COVID in the Street of Boston, Episode 2: Respite

Denise De Las Nueces: When COVID arrived in Boston in early 2020, Boston Health Care for the Homeless Program sprang into action. We quickly set up COVID testing tents, we were symptom screening and testing in our clinics and in the shelters, and we were following the positive cases in New York. We knew we had to stop the spread as soon as we could. But testing kits were extremely limited, they took up to 10 days to get results, and we were only testing people who presented with certain symptoms, like cough or fever. That all changed in early April, when we identified six cases at the Pine Street Inn shelter. It was definitely a cluster, but with just those few positive tests, there was no way to know how widespread the infection was. What we did know was that in a crowded setting like a congregate shelter, the infection could spread like wildfire. We needed more data fast. Here's Jessie Gaeta, who was our chief medical officer at the time.

Jessie Gaeta: Through the course of several hours and a lot of hand-wringing, we sort of figured out that the best thing to do would be to test everybody in the shelter, as well as employees.

Denise De Las Nueces: So we asked the state for more testing kits, and they agreed to send them. We immediately set up a mass testing operation at that site. Over the next couple of days, the team tested more than 400 people. We had never done a mass testing event like this in our entire history. At that point, we thought COVID always manifested with symptoms. Since many of the people we were testing had no symptoms, the tests should have been overwhelmingly negative. But that's not what happened.

Jessie Gaeta: Over the course of a few days, more and more names were coming out of people who are actually positive.

Denise De Las Nueces: Unfortunately, 36% of the tests were positive. 146 positive tests out of 397 people in this one shelter. And most of them were asymptomatic. They couldn't stay at the shelter and risk infecting everyone else, so they had to be told their results and transported to isolation facilities. The patients were roused from their beds and told to dress quickly and assemble in the dining room, where Jessie and Barry Bock, our CEO, would meet them.

Jessie Gaeta: The first night, I remember going to Pine Street Inn, I think it was 9:00 PM, when some of the results were coming back, and you know, walking into the shelter in full PPE and literally standing up on a chair trying to explain this crazy scenario: The tests that we did a few days ago for each one of you for COVID came back positive. And I know that's a total surprise. It's a surprise to us as well. And that we didn't really understand the implications of that yet, but that we knew that they needed to be isolated for probably a couple of weeks.

Denise De Las Nueces: They were understandably terrified.

Jessie Gaeta: I look like an astronaut. I'm telling you you have COVID. You feel fine, or maybe you're beginning to have alcohol withdrawal, so you're beginning to feel agitated and sick.

Denise De Las Nueces: And now Jessie, in full PPE—face mask, face shield, gown, and gloves—tells you you're going to be put on a bus with a doctor you've never met and be driven to a place you've never been.

Jessie Gaeta: And I think for people who have a lot of mistrust, reasonably, of all of these systems—the healthcare system, the shelter system, society at large—this was a very difficult pill to swallow.

Denise De Las Nueces: You're listening to COVID in the Streets of Boston, a podcast from the Boston Health Care for the Homeless Program. I'm Denise De Las Nueces. I'm the current chief medical officer at the program, an internist, and an addiction medicine specialist. This is episode two: Respite.

Denise De Las Nueces: There were a few places the newly-diagnosed men from Pine Street Inn might go. The hospital, if they had severe symptoms and needed acute level care. The tents, if they were in the throes of addiction and could benefit from a highly structured environment. And the newly-created COVID-positive ward in our respite program, if they were mildly symptomatic but still in need of 24-hour nursing care. And Jessie, as our chief medical officer, had to figure out who would go where.

Jessie Gaeta: So I just remember going person to person, spending probably 10 minutes with each person, quickly trying to triage whether they needed hospital, and then trying to help them kind of manage all the anxiety that they had about possibly dying from this infection. A lot of the men in that room had diabetes, heart disease, emphysema, and so there was a lot of worry.

Denise De Las Nueces: One thing that helped alleviate the shelter guests' anxiety was the clinic we'd had in the shelter since 1985. Many of the people Jessie was talking to had longstanding relationships with our nurses.

