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Healthcare

On the Corner of Homelessness and

Emma Hughes

Welcome to today's episode on the corner of Homelessness and Healthcare. I'm Emma Hughes.


Joe Ader

And I’m Joe Ader.


Emma Hughes

Today we're going to explore two questions. What does getting medical care look like when you're experiencing homelessness and what are some of the ways that the medical system itself is helping and some of the ways that it's hurting people experiencing homelessness?


Before we dive in, we always like to give our disclaimer, which is that homelessness is a complex issue. We've been reminded of that throughout each of the conversations that we've had. We don't claim to explain every part of homelessness, but hope that each conversation brings new clarity to the reality as a whole. Please keep an open curious mindset as you listen and seek to learn. Just as we are.


With that said, today we are lucky to have doctor Luis Manriquez with us. Doctor Manriquez is a board certified doctor. His passion is exploring the spectrum of health from acute disease to social factors and their effect on how. You can find him working with people experiencing homelessness through St. Medicine, working with community partners and, among other things, teaching students in a variety of places. So welcome! We are so glad to have you.


Luis Manriquez

Yeah, thank you. Glad to be here. Long time listener, first time interviewee.


Emma Hughes

That’s awesome. I want to give our listeners just kind of a little introduction to who you are. So can you tell us just a little bit about how you ended up in your current work?


Luis Manriquez

Yeah. So, the long answer would be that when I graduated from high school, I left New York City to become a documentary filmmaker. I got there the week before September 11. I watched the World Trade Center collapse from my dorm room window. And when I went out on the streets and, you know, listened to the news report from a cab, what they said to do was to go to the hospitals and try to give blood. And so that's, that's what I did. My roommate was also a filmmaker. He thought we should be filming. To me, that felt a little bit... I don't know... a little bit intrusive and so I should have at that moment kind of realized that my orientation was more towards medicine, but it took me a little while to figure it out. And so while I was in in New York, working in documentary filmmaking, filming protests and demonstrations, and I would see someone get clubbed by the police officer at the protest and I would want to be able to provide aid directly, not stand there and record it with the camera for posterity and so I actually got trained as a street medic, which are volunteer first aid demonstrations, started back in the civil rights movement with the Medical Committee for Human Rights, then started more into medicine, got my EMT, decided to go to medical school.


So really approached medical school as, from a from an orientation of, this is really a trade school and learning the skills of medicine and how to apply those to efforts around social justice. And so initially was working on HealthEquity, working with students, developing HealthEquity curriculum and HealthEquity programs and community organizing. And then. Met through that work, met TJ Byrne, who is running a street medicine program at Heritage Health in Corda Lane. You know, I was familiar with street medicine, but hadn't really been engaged in a meaningful way. And he started coming and teaching at the UW, PA program. The medics program, and so we started looking on how to get street medicine going. We met with the health district. We met with Chad. We met with Kat and people were excited about it. But they were all busy doing their own things and didn't really couldn't really get anything off the ground.


Then when the pandemic started and one of the things that we thought right away is that people on the street are going to be left out if the hospitals are overrun and maybe cycling through infection may have infection running through the shelters. Same thing in the jails and so one of my initial conversations with TJ and WSU is trying to figure out how we could and the health district was, how we could set up a street medicine program. And so we set it out initially as a response to the pandemic being able to make sure that people were getting tested for COVID that they were sheltering in place. We could get them supplies, try to limit infection and increase our access to healthcare, but we had kind of intended for this to ultimately be how we would set up a street medicine program that could be providing care on the streets. And street Medicine is an international movement and you know, effort within.


Joe Ader

Healthcare. Yeah. Yeah. Let's talk about that a little bit. So what, what is street medicine for those that that don't that aren't familiar? What does that look like and how is that different than traditional medicine?


Luis Manriquez

Yeah. So if you go to street medicine institute, you can you can learn a lot of, uh, a lot of well written stuff about it, but what it essentially boils down to is providing for patient care on their terms and in their environment, which means going out onto the streets, to encampments, to shelters, to meet with people and address their concerns. And so it's a I think about it as a form of a community oriented healthcare. So most of our healthcare systems are structured around healthcare and are structured around the convenience of the healthcare system. And then people have to come and show up for that. And street Medicine is bringing people out to the community. But you could do that in any, you know, street medicine is what it looks like for people experiencing homelessness, but you could do that for any population really like what? What does medicine need to look like for this community?


Joe Ader

So it's like the old time doctor with the bag that goes to the house, but now you guys are going to the streets to those that are sleeping on the streets or in encampments or out wherever they're at to meet them, where they're at and provide medical care.


Luis Manriquez

Yeah, absolutely. And you know the way that we think about street Medicine in Spokane and our mission is that the street medicine program is an adapter for a healthcare system that's not well suited or not designed for people that are on the streets and doesn't serve them well. And so if we think about all these assumptions that go into the healthcare system, right assumptions about that you have a phone, that you have an address, that you have transportation to get to the clinic, that you have insurance, which not as not as big of an issue in Washington state, thankfully, but all of these assumptions, you know, especially that like that you have the ability to schedule your life in advance and be able to show up.


You know, when I was working in restaurants and as you know in high school and college, like your schedule is dependent on how together your manager is, which is hopefully two weeks out, but most likely one week or less and so to be told like, yeah, we've got an appointment in three weeks, we'll schedule it for you and say, well, we'll see if I can show up. Because I don't have sick leave and I don't have, you know, the ability to take part time off. And so we'll see. So all of these assumptions mean that healthcare may be technically available to people or they have insurance and they have access, but do they have the ability to actually utilize it? And that's the very different.


