Faces of Public Health: Robert Taube
Faces of Public Health is a recurring editorial series on NewPublicHealth featuring individuals working on the front lines of public health and helping keep people healthy and safe.
“When you’re caring for homeless people, the meaning of medical home is even more profound.”
The Boston Healthcare for the Homeless Project is a model for how to help people who are homeless get needed care and preventive services. In 1985, the Boston Project was a part of a 19-city demonstration project established by the Robert Wood Johnson Foundation and the Pew Memorial Trust. Now, there are more than 200 homeless health care projects across the country.
NewPublicHealth spoke with Robert Taube, Ph.D, M.P.H., Boston Healthcare for the Homeless Project Executive Director, about the challenges and opportunities in creating a medical home for the homeless.
NewPublicHealth: Tell us about the origins of the Boston Healthcare for the Homeless Project.
Robert Taube: In 1984, the Robert Wood Johnson sponsored an initiative limited to cities with a population of 250,000 or more. It required that those cities pull together stakeholders from the healthcare system, from the homeless services and advocacy community, funders of public health and social service providers and government to develop an approach to making sure that people who are homeless didn’t fall through the cracks of the care that was available. We were one of those initial projects.
NPH: How many people were you able to serve at the beginning and how many do you serve now?
Robert Taube: It started with hundreds. This last year we served about 12,000 people.
NPH: What is the program able to offer?
Robert Taube: What we provide essentially is comprehensive primary care and some specialty services, but we provide them in a way that takes into account what it means to be living without housing, what it means to be without a safe, supported place to be when you’re sick and how difficult it is to stay healthy when you’re living on the streets or living in a shelter.
NPH: Does the program try to help find permanent housing for the clients?
Robert Taube: The program was built on the assumption and the faith that homelessness was not going to be part of the ongoing American landscape. It was formed as really part of a response to what was seen at the time as an emergency condition, as something that society would find ways to end.
We get very involved in concrete social services to help people resolve their homelessness and to help people find better options than the ones that they find themselves in. But the sad reality that goes along with that hope is that homelessness has, for some group of people, become a chronic condition. There’s a subset of people, probably somewhere in the vicinity of about twenty percent, for whom homelessness became their lifestyle and there’s no escaping it for them, or they are homeless in a repetitive pattern where they go in and out of homelessness and they’re always living on the edge.
The bulk of people who find themselves homeless at any point in time, about eighty percent, are people who can be helped often pretty easily to end that homelessness. They just need to be supported through a brief period of transition.
NPH: How is treatment for this population specialized?
Robert Taube: The clinicians who work on this program understand the day-to-day realities for someone living on the street or in a shelter and do it with an informed base and come up with much more individualized and often much more creative treatment plan. So there is thought put into the care for a diabetic living in a shelter that can’t control his diet because there’s a limited set of options about what food he or she is offered, or who can’t develop an exercise regimen because the realities of their daily life occupy much of their time and waking thought. The development of a successful strategy to manage chronic illness if it’s done without context, if it’s done without that understanding, often is likely to fail. That’s exactly what someone who’s worked here for a while becomes incredibly adept at.
NPH: Do the clients include children?
Robert Taube: They do, although the overwhelming part of our service delivery is around adults. What we found early on was that families with children who become homeless typically have had a connection to primary care. Boston is a fortunate place to live in the sense that there are 26 community health centers across the city, and typically, families, whether they’ve had insurance or whether they haven’t had insurance, whether they are low income or not, have had established ongoing care at a community health center or at a hospital outpatient department. So our job in working with homeless families with children is to help them stay connected, if it’s at all possible, with the care that they have had.
The opposite is true of adults without children [who currently do not qualify in many cases for public health assistance]. Overwhelmingly, when we started out, homeless adults would tell us they got their care at the emergency room. There was not an existing primary care relationship and any kind of continuity. So we started clinics in shelters and in hospitals, specifically for the homeless population. The first visit typically is to make sure it’s safe to refer, and then working to connect people with primary care. It’s a lot easier if the services are in people’s paths, so we have clinics at 70 different locations across the city in essentially every shelter and most soup kitchens and detox centers and within the walls of a couple of major medical centers where homeless people tend to go.
NPH: Can homeless clients access mental health services as relatively easily as physical health services?
Robert Taube: You’ve just put your finger on the most significant challenge that we and other cities and, our healthcare system overall, face – and that is that the ability, the willingness, and the mechanisms to support behavioral health services at a scale that’s needed. [Our capability to provide] addiction and mental illness services is orders of magnitude less than our capability in providing physical healthcare.
NPH: What strategies might work to improve mental health services?
Robert Taube: There’s a pretty strong consensus now that the way to address this is to provide behavioral health services in integration with primary care. I think a key issue is how do you finance that so that it can occur more easily and grow to scale. I think patient-centered medical home development, which we’re in the midst of all across this country, is a strategy for that. Ultimately, though, it will come down to financing mechanisms that make the development of behavioral health services easier to do.
NPH: What’s ahead?
Robert Taube: We’re very heavily invested now in making sure that our provider teams take ownership of a group of patients as their own and those patients who are receiving care from us will identify with a provider and team rather than mimic the rest of the healthcare system where the tendency is for short visits and more anonymity. When you’re caring for homeless people the meaning of medical home is even more profound, but the core principles are the same. It’s that there is an engagement and a sense of responsibility by a provider for a defined cohort of patients.