Jessie Gaeta: And so just talking to them and identifying ourselves as being from Boston Health Care for the Homeless Program, I want to hope that that meant something to some of those people. And even though I might not have been a familiar face to the people at that particular shelter, I think our clinic played a big role, and the relationship that they have with people there, played a big role in our ability to have some level of trust.

Denise De Las Nueces: By two or three in the morning, Jessie and Barry had gotten almost everyone to agree to come to an isolation facility. For a lot of them, that place was in our newly-created COVID-positive ward in our Barbara McInnis House respite program. Our respite program looks like a step-down hospital. It has 104 beds with 24/7 care for patients who are not sick enough for a costly hospital bed but are still too sick to return to life in the shelters or on the streets.

Suzanne Armstrong: They came to respite like in the middle of the night. Half of them are like, I have no idea where I am right now. They had to enter through the basement, which, you know, could use a facelift. Then being brought up in some elevator and walking onto some floor. I mean, and then here are these strangers in PPE talking to them. It was hard to hear. There was plexiglass in front of the med cards. And so I think that was hard. My name is Suzanne Armstrong, and I was the director of nursing for our medical respite programs during the first wave, second wave, and third wave, I guess. And I'm a nurse practitioner with the program. That's how I started.

Denise De Las Nueces: Suzanne joined BHCHP in 2006. It was her first nurse practitioner job out of nursing school, and she started at our respite program before going to work on our street team, caring for rough sleepers—folks living on the streets of Boston.

Suzanne Armstrong: Which was amazing, being able to care for the rough sleepers with a multi-disciplinary team and do a lot of diverse medical practice, outreach, clinic, home visits, checking in on people in hospitals, too.

Denise De Las Nueces: In 2016, Suzanne left the street team to return to our respite program as the director of nursing. The respite facility is called the Barbara McInnis House, named after a beloved nurse who first trained Dr. O'Connell in homeless medicine when he founded Boston Health Care for the Homeless Program. The McInnis House is located on the top two floors in our main building in the south end of Boston, across from the Boston Medical Center. While our patients are in respite, we coordinate their other specialty care, like dental, optometry, dermatology, and any follow-up medical appointments or testing. Ours is the first medical respite program for homeless folks in the country, and even among healthcare institutions, it's truly innovative.

Suzanne Armstrong: We're not a hospital. We're not a nursing home. We're not an outpatient clinic. We are a massive ambiguity. And so, we just started to think about everything that we do every day in the facility that basically was not going to work.

Denise De Las Nueces: Our respite program tries to foster a sense of community, with communal experiences that are essential to our patients' wellbeing, but those communal experiences were no longer safe.

Dave Munson: So much of like what made the community so great upstairs, COVID necessitated disrupting that. Like eating in the cafeteria together, and all the communal time downstairs, which was like part of what helped people feel comfortable here, that had to go away. Hi, I'm Dave Munson. I'm one of the internist here at Boston Health Care for the Homeless Program.

Denise De Las Nueces: As we talked about in the last episode, congregate settings are terrible for infection control. So the team had to completely transform the respite program.

Dave Munson: So the patients need to eat. They need to take showers. There was trash that had to be changed. There were linens that had to be changed. We had to do, floors that had to be clean. All those sorts of things, we wanted to make sure as best we could. And we had to provide good high quality medical and nursing care. So that's a lot of different types of people to get them to buy in and figuring out how to adapt the processes in that way.

Denise De Las Nueces: And importantly, they had to find a way to separate COVID-positive patients from everyone else.

Dave Munson: The way that we thought about how to design the space was we looked at the blueprint of the floor. And we probably printed out 50 copies of the blueprint of each floor, and then we tried to model it on how a negative pressure room is set up. So we have two negative pressure rooms in McInnis House, which basically has a dirty space, an intermediate space, and a clean space. And we just tried to scale it up to what we had. And then we leaned on some colleagues from BMC, Josh Barocas and Nahid Bhadelia, who helped us kind of think through what was possible and what wasn't possible, and what was safe and what wasn't safe. And that was invaluable. They were invaluable resources. And Josh continued to be an invaluable resource the whole, the whole experience.

Denise De Las Nueces: When you walk off the elevator on the third floor, there's a nursing station and a hallway to the left and another hallway to the right. Doors on either side of the halls lead to patient rooms, and each room has two to six beds.