Emma Hughes

That's hitting on a theme that we've heard in a lot of our episodes of the system was not defined or created with people experiencing homelessness in mind, which means that then there are unintended consequences, exactly like what you're talking about. What would you say are, n the design of healthcare, some of the biggest impactors for people? Scheduling, you've talked about, what are some of the other ones?


Luis Manriquez

Well, I think you know if you start right at the beginning, the assumption that Healthcare is a safe or desirable place to be like a healthcare institution, a clinic or a hospital is not true for most people, right? Like when we were trying to develop mobile programs at WSU, all sorts of Community partners want the mobile unit to be there to take care of people. But people themselves don't want to go to the doctor unless they have a problem they need to address and most don't feel like they're being necessarily well treated, or at least individually attended to in a medical facility. And so for a lot of people that we take care of, it's, it's already--they're already agitated, irritated, triggered. They're already on edge. They're already very concerned when they get to the front door of the clinic, and so it doesn't take really anything to ruin that opportunity. So it's other people in the waiting room that, you know, that are trying to get away from you or looking at you, you know, looking down on you or one person at the front desk or one medical assistant or one other patient who's there. 


So there's so many different ways in which the hostility towards people that are living on the streets gets expressed and so that makes it, you know not something that people seek out unless they have to, which is why a lot of healthcare, even though you know, 95% of people have insurance in Spokane, even though Chaz has clinics all over the place and we have the Denny Murphy clinic that's kind of focused on the downtown population and Providence has their clinic that's focused on, you know, that right next to House of charity, people are still not necessarily interested in accessing that system unless they're developing trusts and are, you know, being engaged in a way that's safe for them and that's what hopefully, that's the relationship we hopefully are building with the Street Medicine team.


Emma Hughes

That's super cool to me that you, like, I wouldn't have thought to start so far back and I'm trained in this work to think about a systemic issue, but that desire of, I would like to. Ask for help in getting a medical thing done, it starts that far back like it starts very early on in that process. How do you anticipate the street team gaining that trust? Like what is the process of starting to shift that perception?


Luis Manriquez

Well, so when we started the street medicine program, you know, we were really intentional about working with community partners for outreach, trusted community partners, so that they could introduce us. So they could help people understand that what we were doing was different. And you know, just being told to go to the doctor. And so Chaz has its own outreach workers, but we also worked with SNAP and Jewels helping hands and VOA and with some of the behavioral health team working in Spokane Valley and in the city. And basically, they were sort of introducing us to people and asking them for help. And then just going and being a presence and being able to actually do something for people. You know, it's difficult to be an outreach worker or anyone who's working in homeless services who sees like this seems bad, seems like something that needs medical attention. And just to say, like, so you should go do that.


There's reasons why people haven't done that already, but they're usually pretty aware that they have a problem. And so being able to actually render that service, you know, the way TJ used to always put it is the best time to take care of the patient is when you're with the patient and so we have to be there with them and then we actually can do that. So our backpacks are full of medical supplies, we can take care of the issue right there on the street, save them a trip to the urgent care or the emergency department or to the clinic. And, you know, people, people appreciate that they recognize being seen and they're interested in engaging, or they're willing to tell other people, like, you know, hey, this team is here for you.


Joe Ader

What types of things, I mean kind of the spectrum of the most common things that you see as well as you know even outliers when you're out on the streets in your, in your work with people, what is that spectrum of needs look like that, that you guys are able to provide?


Luis Manriquez

Yeah. I mean, we see a lot of wound care just cause of the conditions that people are in, like right now we have a Shigella outbreak. So we see a lot of that. We see a lot of respiratory viruses, but you know, a couple of important things to know about medical care in this population is that, yes, there's an over representation of substance use, of mental health problems and the injuries and things that go along with that. But you know, looking at some of the data we have from Boston, Healthcare for the homeless, for instance, is that a lot of the things that people are dying with on the street are the same things that people are dying with who are housed. So it's important to know we're addressing. Heart conditions cancer, pulmonary disease. You know, we've definitely gotten people care and diagnosed their cancer, their heart failure. 


A lot of their, you know, medical, their diabetes, a lot of these conditions from our engagement with them on the street and hopefully we can. You know, use that trust to bridge them back into primary care or specialty care. But usually we can do something for them, like immediately in their need, and then a lot of what we actually do is filling the gaps that already exist in the system. So, if someone gets discharged from the emergency department and they're given a prescription for medication, everything was done properly in the medical sense, but they got transported to the shelter by cab. The cab is not going to stop at the pharmacy on the way, so they have a piece of paper that's a prescription for a known condition that they have that that, you know, was diagnosed appropriately and prescribed for appropriately. But they still don't have the treatment for it, and the fact that we can actually just bring those medications to them in the shelter means it will get treated as opposed to, you know, three days later, being a returning visit.


Emma Hughes

Right. When I think too of various illnesses that if treated early don't become bigger deals, but if not treated they become really big deals, you know, strep throat is the example that came to mind. But if you get your antibiotics and you're taking them, you will get better. But if you don't, bad things are going to happen. Talk to us a little bit about the preventative side because in the this kind of picture that you're painting prevention seems fairly unrealistic, but it's also seems so important.


Luis Manriquez

In the same way that people are not, you know, figuring out how they're going to handle their retirement on the street, they're not figuring out how they're going to get their colon, their colon cancer screening by and large, but surprising, actually, that people are still concerned about preventive screening they do know that their family member or their brother or their sister had diabetes, and they want to get test screened for that. They are concerned about lung cancer, heart disease, all sorts of things that they know from their own experience. So in a in a narrow thought about prevention, like preventive medicine, you know, and preventive screenings, those things are still important. But a lot of those things are hopefully things that will follow once we're able to reestablish people under primary care.


