on the streets. The blankets and sandwiches you give out and the rides you provide to shelter are the gestures of kindness that can get lost in the rhetoric of policy debates, but they’re not lost on the people we serve.”

Reflections in the weeks following from Barbara Poppe:

 Back in Washington, I've been wondering what it might mean if every community that was conducting a street count established that the first priority was to engage and assist, then count.  What would it look like if the PIT Count wasn't just a required activity to qualify for HUD funding? What might happen if we had more volunteers canvassing and outreaching? What if we used this annual event to be more of a "stand-down" type opportunity to connect to resources? What if we learned the name of each person that was unsheltered on that night and found out what they needed then committed to help them achieve it? What would happen if the count volunteers were inspired to become advocates for affordable housing as a result of their experience?    Let's get this conversation started;  we can't afford to waste any opportunity to end homelessness—not for even one person.

Photos courtesy of Jeremiah Robinson/Mayor Menino's Office

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