Dave Munson: We designed it in a way where we could scale it up and scale it back because we knew that we would probably have to start small, and then we had the idea that, you know, we might have to do the whole floor. And so from the beginning we were thinking like, okay, like, what's this gonna look like if we do the whole floor? And we had a couple different ideas, you know, not really knowing if it was ever going to come into play like that, but being pretty certain that it would.

Denise De Las Nueces: We had no idea how many beds we would eventually need, but we were watching the numbers closely, especially the lack of available hospital beds. For staff, Dave and his team designated a storage closet as an anteroom, where staff could safely change in and out of PPE and minimize the risk of exposure. Once they'd completed the design of the new unit, they enlisted the facilities team to build it.

Dwaine Palmer: Back then it was serious. So, you know, once they said there's four or five people coming in that's positive and we need more space, can we build some more walls? We go get busy building it.

Denise De Las Nueces: This is Dwaine.

Dwaine Palmer: My name is Dwaine Palmer, and I'm a facilities guy.

Denise De Las Nueces: Dwaine has been working at BHCHP for more than five years. When someone asks anything of Dwaine, or ofa ny of our facilities team, they are ready to help. Dwaine was used to repairing regular walls, but this task was different. He would be building walls made of thick plastic with zippers, for doors that could isolate a deadly airborne and virus. These walls were the main thing that kept the COVID virus from spreading outside the COVID unit, so they had to be completely sealed off. There was no room for error.

Dwaine Palmer: We got to make sure everything stays tight. No air comes out, you know, so to affect anybody else. So it was, it was a little challenging, but you know, when you get used to something, it becomes easy.

Denise De Las Nueces: Dwaine had a lot of opportunities to practice this new skill. As the virus spread throughout Boston, more and more COVID-positive patients experiencing homelessness needed to be isolated. And so more walls had to be built.

Dave Munson: The walls that made the sort of the changing space stayed, but the end of the ward just kept moving back as we took more and more patients. And then eventually we took that wall down because we took the whole floor.

Denise De Las Nueces: Before long, the entire third floor was a COVID-positive unit with 52 beds and more than 30 staff. One of the first people Suzanne asked to go into the unit was Bridget Sullivan, the nurse educator.

Dave Munson: Bridget Sullivan created this amazing, like, path for people to take on and off their PPE in a way that, you know, was intuitive to people that had never really done this before. And in a way that made people feel more safe in a situation where they probably didn't, you know, where there was a lot of uncertainty and fear.

Denise De Las Nueces: Here's one of our respite nurses, Kate Hamilton.

Kate Hamilton: There was a part of me that when I first put the PPE on, I was so hot and uncomfortable and kind of terrified that I just was like, well, I know I just spent all this time training for this, and I know I just got this job, and, but like, I don't know, I might have to quit.

Denise De Las Nueces: Kate was still in nursing school when she applied to work at BHCHP in early 2020.

Kate Hamilton: I became a nurse in February. I got my license, was very excited, got the job by the end of February. And then COVID kind of descended upon us at the beginning of March.

Denise De Las Nueces: On the days that Kate was assigned to the COVID ward, she'd arrive, take her temperature, and get ready to don her PPE in that little anteroom that Dave and the team had created.

Kate Hamilton: And there was a mirror right before you went in that said, like, you're a healthcare superhero, or something like that, that you'd, like, look in and make sure that your mask was right before you went in. And then you go to this plastic door and take the red zipper and unzip it. And then you’re on the COVID ward.

Denise De Las Nueces: Almost as soon as the COVID ward was set up, the patient started arriving, including the men from Pine Street Inn.

Dave Munson: Well, that was a crazy day. There was a whole group of admissions that came at like eight o'clock. And then I remember being on the ward and Suzanne sent me a message that said there were like 15 more patients coming. And it was like 11:30 at night. And I was like, I was, I thought she was just, she's a notorious joker, Suzanne she's notorious. I was like, she's pulling my leg. Like, this is like, the way this is the case.