Like I said, a lot of people are already Chaz patients. Already have a primary care provider somewhere else. They just don't have a consistent follow up and so. Helping them address barriers to that follow up and also developing the trust in the system allows for allows for addressing some of these preventive concerns. That's thinking about prevention like preventive medicine, kind of narrowly. The way that you know, the way that uh hospitals and clinics and healthcare agencies think about are we doing good in terms of prevention. But if you think about that in terms of, you know, prevention or harm reduction like a lot of a lot of engagement, is it is an investment in a relationship for later, right? If we're handing somebody a bus pass or shoes like that's, you know, going to prevent the frostbite later this winter, that's going to mean that they'll come and ask us for help when they're feeling really sick as opposed to, like, I'm going to go hide in my tent and hopefully this will clear up. So you know in that level just having presence helps prevent some of those things down the road because they know there's someone that that's there for them that they can reach out to that they maybe already have before and like or are interested in, you know, they see it. They see a way of addressing the problem as opposed to being another thing they. Have to live with.


Emma Hughes

I love that blurred line between social work and medical care because you're totally right. You have to earn the right to give advice, medical or otherwise. And so by delivering shoes or giving you know a meal or whatever it is that you are talking about like that really does earn you the right to then have a medical conversation later down the line. I love that.


Joe Ader

Well, I think that goes back to when we're talking about generational poverty and homelessness. Like you survive based off of relationships.  That’s how you survive and so that's that network of relationships and it's usually really tight close group. So one that's really helpful, but coming in as an outsider to gain trust is sometimes difficult to break through that, that wall especially for a lot of our folks that have histories of trauma and abuse and neglect and. And really, you know, over and over again being kind of partially helped, that then, but not fully. And so they have a history of partial help to not then the but that just leaves holes, bigger holes over a longer period of time when you're you've gotten partial assistance. And so I think coming back to that trust factor in relationship, I think it's super important when you're thinking about this population, what do you see with that and can you give any examples of somebody who you know you've had multiple engagements with on the street that have you've been able to develop relationship with over time?


Luis Manriquez

Yeah. I mean, I can't give, like, too much specific examples cause it's protected patient information. But, you know, we've definitely had patients that have reached out to us for something minor, right? Hey, I got this liver. I want to, it looks like it's infected. Can you take it out or something? And then down the road? I got the swelling in my legs and having trouble breathing and then it becomes like we need to get you assessed to see if you're having heart failure and then actually getting them hospitalized, getting that treated like all of those things kind of follow from like you know, you took the time to listen to me and take me seriously about this first thing that I have. So I'm willing to engage down the road and I think that, you know, if I may, it kind of it kind of plays off of something you had in one of your episodes, which is first is the making that commitment right like this is this is something that we are committed to addressing, right. So you know the street medicine team, you know, just to be clear, people who live on the streets have much higher mortality than anyone else, right? So it's 1.4 to five times to seven times as high mortality, depending on where you’reooking and so that isn't because of biology. That's not some genetic failing that people have. That's just how it's going to be. That's because of the systems and structures by which they have access to, or lack of access.


So if we're taking responsibility for saying, you know, they should be getting the same care that everyone else is getting, or possibly better care because they may be a more vulnerable population, then, then you know that commitment. All of the things follow from that. You know, in in healthcare, we don't have a healthcare system. I know people talk about a broken system or, you know the expensive system, but what we more accurately have is a healthcare marketplace. And that means that there are all these different players there, all these different organizations that are providing care for people and are incentivized and required to target certain populations and... But no one is directly responsible for anyone right? There's there was, you know, when we talk about population health within healthcare systems, oftentimes that means the people who come to this clinic as opposed to the original idea and the intending idea of population health, which is this community we're responsible for this community.


And so so we're our focus is in that direction. We’re responsible for this community and so we structure ourselves around what it takes to treat that community. And Chaz has been because we started at WSU and Chaz has been you know, fully on board and committed to developing that capacity. And so you know that gives us a lot of opportunity to go and see people. So you know in the clinic that provider might be limited to 20 minute visits and I see people the way they get seen in the hospital which is. The assumption that we're working hard and we're going to see people as and do what we need to do with them based on their situation. Which means oftentimes we see just as many people as in the clinic, but there's nobody you know, looking at the clock, and there's no one waiting that's impatient that, you know, your 20 minute visit with your one problem is up.


The consequence with that relationship, I think you know in terms of examples, you don't want to give like direct people stories, but I would say I used to work for Kaiser and when I worked for Kaiser, I definitely got yelled at less than I've been yelled at as a as a street medicine doctor. But I also got thanked a lot less. Right? So it really is, it really is true that if you show up, people recognize that you're that and you're there for them. People recognize that and that's you know that's not, that's not necessarily the case, right? You can you can go to the emergency department. You can go to all sorts of social services and never feel like anyone actually cared about you in particular. You were just getting sort of packaged along as a problem to be addressed. So the orientation, what what I say whenever some treatment of any of our patients happens is, you know, the way that like we need to pretend it's a person because mostly homelessness and homeless people are treated as a problem to be solved right? The same way that like the overflow of the sewage needs to be addressed or the, you know, the zoning ordinance needs to be addressed, but they're not a problem. They're people who have problems and so if we start from like, well, let's just pretend this is a person. What we would do for them, and it's a very different answer than like, what do you want? Like, why are you here? And you're somebody else's problem, like, oh, that's great. Go there for this help. Go somewhere else, you know.


Joe Ader

I like that they're they're not the problem. They're people who have problems. I like that a lot. That's really helpful.


Emma Hughes

This whole conversation is awesome. I'm thriving over here. I'm like, wow, I'm writing down all these notes and having all these spin-off questions because I think, like you said, it really does come back to, did you decide to take responsibility? Because that changes everything else. It changes how you solve problems. It changes how you come alongside the people that are experiencing the problem. It changes everything. And so I guess, the solution that I'm hearing really after the responsibility is it takes time and it takes consistency to build the trust that then actually allows you to have access to provide the support. In a system that I'm often hearing is understaffed, overworked. They all have crazy hours. There's not enough nurses COVID really hurt. You know, the medical field. Like, how do we do that practically in a system that is very fast-paced, like how would somebody that is in the hospital right now as a doctor or a nurse or a healthcare provider, how would they actually implement some of these principles?


Luis Manriquez

Yeah. Well, and I guess I should say like I think there's always, you know, people who are burned out. There's always people who don't care about their work, but the vast majority of healthcare professionals are trying really hard all the time to take care of the people that they, that they're trying to serve and and I think our systems make it not only too easy, but kind of require you to push this off to someone else, right? So it's like, oh, you don't have insurance, you need to go see the patient, resource coordinator and then we'll get you set up for an appointment. And you know, we just address that directly because they're here and they may not. We may not be able to find them again. And so you, you know, developing ways to actually address the problem that people have right now, but then also it really is like how how can  I take responsibility for that part, because I think what burns people out and what what you know leads to the degradation of the healthcare system is feeling like you're not making a difference. It's feeling like you're constantly seeing things and not being able to act them. And when you actually have some amount of initiative, control, or ownership of the work that you're doing, the hardness of the work is not is not the problem. Like medicine is hard, but everybody knows that you know. And and there's almost a a thriving on hard work, that is that you can see the outcome of. It's the grinding for the with a sense of no purpose. That is what's toxic.


So you know, and I think there's lots of space for healthcare workers to push for that within their systems and for systems administrators to recognize the value of it and one of the things that really helps here is that Healthcare is very expensive. We have the most expensive healthcare system in the world. And so you know, challenge Spokane just put out their findings in Seattle around how to avoid ED utilization. And they found ED utilization for people that are homeless are $15,000 versus $5000 so you?


Emma Hughes

Know. OK. Wait. What's an Ed utilization?


Luis Manriquez

So the emergency department. So, so people going. Yeah, so it's. How do we, given everything you said COVID and over understaffed hospitals and emergency departments, how do we lower the amount of people who are going to the emergency department unnecessarily or as the only resort because they're living on the street? And so one of the things that they found is $5000 for a regular emergency department visit versus $15,000 for someone who's homeless. And so if we think about that, then that $10,000 worth of outreach and engagement gives you a lot to work with from a financial perspective. So, you know, I think that a doctor or someone who walks towards suffering and I think that doing the right thing for the patient is the end of your concern. But it turns out that doing the right thing for the patient is also usually financially the right thing to do also because it keeps people out of the most expensive ways that we do healthcare.


And so you know, we save one ED visit a week we're paying for our program because that's very expensive care, right? If we can get somebody out of the hospital and not have them go back, right? So rules have changed with hospitals, where if someone is discharged and then gets readmitted for the same problem, they don't get paid for that readmission. So there's a tremendous incentive not to have people come back to the hospital. Well, the way to keep them from coming back to the hospital is to make sure they're thriving at home. And so whatever that you know. So that's why there’s a huge emphasis on Ed follow up visits and things like that, and one of the ways that we can make sure it doesn't happen is when they went to the emergency department, they got appropriately diagnosed and treated. But they got a paper prescription because they got left, they left at 2:00 in the morning. We can actually get them that medicine. Then they won't be back two days later. Right? Or if they got admitted for heart failure but they never figured out how to take their medication, approximately 50% of people don't know why they were hospitalized at the time of discharge.


I used to work in the hospital. I do not think that 50% of my patients didn't know why they were in the hospital, but that's actually probably my bias more than it's more than I'm just the best physician around. It's probably the case that I said a bunch of stuff really fast with acronyms and they didn't understand what that meant. And then I assumed that the nurse was going to explain it with their discharge paperwork and the nurse assumed that had been explained already by the provider and we all assumed that the that they had a primary care provider they would follow up with. And you know what winds up happening is they're at home with a pile of paperwork with all sorts of contradictions in it and several medications and not wanting to be sick again.


Emma Hughes

Specifically, when it comes to housing and homelessness, what if you don't have a home to return to? What kind of impacts does that have? Where you are in this exact situation discharged with your pile of paperwork, your meds and your will, and a prayer to go “home." How does that...?


Luis Manriquez

Yeah, I mean it just it just piles on the the barriers, you know, so. If you're discharged with a broken arm and they casted it, follow up with the orthopedic surgeon in two weeks. But the discharge paperwork just has a phone number. They didn't actually make an appointment because the clinic was closed when when you were seeing. So you have a piece of paper with a phone number on it. Maybe you have a phone, maybe you don't. Maybe you still have your backpack a week later. And maybe you don't so that you can make that call. So you know I have, I have definitely seen people in Spokane, with casts on for months when they should have been on for weeks and had to call the orthopedic office to be like, can you see them today? And thankfully they were able to and willing to and got the cast removed, but it had been there for three months because it was like, I don't know, I don't know how to get this taken care of. You know?