Denise De Las Nueces: Suzanne wasn't joking. The patients started coming in one after the other. As the new patients came off the elevator, the team quickly triaged. If you're really sick, move to one side. If you're okay, go straight to bed. There were just a couple of really sick people in that group, including one patient whose COVID symptoms were audible. It was the first time Dave had heard the disease in someone's lungs.

Dave Munson: It sounded like Velcro crackles. Like, just like velcro rubbing. And then wheezing. I can, you know. I just remember like, oh, this is what it sounds like. It feels like you're finally meeting it or something like that, you know?

Denise De Las Nueces: With all these changes to staff procedure and physical space, patients were experiencing a very different respite than they would have a year before, and it was hard for a lot of them.

Suzanne Armstrong: There were some patients who really struggled to who had an active opioid use disorder. Cause I think a lot of those patients aren't used to staying in a confined area, in a confined space. And so supporting, you know, someone that is not ready to stop using but is being forced to go into isolation and inside. It was like, I don't know what else to say to this person. You know, constantly coming out of their room, when can I leave? How many more days? How many more days? I can't believe it's only day three. And I think there were times where people thought, like, I just don't know if this person is going to get through this stay.

Denise De Las Nueces: Most people made it through their stays, but it was confusing for both patients in the COVID unit and on the non-COVID floor. Even at the highest levels, there were some questions about COVID that we simply couldn't answer because no one could.

Suzanne Armstrong: We would say that things are happening so quickly, like, we don't know if this is the right decision, but this is what we think. This is how we're rationalizing it. This is our thought process. But I think, yeah, I think it was probably hard for people to help alleviate people's fears when they themselves didn't know. But I think that's probably the nature of the industry, and the profession that you, you just kind of learn how to do that.

Denise De Las Nueces: New nurses who were just joining in our program had to learn many things all at once: how to be a nurse, how to practice during COVID, and how to care for our uniquely vulnerable population. Those nurses deserve a lot of credit for what they did.

Kate Hamilton: I mean, it was really hard to learn about all of these things at once. And there was a fair amount of, you know, I would leave and be like, was I a good nurse today? You know? I think that's developmentally normal but particularly difficult when the pandemic is super imposed on it.

Suzanne Armstrong: Caring for homeless people, I think, there's a lot to learn that is just trial by fire. And that just comes with time. I mean, you can teach someone how COVID works, and look at the data, and this is what you do, and this is how you protect the patient, and this is how you protect, you know. But I think the understanding the depth of the homeless population and how they got there, I think that is just time and experience.

Denise De Las Nueces: Suzanne remembers her first time discharging someone experiencing homelessness from McInnis House when she was a brand new nurse practitioner herself. Where would they go if they didn't have a home?

Suzanne Armstrong: The patient was laughing at me because I was, I kept saying like, you're going, where are you going? And he's like, I'm going outside to the park. And I was so nervous to write, like, discharged to the street. And, you know, the other NPS were like, it's fine. This is, this is, it's okay. But I couldn't believe it, and I was like, are you serious? And he's like, yes, Suzanne, please, like, goodbye.

Denise De Las Nueces: Suzanne and finally discharged him, but not without a lot of worrying. She ended up seeing that patient again when he returned to McInnis for care. And then when she did medical outreach on our street team, she got to see where he slept when he wasn't in respite. An experience like that really clarifies who our patients are and what they are dealing with.

Suzanne Armstrong: By the time most of the patients have gotten to us, to where we're caring for them in the program, you can imagine where they've already been. And so you'll hear this from people who maybe aren't as engaged with our patient population, like, yo u know, I don't understand why, why isn't their family, like why did their family kick them out? Or. And it's just, there's so many more layers and it's so much more complicated, and more than I could ever imagine. So, you know, to not think about that piece but just think about how we're here to give care the best we can for the patient.

Kate Hamilton: One of the things that's attractive to me about working at Boston Health Care for the Homeless is that the social determinants of health are undeniable. So if, you know, you're talking with a patient that has intense childhood trauma, diabetes, hypertension, you know, a foot amputation, and is homeless, we cannot possibly, as, you know, a single organization fix all of these compounding conditions. But we can, like, have a moment of…we can have a moment of connection. And as healthcare workers, we can be in a position to be in a room with someone and have time and place to hear their story and make them feel seen and heard.

I remember this one woman that, you know, she's a person who is on the COVID unit. She's isolated. She's sick. She can't go outside for the whole 10 days that she's there. But she looked at me and she said, I have never been treated so well in my whole life. And I think that that's, she's not, I mean, she's, she's talking about the medical care, but she's also talking about people that look her in the eye and are interested in how she thinks and feels about things, you know? So in some ways the medical care is of course important, but it's also the whole philosophy of the organization that this population deserves respect, and time, and energy, and is, like, worthy of that. Not only deserves it, but is worthy.

Denise De Las Nueces: We base our care on building a trusting relationship with our patients and treating them with dignity and compassion. And we know they need much more than just immediate medical attention when they come into respite. A patient might be admitted for wound care or an illness like COVID, but we also work with them to address their behavioral and mental health needs, which are very common, and their housing needs, and connect them to benefits and other social services. And we also give them really good food.

Steve Paquin: We try to give them the best product that we can put out to them, knowing that they may not have had a good meal prior to coming here.
I'm Steve Paquin, the food service director and executive chef for Boston Health Care for the Homeless Program.

Denise De Las Nueces: Steve had been with the program for two decades when COVID hit. He and his team of about 14 full-time staff prepare three meals a day for all the patients in respite, plus bag lunches for others. Before COVID, patients who are ambulatory ate in our communal dining room and built community around the table.

Steve Paquin: They would come into the dining room in line and they would select something off the menu board and it was plated up right then and there for them. Then come mid-March, we had to change all that and feed the patients upstairs in their rooms.

Denise De Las Nueces: Like everyone else, Steve had to completely redesign how he worked.

Steve Paquin: So we had the carry the food up in the back stairs into the edge of the COVID ward there, if you will. And the nursing staff would come out and grab the food and bring it into the unit and pass it out to the patients inside that COVID unit.

Denise De Las Nueces: Steve purchased food warming carts so his team could continue to offer patients multiple hot options for each meal. And he and his staff went above and beyond in increasing the choices and variety of meals over the course of a patient's stay.

Steve Paquin: Anything you can think of. Anything from pizzas, steak and cheese, oven fried chicken, baked fish, spaghetti and meatballs, meatloaf.

Denise De Las Nueces: That made a big difference for our patients, who day in and day out experience food insecurity, among many other traumas.

Steve Paquin: You try to make a difference in their lives, and if you can do that, great. You, you did a good job.

Denise De Las Nueces: With their immediate needs taken care of, patients can focus on getting well.

Dave Munson: It's really great to see patients in McInnis House because they are different than they are outside because they don't have to worry every second of their day about how they're going to eat, and sleep, and be safe, and somebody's going to rob me or whatever, you know. And they can just kind of relax, and you get to see a different side of people.

Kate Hamilton: There was a lot of things about working with this population that I was expecting. I was expecting trauma, and depression, and anxiety, and you know, people that are at the lowest point in their lives. But I think the thing I was most surprised by was all of the, you know, humor and lightness, There was a sense that people were just, like, living their lives, you know? Just putting one foot in front of the other.

Denise De Las Nueces: As the nurses, doctors, kitchen staff, and everyone else in the respite COVID ward was caring for our patients, administrators were working behind the scenes to keep everyone—staff and patients alike—safe from COVID. The most important tool was the personal protective equipment or PPE.

April Ramsey: We have gowns that are part of PPE, and there are surgical masks, as well as the KN95 masks, and then the N95 masks. And then last, but certainly not least, is the eye protection. My name is April Ramsey, and I'm currently the associate director of clinical operations for the program, and I'm also covering, right now, the interim director of nursing role for medical respite.

Denise De Las Nueces: April had been with the program since 2011. She started as a nurse at our clinic at the Pine Street Inn, then joined the team at the Barbara McInnis House and worked her way up and across the organization, including working to address earlier outbreaks of meningitis and hepatitis. Early in the pandemic, April took on a new and critical role managing PPE for the program. April needed to locate and order a high volume of high quality PPE at a time when every healthcare facility in the world was competing for the same limited supply. But she wasn't doing it alone.