Emma Hughes

We use the phrase housing is healthcare, largely because housing helps a lot with prevention. When you have stable housing, you have stable access to resources. Theoretically, you then can avoid a lot of the things that you might present at the emergency department or even to your primary care doctor with I would love to hear maybe Joe and then everybody just jumping in with an opinion.


Joe Ader

Yeah. So, I mean, I'm just thinking about, so we're in the Pacific Northwest, if you're listening to us from some other place, we're going to have -7°. Tomorrow and I'm just thinking about on the street without somewhere to go -7° the impacts of that on health, healthcare and in this and I'm I want to hear from your perspective like... what are you most concerned about as we as we move into these really cold months? What does that look like and what are what what's the most concerning to you as a provider to healthcare to the homeless?


Luis Manriquez

Well, I mean, I think I would say first, absolutely, that housing is health is health care. And I think you know, health care is what I do. You know, very going to narrowly focus, but that's not what produces health, right health is larger than healthcare. So we can think about all of the work we do as contributing to health, without necessarily having to conflate health and healthcare. So that's where I think you know those things those things are really important. And so like, what is the medicine? The medicine is getting housing, the medicine is having someone to talk to you, and also this medication for your, for your hypertension. So you know things that we're concerned about right now not to be too morbid. But we're concerned with people dying, right? The thing that I hear from people is like, how do people live like that? And the answer I say is a lot of them don't.


Every year we have over 100 people who are dying on the street that we're connected to, to homelessness in their life or or we're experiencing homelessness themselves. And so that's what we're concerned about with the temperature is this low, is that you know, going out to encampments and making sure that people are OK. And then you know, short of that, we're concerned about them losing fingers and toes to frostbite. We're concerned about, you know, the cold weather causing all sorts of problems, other medical problems that they have, exacerbating existing chronic problems. So there's there's a lot of things that are going on and then. You know all of the things we see in the winter for everyone else who is housed, right? More respiratory diseases, more things that spread around. Those things are going to spread around even more frequently and possibly more severely when people are packed in tight in a warming shelter and, and so you know, that's a that's just another thing that that's the condition of being on the streets just increases people's vulnerability.


Emma Hughes

Yeah. Well, and in shelters, too. I mean, I remember when I was a family advocate in our emergency shelter and we work with families experiencing homelessness. So, I don't know how much of this was. Just having kids and like, you know, in September when you go back to school and like, then everybody in the family is sick because now there's new germs and whatnot. You know, I can't differentiate, but I can think of multiple occasions where one kid came home with lice and now all of a sudden we got a lice outbreak. Or during the pandemic there was a lot of, you know, one or two people came in with COVID, and now everybody has COVID when maybe under different circumstancesm well, honestly, definitely under different circumstances where everyone was in their own place, it might have just been that family. It wouldn't have been the family and then your 20 closest neighbors and their families.


Joe Ader

We definitely see that. And I mean just the... you hit on several different topics that we've addressed before here. I want to just kind of reiterate. So we've hit on a couple of things with the sense of time. So a lot of our folks are... they're surviving like they're surviving today and all of their thought process is really going into how do I survive today. And so a lot of the medical you mentioned this a lot of the medical side is set up for tomorrow next week, next month, next year where I made an appointment recently that was three months out. If we're talking to somebody in homelessness even 2 weeks out for somebody in homelessness is like you and I, scheduling an appointment for next year, like, I don't know where I'm going to be on June 15th.


Emma Hughes

I don't even know who I'm going to be.


Joe Ader

Yeah. Or where I'm going to be is the other part of that. You know, I'm here right now, but if something comes up, I may be somebody, somewhere else. And so I'm really interested in the street medicine in the fact that it's and it's going to people in providing services when it happens. You mentioned this a little bit but I did have a question on cost. What does it cost to do this type of outreach this type of street medicine work and how is that funded?


Luis Manriquez

So, you know we're not, we're not volunteers, right? We're medical professionals that are taking responsibility for particularly difficult population in the healthcare world and like I said, most people in in Spokane, 94-95% of people have insurance, so they're getting and almost all the patients we see have Medicaid. So their medical care is being paid for by the state one way or another, whether that's spotty, intermittent, sort of emergency care when things come up or whether that's better integrated primary care or some mix of those things, it's getting paid for by the system. So we've already made the commitment as a society, which is one of the better commitments we hold, I think, that people deserve and should be protected from the vagaries of fate and genetics and accidents, right? That it's possible for someone to be born with a heart defect and still live a normal life, because we've figured out how to actually address that problem. And so I think, like, that's one of the, you know successes of being a civilization, and so we've made that commitment then to follow through on that is actually like then taking care of those issues.


Well, if along the way we find ways to say who's the deserving poor and who's the undeserving poor, then the undeserving poor get poor care themselves, but also become just dead weight that drags down the rest of the system that just become a, you know, ongoing expense with no possibility of engaging in a in a positive way. And so there's some concern for what these things cost, but it's--that's why I say like doing the right thing for the patient is usually financially the right thing too. Because we don't kick people out of the city beyond the city walls. We still take care of them. We just take care of them the most expensive way possible, right?