April Ramsey: I was fortunate enough to have the help of Bessy Wrights in dental, who was probably our in-house PPE expert unofficially when this all started.

Denise De Las Nueces: Also on the team was Anny Bautista, the new PPE coordinator.

April Ramsey: And so Anny and Bessy really were the leads in going through all the donations that were coming in through development. Development did a great job of reaching out to some of our routine donors to ask for specific things that we needed because we recognized early on that although folks' hearts were in the right places for wanting to donate supplies, we also really had to be thorough in what we were willing to accept to be sure that it would protect our staff.

Denise De Las Nueces: Once April and her team had brought in and verified all the PPE, they had to get it out to the various clinic testing sites and isolation facilities across the program. So April would load up her SUV with supplies and make the rounds. Meghan Krueger, an operational nurse in our program, had another way of getting around.

April Ramsey: If anyone remembers Meghan, they know that she was on her bike, through traffic, in all weather, all the time, before COVID and during COVID. She had her big old backpack and she would stuff supplies in and sometimes be able to get to places faster than I could in my car with Boston traffic.

Denise De Las Nueces: As the weeks wore on, new guidelines came out for how to safely extended the use of PPE. Instead of replacing their N95 masks each time they enter or exit a space, a clinician might now be able to keep their mask in a plastic container during a break or put their face shield in a paper bag. And there was another major development.

April Ramsey: One of the other ways that we were able to preserve PPE supply was shifting from using all disposable gowns to using some cloth gowns that we were able to launder specifically for the needs that we had up in respite.

Denise De Las Nueces: They contracted with a local laundry service.

Suzanne Armstrong: They were amazing. They would come and turn around scrubs and gowns in 24 hours. We would text this guy every day, this guy Bruce, and say we're low, and he would have his staff do another load and he would drop them off at like five in the morning for us.

Denise De Las Nueces: But that vendor was closed on the weekends. So someone from our organization stepped up.

Dwaine Palmer: The nurses, they really needed the PPE, and there was no one around else to do it.

Denise De Las Nueces: This is Dwaine Palmer again, from facilities, whose team built the walls to the COVID unit. Dwaine volunteered to spend his Saturday shift each week washing enough gowns and scrubs to last the nurses until Monday.

Dwaine Palmer: Once I come in Saturdays I'd be like, I'm on it! From seven in the morning if it takes me till seven in the evening. You know? Once one's washing, I'm over here folding, waiting on the other load. When I'm finished folding, I put back in the machine again, you know, just to keep me going for the whole day.

Denise De Las Nueces: Dwaine himself was wearing full PPE as he washed and folded. After all, the gowns and scrubs he was washing were potentially covered in the coronavirus.

Dwaine Palmer: The only time I was uncomfortable is when I have to open the bag. Cause, you know, I don't know—poof! What's gonna, you know, if that scent from the bag or whatever's in the bag, I don't know what COVID is, you can't see it. So I'm always like, damn, I wonder if when I open the bag, I'm gonna catch it.

Denise De Las Nueces: The clinical staff was extremely grateful for Dwaine's contribution because without PPE, they couldn't do their jobs.

Dwaine Palmer: Sometimes I go up there and the weekends and they're on the last bag. And when they see me coming up with like four or five big bags, they'd be like, oh, thank you so much. Cause we didn't know what we was gonna do. And I took that into consideration, and, you know, makes me want to do it more, you know. So that's how I get through it. Togetherness, you know?

Denise De Las Nueces: Despite all the precautions, our staff couldn't escape COVID entirely.

Suzanne Armstrong: We had a core group of staff who were constantly working on the unit, and I would say it went through a lot of them. And that's when I think we probably, there were some people who maybe their ideal situation at home wasn't lending themselves to work on the COVID floor, but I think everyone recognized like, oh, this is, this is actually just going to happen.

Denise De Las Nueces: When staff members did get COVID, they had to stay isolated at home for 14 days, which caused real complications for the people who were staffing different sites.

April Ramsey: With the supplies, it's pretty straightforward. You either have it or you don't. The staffing for the COVID spaces was a little more complicated.