So if your housing is, you know set up through a shelter and you get into supportive housing. There's going to be a cost associated with that, but it is, much by orders, by an order of magnitude, that's less than the cost of living in the hospital, and there have definitely been, there's, I'm sure there are right now patients on the hospital census who've been there 203 hundred, 400 days and that's not the appropriate place for them to live. They're not getting necessary services, they're actually taking some utilization of services from other people that could use that. So you know and the reason that they wind up staying in the hospital is because there isn't a safer place for them to be. So you know the solution to that problem is creating a safer place for them to be housed than for them to be in the hospital you know, burning resources, essentially. So the financial problem is usually more about how to align the money we're already spending in a useful way than just kind of shoveling more, more cash into the fire.


Emma Hughes

Just to play, you know, the critical listener over here. What whole--I mean, if I'm hearing what you're saying, we're already spending the money. The money's already in the budget. It's already being dulled, you know, doled out, and we're just buying the most expensive product, if you will. Why? Why? What's holding us up in in making a more financially beneficial decision that also is helping people better?


Luis Manriquez

You know, I think it's complicated, but it is understandable. It's not just like some, you know, left wing ravings. Like I said, we have a healthcare marketplace, which means that everyone's incentivized to get money for the things that they do and not necessarily like the long term prevention and engagement. And so that creates some misallocation of our healthcare resources, right? The emergency department should be used for true emergencies, but it's actually primarily used because there's a lack of a sufficient primary care or ongoing primary relationship with healthcare, and so people wind up having to go to the emergency department. Where whereas if they had a connection with the primary care provider, or if there was a better access to afterhours support, they could get that that care done somewhere else and they wouldn't have this six hour wait and then they wouldn't be, you know, taking up a bed when someone who actually did have a rollover accident and needs to be in the hospital shows up. So that's one financial piece. The system gets incentivized to meet the wrong things because reimbursement is for stuff you do not necessarily for the outcomes that people have. There's a lot of effort to try to change that, but that's definitely how healthcare works and healthcare, to be clear, like the most money is gonna change hands in healthcare than probably any other industry in the city because of the great expense that goes with it. So you know, we're talking about billions of dollars, right?


Joe Ader

So interesting. So the crossover of some of these concepts and themes we, we... In our, two episodes ago, we were talking about just the, how our system on the homeless side does not reward outcomes. And it doesn't even doesn't even track. We don't even report outcomes. We are tracking, beds and bed utilization. How many shelter beds do we have and how many people are in those beds and how many people are still on the street. Rather than how many people were prevented from becoming homeless? How many people that were homeless got into housing and how many came into the system? Which is really, that's the equation where you solve homelessness. There has to be less people entering than are leaving the system for you to actually solve this problem, but we see this with our with our federal funding. They are focused on beds, bed count, bed night. The grant pays for this many beds. Not necessarily, how fast somebody, how long somebody stays in that bed. How quickly they get out of that and actually get into housing, which would be a successful outcome for us. And so to hear that same concept on the medical side, it's really interesting.


Luis Manriquez

Yeah. And you know it's, it's also the externalizing of the cost, right? So the hospital is not in the business of. Maintaining housing. Like if you have someone who's uninsured and you have them sitting in the hospital for 100 days, they're not going to pay that bill. That bill is going to be written off at great expense to the hospital. So it would be cheaper for them to put this person up in an apartment. But that's not the way that, you know, they're already running 100% just maintaining healthcare services. The you know those collaborations create these areas where like just a ton of waste happens, right? Like I thought about this all the time working in the hospital. There's just this trash can fire and we just shovel money into it because we make decisions that are the only options short term, whereas they might be like a better solution longer term.


Emma Hughes

Well and correct me here if I'm wrong, but what I'm hearing you say also is when the health care marketplace system tries to do things that other people or systems should be doing, it doesn't work, but when they try to do it all themselves, it also doesn't work and so that's where like this overlap of integration between, in this case, maybe a housing provider and the medical system needs to have like a program like Street Medicine, that's that is a hybrid, a hybrid middle space for the people that might otherwise get caught in the gap between two systems, is that...?


Luis Manriquez

Yeah. So ,what makes a shirt right? Like there's a pile of fabric and it's the seams that hold together and make it a useful garment. Right. So that matters. So, those seams are actually the most important thing, but the most overlooked. And so if we're thinking about that in terms of institutions, the connections we have between each other are what actually make us a functioning system versus a bunch of silos. And so that's where I think a lot of priority would pay off in massive, massive ways, both in terms of outcomes for the people we're serving, but also just in terms of expense for the healthcare systems, right. So that's that's the way of looking at that problem. But if your focus is around maximizing your patient counts or your occupancy, then the actual outcomes that are going to move the, move the community forward may be overlooked, or may just, you know you're not allowed to look at those.


Emma Hughes

Well, and to use your analogy, the less people will be clothed if we don't figure out how to make the seams work.


Joe Ader

Yeah, it's, I love that analogy. That's a great... So the way that the seams hold that together the seams between different systems is what holds our community together with that. We have a way that we address things with different groups of people, kind of internal biases that may come out in in how we do our jobs. Do you, what types of things do you see like that, that, that, just if if folks knew they might have an internal bias, what types of things should they be looking for from the healthcare side of things that could better serve this population?


Luis Manriquez

Well, and so biasis is real and it's a huge problem, but I think our systems set people up to be acting on bias. So you know, I teach a class about bias at the College of Medicine, and one of the things you know, looking at what makes people vulnerable to their biases or what makes those things come out the most, you know, the situations are it's high stress, there's incomplete information around decision making. There's people who are tired and there's people who feel like they have a lack of resources to address the problem. Well, that is essentially the life of an emergency medicine physician, right? That's the life of someone who's taking care of people in in an acute setting. And so it's no surprise that people are acting on, consciously or not biases because the system sort of sets them up to respond in a reflexive way, in a sort of reactive way. And so you know that has, and like I said earlier, you know, it doesn't have to it's not all about what the doctor or nurse does. It's literally anyone of the 50 people that they're going to be interacted with that could be triggering that bias. And therefore, you know, someone's storming out upset and I don't want to be treated like this again. And not getting their problem addressed.


You know, as an example at one point I called an ambulance for someone and they came to pick him up and you know this person had lost control of their bowels. They couldn't walk and they had back pain and a fever and so not to get hugely into the medical thing, but what fever plus inability to walk plus loss, loss of bowel function means is that they have an Abscess in their spine. They have an infection in their spine that needs to be operated on immediately to address this problem. So I called the EMS to take this person to the hospital and the response I got from the EMT was like so, how do you know who to take care of? And I said, what do you mean? And she said, well, they're bums, right? And so like, that was the response from someone in health care about someone who by the Book of Medicine, clearly needs to be in the hospital and like, right now. And so, you know, that's the bias that we see and to be clear, most of the people who are working in EMS are underpaid, underappreciated, and working really, really hard and trying to do really good things for people.


But again, the system kind of encourages at turning of people into problems, you know, turning it into something that makes it, that it's easier to get through this by treating someone as a problem as opposed to like someone to look at, eye to eye and actually try to understand and engage. And so the, to me, the question is like or I guess the way I think about it is like I'm glad that we have as much compassion and care that we do in a system that's actively pushing against those things. So you know the answer is in addressing the system. Yes, individuals can work on their bias if they, you know, if they spend some time volunteering in homeless services or they spend some time listening with other communities, you know, systemic racism, sexism, all of these things exist and are documented and are killing people. There are definitely ways where people can recognize assumptions that they might have biases they might have that they don't carry well, but it has to be transferred into the system doing better. It has to be transferred into the system, supporting people taking the initiative and doing best for their patient as opposed to like hitting their metrics, which means getting people in and out as fast as you can.


Joe Ader

I got a couple of questions that are kind of to string together here, but you mentioned teaching in what you do, can you share you? You teach at several different universities. Would you just share which universities you do teach at? And then I have a follow up question too.


Luis Manriquez

That, yeah, so I'm an assistant clinical professor for WSU. Elson S Floyd College of Medicine. I'm an adjunct professor for Gonzaga. And I'm a clinical instructor for the University of Washington.


Joe Ader

Awesome. And so to take on that many teaching roles, there's got to be something driving you to a desire for this future generation of folks coming into the medical field, what is it and what are you teaching? What do you hope to pass along about this population that might be different than the way that the system has been operating?


Luis Manriquez

By and large, students come in interested in health care because they want to do something for other people. They want to improve things, you know. Their essays are always about trying to serve the underserved and how they want to engage. And that's not just so they can get into school, right? That's a legitimate passion and interest that they want to focus on. And so, I remember when I went to medical school, I was asking some of the professors, like, so why do you think it is that we come in with this desire to support people in this passion, and we come out happy to, like, do the job? And he said, you know, the narrowing down on biomolecular problems and sort of the narrowing of that focus, it makes it hard to bring it back out sometimes. And you kind of are stuck doing that on your own right? It's going to take it for granted that you'll be good at engaging with people and addressing your bias and all these things because you know the medical knowledge and the medical knowledge is what's really important.


But that's actually not true, right? The whole package is what's important. The medical knowledge is essential but insufficient for actually care of the patient. So then what does that mean for teaching? What that means? Is it part of the professional development of a student needs to be the understanding of those systems that impact health and that structure health and also needs to be the understanding of how those things play into their work as professional and the expansion of their understanding of themselves to be beyond a diagnosis machine to actually be someone who can engage with people in in a useful way in a meaningful way. Someone who would want to follow up with you when they have a question and has trust in your ability to solve that problem. So that's what has to be added to the curriculum. And so that's, you know, developing the HealthEquity curriculum for WSU and helping develop it at University of Washington several years ago. That's the focus and that's really about developing those pieces that were overlooked or taken for granted. They just weren't really considered in traditional medical education because of some of the biases of the system and some of the biases of the people who run the system, right?


The reason why Healthcare is structured around a middle-aged person who has, who's a professional is because that's who runs healthcare or middle-aged professionals and so a system that works well for me seems like it just a fine system. But if I don't have housing, that's a different system, right like, so I'll give you an example from Spokane like this is a real patient example. I won't give any patient details, but so someone came in to see us at a clinic. I won't name the clinic and I was getting ready to go see them and the security officer showed up. And I was like, that's weird. Why is the security officer here? And then I went to see the patient. He's a middle-aged black man who's on the street and totally reasonable person who wanted to address a skin lesion that was going on. And we had a conversation about it. And I asked them about their housing. And they said they weren't interested in living in shelters and they weren't interested in the transitional housing because they were a military veteran.


They were 60 years old, and they didn't feel like they needed to ask anyone's permission to have someone come over at 8:00 at night and that they didn't have to kick out their guests by 9:00 at night, so they weren't interested in being infantilized and working in this rules. So they were more happy to be living on the street where at least they had the control of their situation. Makes a lot of sense to me. I I probably would feel similarly. So then I left the exam room and, you know, patient left and then the security guard was like everything OK and was getting ready. I was like, were you here for him? And they're like, oh, yeah. Like, the staff had called security to come in because they were concerned about, you know, potentially a dangerous black man who is totally reasonable, patient, totally reasonable person. Like, that's the context in which the, this care is going to be delivered. So you know, if he's saying, I'd rather take my chances on the street than the way the systems are treating me that was in real time and example of exactly what he was worried about.