Denise De Las Nueces: Sharon Tan did the staffing for respite, but April and her team handled the staffing for our other clinical sites. We run over 30 clinics throughout the city that are embedded in the shelters.

April Ramsey: I had a lot of different calendar printouts with a lot of crazy notes on it. But we also had Evan Liu and Sanju Nembang, who were amazing behind the scenes helping with staffing. They were remotely working I don't even know how many hours to ensure that we had staffing in all of these locations.

Denise De Las Nueces: Unlike supplies, staff members can't just be deployed to fill a need because they have families and needs of their own.

April Ramsey: For some staff, it was especially challenging when they had to make those decisions around coming to work when they know they're working in a high risk space, but also maybe having loved ones or folks that you live with that may be vulnerable and, and COVID might have significant impact to them. And so I think, in hindsight, everyone could have used an extra dose of support. But I think we did the best that we could in the spaces that we were to try to rally both morale, but also just hope that we were filling these gaps for our patients, even though it may have felt like we didn't exactly know what the plan was.

Denise De Las Nueces: With so many staff members across so many sites, communication was a struggle. Our leadership team communicated to respite and other facilities about testing strategies, which impacted the number of patients that might be admitted. Meanwhile, researchers were discovering new things about how the virus was mutating, and the CDC and the state were issuing new guidelines around transmission and PPE.

Suzanne Armstrong: Things were changing so quickly, and sometimes things would change from the morning until the afternoon to the night. And so we had to make sure everyone was communicating. Like, I know we said this this morning at 7:00 AM, but actually tonight at 7:00 PM it’s completely different.

Denise De Las Nueces: It was a constant rollercoaster.

April Ramsey: And so we had recognized that we needed to keep staff aware of where we were on that rollercoaster ride. And so we did have daily staff calls and sometimes several emails daily to staff with updates around what the plans were and how they may have changed since the previous communication. And knowing that there were a lot of questions that we couldn't answer, so answering the ones that we could in the most tangible way possible, hopefully was supportive and also realistic for staff around what to expect in the coming days or weeks.

Denise De Las Nueces: Those constant updates and regular changes to both procedure and scientific knowledge were yet another variable for the nurses on the floor.

Kate Hamilton: It was a great opportunity to do the best you could with the information that you had and to place emphasis on being flexible and adaptable and able to quickly change the way that things are done.

Denise De Las Nueces: Thanks to everyone's adaptability and persistence, we were able to keep our team supported or site staffed and our PPE robustly stocked. Except for once, in November of 2020, when April was running low on one important item.

April Ramsey: I did have to go to my boss and say, I'm nervous that we're going to run out of gloves, and I have a couple of solutions, but if none of those work out, then I'm really not sure what we're going to do.
Denise De Las Nueces: She was pushing on one vendor in particular, hoping they could send a shipment of 30,000 gloves. Huge for us, but a drop in the bucket compared to what the nearby hospitals were using.

April Ramsey: I just sort of explained how our need for PPE was expanding as we were filling these gaps for patients. And, you know, I was able to just really reinforce our desperate need and just explain all that we were doing to try to not overload our hospital systems or our community partners.

Denise De Las Nueces: If we didn't have gloves, we couldn't care for our patients. And if we couldn't care for our patients, the burden of isolation would fall onto our hospital partners, who were already stretched and at full capacity.

Dave Munson: You would have been faced with a situation where all of these people infected with COVID would be either like outside, like, sleeping outside on the street, or they would have been in the emergency room or something like that, which is crazy. You can’t, like emergency rooms, hospitals have enough on their plate to have like, you know, asymptomatic or minimally symptomatic COVID-positive there.

Denise De Las Nueces: The vendor finally agreed. Now it was just a matter of making sure the gloves actually arrived before a supply ran out. And to make matters more stressful, April was about to be out of the office for three weeks.

April Ramsey: I had taken some time off to get married and so one of the few things that I asked to be notified of during my time away was that the gloves had arrived. And so fortunately when they got here, Meghan Krueger did text me and let me know that they had arrived. And then I was able to sort of rest a little easier for my wedding and honeymoon, knowing that the nurses that I was supporting and the rest of the clinical folks had the gloves that they needed.

For some reason, it always does work out for us. And I don't know if that's just because we're doing the right thing and, and the, the good stuff follows us. But it was, I think I go back to, it takes a village to do anything. And so similarly with PPE, it took a village to not only obtain it, but to get it out to sites and to make sure that folks had the most up-to-date information on how to use it. And I’m just really grateful for everyone that stepped up to figure out those processes and to keep our staff safe.

Denise De Las Nueces: That's how we got through all of it, especially in those first couple of waves before we had a vaccine for COVID or medications to treat it. Our village included everyone from facility staff, to kitchen staff, to respite aids providers, case managers, security officers, dental and front desk staff, testers and pharmacists, behavioral health specialists, and many more. And the nurses who, whether they knew it or not, had been preparing for a moment just like this, and who truly saved the day for all of us

Suzanne Armstrong: The core of nursing was brought out by the pandemic, and what you go into the profession to do, which is, it sounds, I mean, when you say to help people, it sounds so, I don't want to sound like generic, but I think it is, it's like a calling really. And you could see it when someone just decides to go onto the floor and they don't question it, right? You just kind of have that, that drift, or that urge, like you, you couldn't help yourself from getting involved, I think.

Denise De Las Nueces: That urge to get involved ran through all the nurses at every level of the organization.

Kate Hamilton: There is a saying in nursing that nursing eats their young, and I found that there was not a whiff of that at BHCHP during the pandemic. There was a culture that you could always talk about your, your fears, your worries, and that the senior nursing staff, Suzanne and Bridget and April, were going to do the best they could to provide whatever you needed to feel safe.

Denise De Las Nueces: By transforming McInnis House, we were able to continue to care for our patients with dignity and compassion and do our part to support the broader healthcare infrastructure in Boston

Dave Munson: We were playing a role that no one else was playing at that time, you know? You would have people who are experiencing homelessness, who had COVID, who didn't need to be, they didn't need oxygen, they didn't need a breathing tube, they had no indication to be in the hospital, and there was no place for them to go. And so, you know, creating a space that allowed those people to be somewhere safe, where they could isolate, where they would minimize that risk of infecting other people, no one else was doing that for this population, for our population. And you know, we did as much as we could do at McInnis House, and then when the numbers got bigger than we could do, because we, you know, we only had 104 beds, the program created Boston Hope.

Denise De Las Nueces: Hope. That's what we promise to give our patients. And trust, and dignity, and respect. In our next episode, we'll talk about Boston Hope, a 1,000-bed field hospital constructed inside the cavernous Boston Convention and Exhibition Center, where Boston Health Care for the Homeless Program managed 500 beds for a patients experiencing homelessness. Don't miss it. Subscribe to COVID in the Streets of Boston wherever you listen to podcast.

Credits: This episode was produced by Galen Beebe and directed by Sara Pacelle. It was sound designed, mixed, and mastered by Jack Pombriant. Music from the Epidemic Sound Library and Jack Pombriant. Thanks to our intrepid BHCHP team, especially Barry Bock, Jessie Gaeta, Omar Marrero, Dave Munson, Suzanne Armstrong, Steve Paquin, Dwaine Palmer and Kate Hamilton. We are grateful to our IT Staff for helping to keep the engine running.

Our deepest thanks to all staff members who worked in the COVID respite unit, in full PPE, at a time when there was so much unknown and frightening about the virus. The nurses, nurse practitioners, doctors, case managers, social workers, and facilities staff, who donned their PPE, fearlessly unzipped the COVID unit door, and entered that unit to do their jobs.

We are grateful to all our staff who care for our courageous patients and those who support the caregivers. Our kitchen staff, our dedicated board of directors, our remarkably kind donors, many who give without ever meeting a single staff member or patient, we are thankful for your trust. Thank you to our 30+ shelter partners, hospital partners, including Boston medical center and Mass General Brigham, Dr. Josh Barocas, the Boston Public Health Commission, the City of Boston, the Commonwealth of Massachusetts, MASS Design, and to the restaurants and individuals who brought our tired staff nourishing meals. And of course we thank our resilient patients who have had so many setbacks in their lives but continue to teach us every day about our shared humanity. And thank you for listening.