Joe Ader

Interesting.


Emma Hughes

It's really important, I think, one of the things that you said earlier about the... there are 4 contributing factors to bias, one of which was being tired, one of which was, you know, not having you as the helper, having your needs taken care of and I think what about that is like the best argument for, among other things selfcare. Like, you actually choosing to slow down. To get a good night of sleep, to maybe not study quite so long or you know, like that stuff makes a big difference, and it allows you to show up every day to do the work that does eventually change the systems because you're right, the systems themselves are going to continue to push and push and push the way that they've been designed and so to have compassion and to move towards, even in the midst of that conflict, you have to be able to, to center in yourself. Take some breaths and then move towards those that really do need help. I love that.


Joe Ader

So one of the things that we try to do in each of these episodes is try to broaden it to you’re a community member. You're listening to this, this podcast. Well, what can they do to help out with this?


Luis Manriquez

Well, there's so many things that people can do, but so you know, we have outreach teams that are giving out, giving out supplies, resources to people and we always are in need of those. There's always the ability to do donations. That's kind of the most mainstream, the most sort of common thing you would think about, like how would you take care of—how would you help people at homes, give them a blanket, right like that seems like the, you know, the most direct response, but other ways of engaging are, you know, I was actually just talking to people at the city about like if complaints are made to 311 about, there's this encampment here. They're loud, they're and unruly, get them out of my neighborhood. That's one way of dealing with people. But it could also be like, I'm worried about these people over here because it seems like they're not walking around so well or it's going to be really cold. Is there some way that they could get, you know, call 311 and we'll have some medical support or some behavioral health support out to people? Like, that's another thing that is a is a different framework.


It's like, pretend it's a person. What would you do for them, right, if you had a problem with the dog that was barking, you'd complain about the dog barking. But if you think about it as a person, it's like, what would a what would this person need? Right? So I think there's lots of opportunities for community members on their own. The reason why lots of things aren't done. That legislators might want to do is because of pushback from the community and what that means is usually a few people angrily saying they don't want something to happen. And if you actually, through your own experience, through your own values, wherever they, whatever they be, religious or otherwise, think that we actually should be inviting and providing support for people that are vulnerable in our community. Then you could show up and be that voice right, as opposed to the voice of like, you're going to destroy my property values. You can show me the voice of, like, actually want to make sure that people are being taken care of, you know? And so I want to encourage legislature—legislators to do that thing, even though there's other people that are, you know, that are against it. You know, I'm always talking about the systemic piece because that's ultimately where I think... where things change, right? We all live within structures and systems, and the system that we live in allows us to be as good or bad and encourage us to be as good or bad as as possible. And so, you know, community members can be involved in public life in a way that is not reactionary, but in a way that's like, what do we want to see thats possible for people in this community.


Emma Hughes

Anything else that you want to communicate to talk about? This has been a fantastic conversation.


Luis Manriquez

Our purpose is not just to provide care for people that are living on the streets or experiencing homelessness, but it's also to be supporting all of the organizations and homeless services because a lot of people are put in very difficult situation of having to play. Doctor with no medical training and no support. And so you know, everyone in homeless services, everyone who has engagement with this with this community should know that the street medicine team has a has a provider line. The provider is always carrying it and you can always call that number if there's someone who needs to be seen. That number is 509-481-3152. And so, and we are trying to expand our ability to do triage beyond so that we have that, you know, seven days a week, but that's something that people need to, need to know if they if they if they need our help, that's what we're here for, right? Call us. We'll show up. Instead of fretting about someone and not knowing what to do, call us right. Our goal is for our expertise not to be on top, but to be on tap. Right as a community resource.


Emma Hughes

I also just Googled street medicine Spokane and it's the first thing that pops up. So never underestimate the power of Google. But thank you for making just those resources and that commitment to our community. And as somebody who not only works in this community but lives in this community. It's really cool and encouraging for me to see somebody from what I would consider it kind of a different service sector also doing the hard and important work that really does hold the fabric of our community together, so thank you.


Joe Ader

Yes, thank you so much.


Luis Manriquez

Well, I will take the last word and actually say that like I think it's you all, all of the homeless service organizations that have been striving and struggling for a long time with much less money with much less support with much less recognition. And so it really is like we are here to o help support those needs and support that work that's ongoing and needs continuing support and recognition. So thank you all.


Emma Hughes

Wow.


Joe Ader

Oh, awesome. Thank you.


Emma Hughes

On that note.


Joe Ader

It's interesting as we do more and more of these episodes, these themes that we continually see of, of understanding people, meeting people where they are at. I love your consistent refrain today. Let's pretend that that person's a person. Like and you said, pretend that that person is a person multiple times, but it's really true. Like, we don't see people as human beings, we don't see them as people, and we don't, and therefore we treat them as a problem rather than a person. And so I think that is the big take away from today. Treat people as people, not as problems, and people do have problems, but the person is not a problem and so I think that's really important as we move on from this episode and move into, you know, later episodes. I love that. Coming back to this, thank you so much for the work that you do in our community, and we are looking forward for our community to really support these guys of what they're doing on street medicine, but also continually support the work that we're doing as shelter providers.


Emma Hughes

Until next time, I'm Emma Hughes.


Joe Ader

And I'm Joe Ader


Luis Manriquez

And I'm Luis. You can call. Me, Luis. Dr. Manriquez is my mother’s name.


Emma Hughes

Thanks for being curious with us.

On the Corner of Homelessness and

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